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Evidence-based practice II. Dr Cath Jackson and Ian Grigor. Aims of session. To review contemporary Department of Health (DH) and National Institute for Health and Clinical Excellence (NICE) guidance on Measles/Mumps/Rubella (MMR) vaccination

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Evidence based practice ii

Evidence-based practice II

Dr Cath Jackson and Ian Grigor

Aims of session
Aims of session

  • To review contemporary Department of Health (DH) and National Institute for Health and Clinical Excellence (NICE) guidance on Measles/Mumps/Rubella (MMR) vaccination

  • To give an overview of MMR research activities in the School of Healthcare

The dh approach
The DH approach

  • An overview of the benefits of immunisation holistically http://www.immunisation.org.uk/

  • Note that the above website carries the NHS logo

  • A “News” section carries evidence of recent research in the respective topics

The dh approach1
The DH approach

  • From the NHS Immunisation information homepage, there is a link exclusive to MMR

  • e.g. “MMR in the news”

The dh approach2
The DH approach

  • More importantly:- a resume of all the information for parents to make an informed decision about vaccinating their children against MMR

Nice guidelines
NICE guidelines

  • Offer Adobe Acrobat files that can be searched for MMR information

  • Why is this less user-friendly for the public?

As academics
As academics…

You will, no doubt, want to hear about the latest, in-house research on MMR

Supporting informed decision making in relation to the mmr vaccine
Supporting informed decision-making in relation to the MMR vaccine

Cath Jackson

Francine M Cheater

Innes Reid



Tel. 0113-343-1576

School of Healthcare

Background vaccine

  • Department of Health funded

  • 4 years’ research

  • Phase 1: Interviews

  • Phase 2: Systematic review of literature

  • Phase 3: Exploratory trial

Top down approach
Top-down Approach vaccine

Cognitive-deficit model

  • Assume that lack of knowledge is the problem

  • Health professional communicates information to parent

  • Ignores the influence of own experiences

  • Conforming with ‘expert’ opinion

  • Informed consent

Bottom up approach
Bottom-up Approach vaccine

Engagement model

  • Acknowledges importance of knowledge and trust in the information source

  • Making sense of information in context of own experiences

  • 2-way communication process

  • Facilitating an informed decision

Informed decision
Informed Decision vaccine

  • Several definitions 1, 2

  • Based on relevant information

  • Consistent with the decision maker’s values

Research question
Research Question vaccine

  • What is the most effective approach to support informed parental decision-making in relation to the MMR vaccine?

    • Interviews

    • Systematic review

    • Intervention to be tested in an exploratory trial

Interviews methods
Interviews: Methods vaccine


To explore parents’ accounts of decision-making relating to the MMR vaccine controversy, identifying uptake, determinants and education needs.

  • 69 interviews with parents

  • 12 interviews with health professionals

  • Tape recorded, fully transcribed

  • Framework approach for analysis3

Interviews results
Interviews: Results vaccine

  • 62% parents did not feel that they had made an informed decision

  • Parents and health professionals identified a need for new ways to support informed decision-making

Review questions
Review Questions vaccine

  • What are the decision support needs of parents attempting to make an informed decision about their child’s health?

  • What are the decision support needs of adults attempting to make an informed health decision for which there is controversy?

  • How effective and appropriate are existing decision support interventions in these contexts?

Review methods 1 search strategy
Review Methods 1: vaccineSearch Strategy

  • Major databases: Medline (1996-), EMBASE (1980-), CINAHL (1982-), PsycINFO (1967-), ASSIA (1987-)

  • Specialist databases: Bibliomap, HealthPromis, Cochrane Library

  • Reference lists from key primary and review articles

Review methods 2 inclusion criteria
Review Methods 2: vaccineInclusion Criteria

Decision Support Needs Papers

Types of participants

  • Parents/guardians/carers making a health decision for a child

  • Adults making a controversial health decision for themselves or someone else

    Types of decisions

  • Parent decisions: treatment, immunisation, pre-natal screening / testing and related reproductive decisions, lifestyle / behaviour change, palliative care and stopping active treatment

  • Controversial decisions: HRT, MMR, pertussis vaccine, PSA, antibiotics for otitis media

  • Excluded hypothetical decisions

    Types of studies

  • Studies of all designs (quantitative and qualitative), published in English

  • Opinion papers excluded

Review methods 3 inclusion criteria
Review Methods 3: vaccineInclusion Criteria

Decision Support Intervention Papers

  • Same types of participants and decisions

    Types of studies

  • All designs that describe and / or evaluate and / or discuss a decision support intervention.

  • Published in English

  • Effectiveness evaluations: Studies included a control or comparison group.

  • Appropriateness evaluations: Studies reported a ‘formal’ evaluation

Review methods 4 data extraction and synthesis
Review Methods 4: vaccineData extraction and synthesis

  • 3 reviewers independently

    • extracted data

    • quality assessed the studies

    • synthesised the data

Review results 1
Review: Results 1 vaccine

12123 papers identified

including overlap

2494 papers

after title screen

575 papers

after abstract screen

259 papers


3 papers

not obtainable

313 papers


205 papers

Decision Support Needs

54 papers Decision

Support Interventions

Review results 2
Review: Results 2 vaccine

Decision Support Needs

3 key areas emerged

  • Information

  • Peer support and networks

  • Feeling in control over making the decision

  • Consistent across method and type of decision

  • Review results 3
    Review: Results 3 vaccine

    Decision Support Interventions

    • Most use decision aids

    • Most (decision aid, educational, empowerment) show some improvement in some outcomes compared to usual care

    • Many do not change decision-making outcomes

    • Some reduce uptake of the treatment / screening etc.

    • Guidance re: how to present info but no consensus re: delivery

    Review discussion
    Review: Discussion vaccine

    • Broad range of studies across health decisions

    • Less than 30% studies focused on informed decision-making

    • Decision support needs consistent across parental and controversial health decisions

    • More than just information needs

    • No interventions to promote informed decision-making for MMR

    • Issue of ‘persuasion’ and gaining informed consent not informed decision-making for MMR

    Trial methods 1
    Trial: Methods 1 vaccine


    To conduct a cluster randomised controlled exploratory trial to compare usual care in general practice with a parent forum plus usual care in relation to MMR parental decision-making

    • 140 parents of children eligible for MMR vaccine

    • 70 in the control group - MMR leaflet (usual care)

    • 70 in the intervention group – MMR leaflet and a 2 hours parent forum

    Trial methods 2
    Trial: Methods 2 vaccine

    • Forum co-led by a parent and a researcher

    • Incorporates

      • Information

      • Parent support / network

      • Question prompt card and coaching

    • Collected data on informed decision-making, attitudes, knowledge, vaccine uptake

    • Postal questionnaire at baseline, 1 week-post intervention and 3 months post-intervention

    Conclusions vaccine

    • Range of research methods applied to a ‘real life’ health issue

    • Dissemination

      • DOH

      • PCTs and primary care health professionals

      • Academics

      • Parents

    References vaccine

    • Bekker, H. et al. (1999). Informed decision making: an annotated bibiography and systematic review. Health Technology Assessment, 3, 1.

    • O’Connor, A. et al., (2003, 2006). Decision aids for people facing health treatment or screening decisions. The Cochrane Database of Systematic Reviews, Issue 1.

    • Ritchie J. & Spencer E. (1994). Qualitative data analysis for applied policy research. In A. Bryman & A. Burgess (Eds.), Analysing Qualitative Data. Routledge: London, UK.

    • McMurray, R.; Cheater, F.M. et al. (2003). Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions. British Journal of General Practice, 54, 520-525.