Turning Theory into Practice, Childhood Immunisations - Pete Thompson

Turning Theory into Practice, Childhood Immunisations:

February 2011 Turning Theory into Practice, Childhood Immunisations Pete Thompson, Commissioning Support for London

Behaviour change - MMR:

1 Behaviour change - MMR We spend a lot of effort communicating to our customers as if they are purely rational, engaged and carefully weighing up their options. We all live in the real world and know this not to be true but somehow we return to our day jobs and pretend otherwise! Default options should be the right choice for the individual, they are free to opt out, but making the right choice should be very easy so they will ‘automatically’ do the right thing. If we are to change behaviour we need to understand actual v desired in detail – top level / strategic not good enough. To really understand behaviour many possible sources such as operational data, observation, ethnography, customer journey, co-creation…

The problem, low uptake of MMR. The solution?:

2 The problem, low uptake of MMR. The solution?

Advertising banner:

3 Advertising banner

Issues with the campaign:

4 Issues with the campaign The ‘1 in 10’ line did not have much impact on them Confusing Not a particularly big risk Plus, ending up in hospital did not necessarily mean it was serious “You think it ain’t going to happen to mine” “I wouldn’t take much notice of stats. Anybody can make them up” “You interpret them how you want to” “It’s telling you one in 10 with measles ends up in hospital, but it doesn’t tell you the risk of catching measles in the first place” “We go to hospital quite a lot, it’s not that serious”

Health professionals’ views on the barriers to MMR:

5 Health professionals’ views on the barriers to MMR Hints that, for some GP practices, MMR was not a high priority Possibly because of this ‘negative’ incentive Or because they put a higher priority on other campaigns Or because they were also un convinced about the safety of MMR Or because they were resistant to targets “It isn’t a high priority to the GPs, but it is to me….but there are so many other campaigns that are high priority.” (Practice nurse) “You don’t get additional income from MMR if you meet your targets.… to them (the GPs), it’s targets and payment, so there’s no priority being placed on MMR” (Practice nurse) “We had a significant number of health professionals who didn’t have conviction and weren’t promoting MMR as they should have been” (Immunisation lead)

Before we rush to solution…:

6 Before we rush to solution… Preparation Preparation Preparation Define Insight Planning Implementation Review

MMR = a discourse of fear:

MMR = a discourse of fear Emotionally charged metaphors esp. fire, natural disaster and warfare “Unlike most scientific controversies which flare up and die away, however, this one has simmered for a decade - and may now be fired up again by the preliminary verdicts in the GMC case.” ( Independent ) “Wakefield ... published his research ... which unleashed a tsunami of fear about MMR.” (Times) “His research paper ... sent shockwaves across the world of medicine and into the homes of families” (BBC News) “I was there when Wakefield dropped his bombshell ” (Independent) “The Lancet knew it had a potentially explosive paper on its hands.” (Independent) This tendency more pronounced than in average media coverage: reflects the location of MMR across ideological tensions and fault lines

‘The (misguided) middle classes’ vs. ‘the common good’:

‘The (misguided) middle classes’ vs. ‘the common good’ MMR poses a cultural paradox: educated people are rejecting a) science and b) the common good Provokes anxiety and some vicious attacks e.g. Mail Reflected in women's own language – ‘I’m not an evil mother’ ‘…middle-class twits like Joanne pottering around the kitchen brewing up potions‘ (Mail) One correspondent - a highly educated and intelligent woman - asserted that girls have died in the US from the vaccination, and implying that profit-seeking drug companies (with the connivance of governments, presumably) were prepared to kill our kids in order to make money. (Times) [The parents] are middle class and university educated, but they are behaving like morons. (Mail)

3. Parents’ (i.e. mums’) websites:

3. Parents’ (i.e. mums ’) websites Amplified version of the tensions seen in other areas Highly emotional esp. mumsnet.com; MMR a highly contested subject Gendered – one poster ‘accused’ of being male through tone of his/her argument Mums’ own research can be deep and highly specific – they post academic articles for others to read Scathing about NHS ‘party line’ - and brutally to the point: “Measles being dangerous does not make MMR safe” Longing for real information, but within a dialogue – have to look to the peer group for this, but room for DH to take a different approach: I can see why they might not want a measles epidemic, but if tactics so far haven't worked to increase numbers then perhaps they should try another. They have been shouting the MMR is safe line for years, Wakefield's reputation is now destroyed. If people still refuse MMR then maybe they need to look at why and approach the public differently (mumsnet.com post 24 th Feb 2010)

PCT letters: seem unlikely to connect with parents:

10 PCT letters: seem unlikely to connect with parents Obligation prominent; pressurising without recognising where parents start from Cumbersome and stilted; poor grammar, spelling and punctuation could make the sender seem untrustworthy to educated parents In addition : some problems common in public sector comms : Sense of self-absorption and lack of focus on the reader Concerned with own official discourse, not what will make most sense to readers Clash between the private world of the parent and the public sphere of health institutions

Dialogue:

11 Dialogue Must ‘turn down the temperature’ of this discourse There is no point in shouting the same messages louder; we need different conversations Engage in dialogue – properly. Conversations, not ‘messages’ Construct a different relationship between health care providers/the institutions behind them and parents, esp. mothers not parent/child nor a gendered asymmetry of power but an adult-adult, respectful relationship and/or use a more human approach, replacing institutional authority with peer authority .

MMR Customer Journey:

12 MMR Customer Journey

Immunisation schedule – 16 injections:

13 Immunisation schedule – 16 injections AGE Immunisation (Vaccine Given) 2 months DTP/polio/ Hib (diphtheria, tetanus, pertussis (whooping cough), polio, and Haemophilus influenzae type b) - all-in-one injection, plus: PCV (pneumococcal conjugate vaccine) - in a separate injection 3 months DTP/polio/ Hib (2nd dose), plus: MenC (meningitis C) - in a separate injection 4 months DTP/polio/ Hib (3rd dose), plus: MenC (2nd dose) - in a separate injection, plus: PCV (2nd dose) - in a separate injection Around 12 months Hib / MenC (combined as one injection - 4th dose of Hib and 3rd dose of MenC ) Around 13 months MMR (measles, mumps and rubella - combined as one injection), plus: PCV (3rd dose) - in a separate injection Around 3 years and four months 'Pre-school' booster of: DTP/polio (diphtheria, tetanus, pertussis and polio), plus: MMR (second dose) - in a separate injection Around 12-13 years (girls) HPV (human papillomavirus ) - three injections The second injection is given 1-2 months after the first one. The third is given about six months after the first one. Around 13-18 years Td/Polio booster (a combined injection of tetanus, low-dose diphtheria, and polio)

Slide 14:

14 Parents immunisation journey “the first thing they (HCPs) do when the baby is born is stick ‘ em with a needle...they stab ‘ em ...” “literally straight away – they don’t even explain anything” It is not a coherent programme about which they have been forewarned and for which they are prepared. Inflexible timing: appointment or drop in at restricted times Child unfriendly surroundings A rush It can feel brutal – the child is ‘pinned down’ by the parent, their skin is ‘pinched’ and then they’re jabbed.

Slide 15:

15 How could the experience be better ?

Slide 16:

16 HCP Journey “If I could get away without having the parents there it would be great!” PN They make it harder: Children tend to exhibit their worst behaviour in the presence of their parents. “The 4-5 year olds are the worst because they fight and kick.” “You find in K&C that you have a lot of Google mothers and they challenge everything with lots of questions ... but they listen more to the GP than they do to nurses.” “The parents who resist usually know someone who has had a bad experience or they’ve heard something on the grape vine but they don’t tell you this when they come in so it’s really difficult to work with because you don’t really know what the issue is”

MMR choice architecture - whose behaviour do we need to change first?:

17 MMR choice architecture - whose behaviour do we need to change first? Poor data systems make tracking patient records problematic Often no standard process for call / recall – send a letter and hope for the best? Experience of immunisations can act as barrier to uptake All staff are on message aren’t they? We know best – patients who don’t play ball are an annoyance… Because we know best important that we flash clinical credentials to put paid to patients concerns

Best-practice 12-month vaccination journey:

18 Best-practice 12-month vaccination journey Send letter A to parents/carers once child reaches 1 year Parent/carer makes appointment If child does not attend appointment, phone to make follow-up appointment If child does not turn up again pass information to child health & HV If parents still refuse, pass information to child health and document in records If no response after 4 weeks, send letter B Send parent/carer text message to remind them about the appointment Conversation about vaccinations prior to injections – may be over several appointments After injections, nurse records them in child health record & red book If no response after 4 weeks, send letter C If still no response after letters A, B & C phone parents to make an appointment. Refusals If parent /carer doesn’t take up immunisation, practice nurse to promote vaccinations and explore reasons for refusal Letters D, E & F to be used as A, B & C for Second MMR and pre-school booster

Conclusions:

19 Conclusions We are all choice architects! What seems trivial might not be! Define the problem early on and focus effort where you can make a difference, segment customers. Behaviour change often starts with our own staff / but don’t expect this to be easy If we have limited / no budget we can still plot a customer journey and really try and see it from the perspective of different segments of our customers Don’t overestimate peoples level of engagement, your doing it as a job! Don’t be afraid to try new ways of doing things – evaluate and build on.