Over three decades of research has led to the discovery of numerous evidence-based and feasible treatments for the management of pain during childhood vaccine injections [7
]. Despite this evidence, few children are benefitting from this scientific knowledge [10
]. The practice of performing vaccine injections in children without analgesia is associated with significant harms, including the development of life-long needle fears and immunization non-compliance [3
]. As part of the first step in addressing this important knowledge-to-care gap, we developed a CPG and educational tools for parents to present research knowledge in a clear, concise, and user-friendly format. [12
] According to the Knowledge-to-Action Framework [11
], the development of high-quality educational tools as an intervention to promote the adoption of the CPG requires the inclusion of research evidence as well as customization of the evidence to the local context through an iterative process of obtaining feedback from potential users and modifying the tools according to the emerging needs of end-users. In this study, we adapted the educational tools to the needs of new parents and evaluated the usability of the tools and the uptake of knowledge as a result of the tools.
The results demonstrated that parents have a keen interest in learning about pain-relieving interventions for infant vaccinations. They identified a variety of methods of dissemination of this education to better reach new parents, including; parent classes, birthing hospitals, doctor’s offices, and the internet. In addition, they expressed a preference to have access to both the pamphlet and video because they viewed them as complimentary. With respect to the content of the tools, parents reported that they understood the information and it met their needs in terms of breadth and depth. Furthermore, parents reported that they intended to use the information in the pamphlet and video for their infant’s vaccine injections.
These findings are consistent with previous studies demonstrating that parents are concerned about a child’s pain during vaccinations [20
] and that they have a strong desire to mitigate vaccination pain [10
]. Therefore, the current practice of under-treating pain during routine childhood vaccinations cannot be attributed to parent apathy about pain. The major barrier to routine pain management, as identified by parents themselves, is a lack of knowledge about evidence-based interventions [10
In addition, significant improvement in parent knowledge about pain management strategies and in confidence level in knowledge occurred after exposure to the educational tools. Parents were largely uncertain about evidence-based pain management options prior to reviewing the educational tools. There was an increase of 250% in the number of responses to the knowledge test that were both correct and whereby parents were completely sure, with significant increases occurring between the baseline and post-pamphlet phases and also between the post-pamphlet and post-video phases. Importantly, evaluation of parent knowledge uptake considered not only correct responses but also level of certainty in responses, as individuals would not be expected to act on their knowledge unless they are confident in it.
We directed the educational tools to new parents because they are the primary stakeholders involved in childhood vaccination and because education is routinely provided to parents around the time of delivery of an infant, thus opportunity exists to incorporate education about vaccine injection pain management within current hospital education programs provided to families of newborn infants. In addition, teaching new parents about pain is the most efficient method of ensuring that children will receive consistent pain management over time and across all medical settings and for all medical procedures encountered, which is key to creating an environment that promotes healthy child development (i.e., is free from harm). A growing body of literature demonstrates the effectiveness of parent training interventions for developing skills necessary to promote optimal infant and child development, including emotional, social and cognitive development [21
The feedback from stakeholders at our HELPinKIDS’ meetings, including parents, clinicians, and policy makers, suggested: 1) a multi-modal approach for parent education, and 2) the use of flexible and portable education formats. Specifically, written information supplemented with pictures and a video with vignettes of children undergoing vaccination with the pain-relieving interventions promoted by the CPG was deemed as vital components of an effective teaching intervention. To this end, a pamphlet and video were developed to promote the adoption of the CPG. These tools allow for a multitude of education formats, including; self-administered, group-based or individually-administered [23
]. The results from our previous qualitative and quantitative studies conducted in the same setting and population informed decisions regarding the content and presentation of the educational tools [10
], that is, they were derived from the learning needs identified by new parents in this setting. The findings of the present study verify that both tools together are optimal to parent training because: 1) parents expressed a preference to have access to both tools, and 2) uptake of knowledge was greater when both tools were used together. It is important to note that both the pamphlet and video focussed on actions parents can undertake to reduce pain during their infants’ vaccine injections and that parents reported that they intended to implement the knowledge at future vaccine injections.
We observed that some knowledge test questions were frequently answered incorrectly by parents, even after review of the pamphlet and video. These questions related to the effectiveness of oral analgesics, rubbing the skin (i.e., tactile stimulation), applying ice, and bottle-feeding. Since information about these interventions was not prominent and in some cases was not even included in either the pamphlet or video, there was no expectation that parents would score perfectly. A priori, a decision was made to emphasize effective rather than ineffective or unproven pain management strategies and to include questions about ineffective strategies to reduce responder bias.
Although we targeted parents, clinicians constitute important knowledge transfer targets for vaccine injection pain management. Prior research by our group demonstrates that parents seek endorsement by health care providers for pain management strategies [10
]. This notion was confirmed in two ways in the present study. Firstly, parents reported they planned to consult their doctor about the information before using it. Secondly, parents indicated that the pamphlet and video should be available in their doctor’s office. Efforts to improve current pain management practices must therefore also include clinicians to support and facilitate parent efforts to mitigate their child(ren)’s pain. We are currently conducting parallel studies of clinician-directed educational tools in different practice settings in order to ensure that their needs are being met.
Although we demonstrated interest and knowledge acquisition from our educational materials in our study sample, the immediate post-partum period may not be the optimal time for learning about this information because it will not be acted upon by parents until two months later, the age of initiation of an infant’s primary immunization series in many geographical regions. There is also the possibility that some parents may feel fatigued or overwhelmed by the birth of their infant and added responsibilities, and therefore not receptive to learning about this information. In both cases, however, having the information or knowing about how/where to access the information in the future (e.g., internet) may be sufficient as parents can self-administer the education when they are ready to learn.
Strengths of the study include the setting and design. First, the study setting, MSH, afforded us with the opportunity to recruit parents from a large catchment area as it draws patients from the most populated metropolitan area in Canada (over 5.7 million inhabitants). This facilitated inclusion of parents with diverse cultural and ethnic backgrounds, perspectives and practices. In addition, there was ample time for parents to participate in the study since they typically stay in hospital for over 24 hours after the delivery of an infant. The timing of information was synchronized with other educational programs offered to new parents, and takes advantage of their information-seeking needs and motivation for learning. Finally, both parents were included, rather than mothers alone.
Second, the study design included an in-depth exploration of the usability of the educational tools and objective measures of knowledge uptake derived from them. The qualitative component included robust usability testing process, which consisted of a heuristic evaluation and interviews with end-users (i.e., parents) to validate and improve the material based on usability principles. The involvement of the end-users (i.e., parents) in this process improves the probability that it will lead to subsequent changes in behavior [11
]. The quantitative component included evaluation of parent knowledge about effective pain-relieving interventions. Demonstrating knowledge acquisition ensures that the educational tools are sufficiently effective for diffusion of knowledge in the relevant user group [11