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Outline: Communicate To Vaccinate: The COMMVAC Systematic Review
Outline: Communicate To Vaccinate: The COMMVAC Systematic Review
CommunicatetoVaccinate:theCOMMVAC
systematicreview
JessicaKaufman
ResearchOfficerandPhDCandidate
GuestLecture AppliedHealthResearch
10August2015
latrobe.edu.au/chcp
CRICOSProvider00115M
Outline
Communicationforchildhoodvaccination
Identifyingatopicforasystematicreview
Definingthereviewsquestion(PICO)
Searchingandscreeningstudies
Assessingstudyquality
Evidencesynthesis
Findingsandimplications
10/08/2015
Asnapshotofchildhoodvaccination
GLOBAL: In2013,21.8millioninfantsworldwidedidnotreceivethefull
seriesofbasicimmunisations(WHO,UNICEF2014)
LOCAL: In2014,Victoriahad7outbreaksofmeasleswith75notifiedcases
(RUSSO2015)
Strategiestoincreaseuptake:
Supplysideinterventions:vaccineaccessand
availability,newtechnologies,healthpersonnel
Demandside/consumerlevelinterventions:
communication(e.g.remindersto
parents,education,decisionaids)
Examplesofcommunicationstrategies(interventions)for
childhoodvaccination
Informingoreducatingpeopleaboutrisksandbenefitsof
vaccinesandwhereandwhentogetthem
Remindingorrecallingtoappointments
Teaching peoplehowtocommunicatemoreeffectively
Supporting parentsandhelpingfacilitatedecisionmakingabout
vaccination
Involvingcommunitymembersinplanningandevaluating
vaccinationprograms
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Whydoweneedevidencebased vaccinationcommunication?
NEEDTOKNOWWHATWORKS:
manytrialsbutfeweffortstosynthesise availableevidenceglobally
Effective communicationenables:
Rapidrebuttalofmisinformation
Communitydialoguetoachievewidespreadsupport
Educationofparents,communitiesandvaccinators
Consistentandeffectiveadvocacyofvaccinebenefits
Ineffective communicationmay:
Consumetimeandresources
Underminetrustinhealthsystem
Havenooradverseeffectson
healthoutcomes
Vaccinepreventablediseaseoutbreaks
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CommunicatetoVaccinate(COMMVAC)projects
COMMVAC1(2010 2012)andCOMMVAC2(20132017)
Aim:Tobuildtheevidencebaseandimprovecommunicationabout
childhoodvaccinationswithparentsandcommunitiesinLowandMiddle
IncomeCountries(LMICs)
InternationalresearchcollaborationwithpartnersfromAustralia,Norway,
France,Switzerland,SouthAfrica,Nigeria,Mozambique,andChile
10/08/2015
Evidencemapping
Runtestsearchfortrials
(CENTRALdatabase)and
otherliterature(MEDLINE)
Countarticlesevaluating
eachintervention
Maparticlestothe
communicationthey
evaluated
Orange=Trials
Blue=Nottrials
Systematicreviewan
interventionwherethereare
trials
Identifyingatopicforasystematicreview
Deliberativeforumswithkeystakeholderstoprioritise review
topics
Representativesofgovernmentalandnongovernmentalagencies,
consumergroupsandexperts
Facetoface(NewYork,Ottawa)andonline
Identifiedhighprioritycommunication
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COMMVACsystematicreviews
Goldstandardforevidenceof
effectiveness
Facetofaceinterventionsfor
informingoreducatingparents
aboutearlychildhoodvaccination
Communitydirectedinterventions
forinformingand/oreducating
aboutearlychildhoodvaccination
Kaufman, J., Synnot, A., Hill, S., Willis, N., Horey, D., Lin, V., et al. (2013).
Face to face interventions for informing or educating parents about early
childhood vaccination. Cochrane Database Syst Rev, 5, CD010038.
Saeterdal, I., Glenton, C., Austvoll-Dahlgren, A., Munabi-Babigumira, S., &
Lewin, S. (2014). Community-directed interventions for informing and/or
educating about early childhood vaccination. Cochrane Database Syst
Rev, 11, CD010232.
Definingthereviewsquestion
Population
Intervention
Comparison
Outcomes
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Population
Included
NotIncluded
Healthworker
motivation
program
(involvecommunicationandconsumersorcommunities)
Reminders
forparents
Vaccine
programme
funding
Trainingfor
health
professionalto
improvetheir
communication
skills
Trainingforhealth
professionalsin
vaccinedelivery
Chartprompt
remindersfor
health
professionalsthat
appearduring
consultations
Incentivesfor
consumersorhealth
professionals
More
convenient
organisation
ofcare
Vaccination
support
hotline
Parentheld
symptom
diarytotrack
adverse
events
Community
vaccination
events
Parentingskills
trainingfor
newparents
Community
coalitionstoplan
andimplement
vaccineprogram
Interpreters
Educational
materials
forparents
Decisionaids
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Definingthereviewsquestion
Population
Intervention
Comparison
Outcomes
Parents/
caregivers
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Intervention
Complexnonclinicalintervention
Cleardefinitionattheprotocolstage
Informing v.educating:literaturereviewindicatesthereisno
agreementaboutthedifferencebetweeninformingandeducating
Relevantinterventionsarethosewhichmakeconsumersawareofthe
practicalorlogisticalfactorsassociatedwithvaccinationorseektoenable
themtounderstandthemeaningandrelevanceofvaccinationfor
themselves,theirfamilyorcommunity.(KAUFMAN2013)
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Definingthereviewsquestion
Population
Intervention
Comparison
Outcomes
Parents/
caregivers
Anyfacetoface
communicationto
informoreducate
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Comparisons
Whatistheinterventioncomparedtowhenitisevaluated?
Facetofacecommunicationdirectedtoindividualparentsv.usualcare
Facetofacecommunicationdirectedtogroupsofparentsv.usualcare
Facetofacecommunicationdirectedtoindividualparentsv.facetoface
communicationdirectedtogroupsofparents
FacetofacecommunicationtypeAv.facetofacecommunicationtypeB
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Definingthereviewsquestion
Population
Intervention
Comparison
Outcomes
F2Fdirectedto
individualparentsv.
usualcare
F2Fdirectedto
Parents/
caregivers
Anyfacetoface groupsofparentsv.
communicationto usualcare
informoreducate F2Fdirectedto
individualparentsv.
groupsofparents
F2F typeAv.F2F
typeB
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Outcomes
Whatmightbeaffectedbythisintervention?(e.g.behaviours,healthstatus,
thoughtsorbeliefs)
Whichoutcomesmightbeimportanttodifferentpeople(e.g.parentsv.
doctors?)
Systematicreviewshavetorespondtotrialsbutcanalsoleadfutureresearch
withcarefullyselectedoutcomes
Reviewliteraturefirsttounderstandtheoutcomesdifferenttrialsareusing
Processoutcomes(e.g.knowledgeandintentiontovaccinate)areasimportant
asendpointoutcomes(e.g.vaccinationstatus)
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Definingthereviewsquestion
P
Population
Intervention
Comparison
Outcomes
*Vaccinationstatusofchild
F2Fdirectedtoindividual *Parentsknowledgeor
understandingofvaccination
parentsv.usualcare
Parents/
caregivers
Anyfaceto
face
communication
toinformor
educate
F2Fdirectedtogroupsof
Parentsintentiontovaccinate
parentsv.usualcare
child
F2Fdirectedtoindividual Parentsexperienceofthe
parentsv.groupsof
intervention
parents
Costofimplementingthe
F2F typeAv.F2F typeB
intervention
Adverseeffectsofintervention
Facetofaceinterventionsforinformingoreducatingparentsaboutearlychildhoodvaccination
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10/08/2015
Searchingandscreeningstudies
Professionallydevelopedsearchstrategyacrossmany
databases
Twoauthorsscreenresultsseparatelyandcompare
Inclusioncriteria
Studydesign:RCTsorclusterRCTs
Childrenandvaccines:Childrenunder5or6(schoolage),any
WHOrecommendedroutineearlychildhoodvaccine(HPV
excluded)
Interventions:notcombinedwithanyother
intervention(e.g.reminders,improvedaccess)
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Includedstudies
Screened9119abstractsandtitles
Included7studies
6RCTsand1clusterRCT
Settings
HIC:Australia(2studies),Canada,UnitedStates
LMIC:Pakistan(2studies),Nepal
Mixofhomeandclinic
Participants
2978participantsacross7studies
Groupsorindividualparents,expectantparentsorotherguardians
3studiestargetedhighriskmothers(drugusers,adolescents,lowsocio
economicstatus)
Interventions
Mixofsingleandmultisessioninterventions
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Outcomesmeasured
Primaryoutcomes
Vaccinationstatusofchild(measuredbymost studies)
Parentsknowledgeorunderstandingofvaccination(measuredbysome
studies)
Secondaryoutcomes
Parentsintentiontovaccinatechild(measuredbyno studies)
Parentsexperienceoftheintervention(measuredbyno studies)
Costofimplementingtheintervention(measuredbyone study)
Adverseeffectsofintervention(measuredbyno studies)
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Assessingthestudyquality
Quality:themethodologicalstrengthofarelevantstudy,orhowableitis,throughitsdesign
anditsconduct,topreventsystematicerrors,orbias (RYAN2013)
Biasedstudiesaremorelikelytoproducemisleadingresultsthanthosethatarerigorously
designedandconducted (RYAN2013)
RISKOFBIAS:
Type ofbias
Relevantdomainsinthe
CollaborationsRiskofbias
tool
Description
Selectionbias
Systematic differencesbetween
baselinecharacteristicsofthe
groupsthatarecompared
Performance
bias
Systematicdifferencesbetween
groupsinthecarethatisprovided,
orinexposuretofactorsotherthan
theinterventionsofinterest.
Detectionbias
Systematicdifferences between
groupsinhowoutcomesare
determined
Attritionbias
Systematic differencesbetween
groupsinwithdrawalsfromastudy
Incompleteoutcomedata
Reportingbias
Systematic differencesbetween
reportedandunreportedfindings
Selectiveoutcomereporting
Sequencegeneration
Allocationconcealment
Blindingofparticipantsand
personnel
Otherpotentialthreats to
validity
Blindingofoutcome
assessment
Otherpotential threatsto
validity
(HIGGINS2011)
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Synthesising
theevidence
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Synthesising theevidence
Metaanalysisiscombiningandanalysingdatafrommorethanonestudyat
once(BASTIAN2014)
Heterogeneity isvariationordiversity
Intheparticipants,interventionsandoutcomes(clinicalheterogeneity)
Instudydesignandriskofbias(methodologicalheterogeneity)
Intheinterventioneffectsbeingevaluated(i.e.theobservedeffectsaremore
differentfromeachotherthanonewouldexpectduetochancealone)
(statisticalheterogeneity)(HIGGINS2011)
Ifcalculationofstatisticalheterogeneityishigh,yourassumptionsareunsafe
andyoushouldnotpoolyourresults.
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Narrativesynthesis
Narrativesynthesis:describingresultsofincludedstudiesinawrittensummary
Groupstudiesbyintervention,comparison,orothermeaningfulcategory
Providethesameelementsofinformationabouteachstudyinthesameorderto
avoidbeingselectiveoremphasisingcertainfindings
Example:
Comparison1:Facetofaceinterventionsdirectedtoindividualparentsversus
control
Primaryoutcome:Immunisationstatus
o
Immunisationstatusmeasured3monthsafterasinglesessionintervention
Populationwasdiverse
Overalleffectwasuncertain
Evidenceoflowquality
Descriptionofeachstudyseffect
(KAUFMAN2013)
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Forestplots
Forestplot:avisualrepresentationoftheresultsofeachstudy
Horizontallinesareconfidenceintervals,ormarginoferrorforeachresult
BelowisaNARRATIVESYNTHESISforestplot.Ametaanalysiswouldinclude
adiamondatthebottomshowingtheoverallsummary
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Forestplots
Forestplot:avisualrepresentationoftheresultsofeachstudy
Horizontallinesareconfidenceintervals,ormarginoferrorforeachresult
BelowisaNARRATIVESYNTHESISforestplot.Ametaanalysiswouldinclude
adiamondatthebottomshowingtheoverallsummary
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Summaryof
findingstable
Organisedbythe
outcomes
Includesassessment
ofquality,
descriptionofeffect
andhowcertainwe
areofthateffect
Includedatthestart
ofallCochrane
reviews
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Summaryoffindings narrative
Facetofacestrategiesdonotconsistentlyimproveeitherimmunisation
ratesorparentknowledgeandunderstandingofvaccination,butthe
evidencewaslowtoverylowqualityfortheseoutcomes
Onlyonestudymeasuredcostandnostudiesmeasuredotheroutcomes
Theresultsofthisreviewarelimitedbythesmallnumberofincluded
studies,smallnumberofoutcomesmeasuredandproblemswithstudy
methods
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Implicationsforresearchandpractice
Effectsizemaydependonbaselinevaccinationrates
Impactmaydifferforpopulationswithlowliteracyorlimitedaccessto
printedoronlinematerials
Futurestudiesshouldmeasureprocessoutcomesincludingknowledgeor
intentiontovaccinate
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Nextsteps
COMMVAC2project createevidencebased
globalguidanceonimplementingvaccination
communicationinterventionsforprogram
managersandpolicymakersinLICs
PhD Developacoreoutcomesetso
futureresearchcanhelpinformbetter
communicationdesignanddelivery,
andfuturetrialscanbemetaanalysed
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References
Bastian,H.(2014)5keythingstoknowaboutmetaanalysis.ScientificAmericanBlogNetwork.
http://blogs.scientificamerican.com/absolutelymaybe/5keythingstoknowaboutmeta
analysis/
HigginsJPT,GreenS(editors).CochraneHandbookforSystematicReviewsofInterventions
Version5.1.0[updatedMarch2011].TheCochraneCollaboration,2011.Availablefrom
www.cochranehandbook.org
KaufmanJ,SynnotA,RyanR,HillS,HoreyD,WillisN,LinV,RobinsonP.Facetoface
interventionsforinformingoreducatingparentsaboutearlychildhoodvaccination.Cochrane
DatabaseofSystematicReviews2013,Issue5.Art.No.:CD010038.
Russo,K.(2015)ImmunisationUpdateApril2015.NetworkingHealthVictoria.
www.lmmml.org.au/LiteratureRetrieve.aspx?ID=191955 (accessed6/8/15).
RyanR,HillS,PrictorM,McKenzieJ;CochraneConsumersandCommunicationReviewGroup.
StudyQualityGuide.May2013http://cccrg.cochrane.org/authorresources (accessed30/7/15).
Saeterdal I,LewinS,AustvollDahlgrenA,GlentonC,MunabiBabigumiraS.Interventionsaimed
atcommunitiestoinformand/oreducateaboutearlychildhoodvaccination.Cochrane
DatabaseofSystematicReviews2014,Issue11.Art.No.:CD010232.
WHO,UNICEF.(2014)Progresstowardsglobalimmunizationgoals 2013.
http://www.who.int/immunization/monitoring_surveillance/slidesglobalimmunization.pdf
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Thankyou
www.commvac.com
j.kaufman@latrobe.edu.au
latrobe.edu.au/chcp
CRICOSProvider00115M
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