Implementation by ‘leading from the front’ may enhance the success of vaccine drives among healthcare workers: a reanalysis of systematic review evidence to identify key implementation features

BackgroundThe COVID-19 pandemic has brought into sharp focus the need for effective and appropriate vaccination policies for the healthcare workforce. Systematic review evidence shows that interventions to encourage uptake of seasonal influenza vaccination of healthcare workers (HCW) that involve hard mandates, such as loss of employment for non-vaccination, are more effective than soft mandates, such as signing a declination form, or other interventions such as incentives. Resistance to hard vaccine mandates during the COVID has been evident. Moreover, residual ‘substantial heterogeneity’ was observed in the review evidence on flu vaccine drives, indicating that factors other than the vaccination policy itself may influence uptake. Using novel reviewing techniques – Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA) – we re-examine the evidence to identify whether implementation strategies moderate the success of mandates and other interventions.MethodsICA was used to extract authors reflections on what underpinned the success of the intervention they evaluated and information on implementation procedures. Two QCA analyses, informed by the ICA findings, were undertaken. Analysis 1 examined hard mandate studies. Analysis 2 examined soft mandates and other interventions. Each analysis systematically compared more and less successful interventions of that type to identify whether the variation in outcomes observed was associated with implementation features.ResultsICA revealed that authors of the most successful interventions of each type recommended a ‘leading from the front’ (LFF) implementation strategy. Four key components underpinned the collaborative, rather top-down, LFF implementation strategy: strong support from institutional leadership;education prior to implementation;two-way engagement with HCW so they can voice concerns prior to implementation;and previous use of other strategies so that institutions ‘don’t-go-in-cold’ with their approach. QCA revealed that the success of both hard mandates and soft or other mandates were enhanced by a LFF implementation strategy. For hard mandates, either of two configurations were associated with greater success. The first involves strong leadership support, two-way engagement, and a ‘don’t-go-in-cold’ approach. The second involves leadership support, education and a ‘don’t-go-in-cold’ approach. Analysis 2, on soft mandates and other interventions, revealed similar patterns.DiscussionA thoughtful approach to the implementation of flu vaccination drives among HCW, characterised by a ‘leading from the front’ approach, will likely enhance intervention success regardless of the basic intervention strategy. Given the current prevalence of vaccine hesitancy, these findings may be relevant to ongoing public health campaigns regarding COVID-19 and other vaccinations.

'Leading from the front' implementation increases the success of influenza vaccination drives among healthcare workers: a reanalysis of systematic review evidence using Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA).

BACKGROUND: Seasonal influenza vaccination of healthcare workers (HCW) is widely recommended to protect staff and patients. A previous systematic review examined interventions to encourage uptake finding that hard mandates, such as loss of employment for non-vaccination, were more effective than soft mandates, such as signing a declination form, or other interventions such as incentives. Despite these overarching patterns the authors of the review concluded that 'substantial heterogeneity' remained requiring further analysis. This paper reanalyses the evidence using Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA) to examine whether the strategies used to implement interventions explain the residual heterogeneity. METHODS: We used ICA to extract implementation features and trialists' reflections on what underpinned the success of the intervention they evaluated. The ICA findings then informed and structured two QCA analyses to systematically examine associations between implementation features and intervention outcomes. Analysis 1 examined hard mandate studies. Analysis 2 examined soft mandates and other interventions. RESULTS: In Analysis 1 ICA revealed the significance of 'leading from the front' rather than 'top-down' implementation of hard mandates. Four key features underpinned this: providing education prior to implementation; two-way engagement so HCW can voice concerns prior to implementation; previous use of other strategies so that institutions 'don't-go-in-cold' with hard-mandates; and support from institutional leadership. QCA revealed that either of two configurations were associated with greater success of hard mandates. The first involves two-way engagement, leadership support and a 'don't-go-in-cold' approach. The second involves leadership support, education and a 'don't-go-in-cold' approach. Reapplying the 'leading from the front' theory in Analysis 2 revealed similar patterns. CONCLUSIONS: Regardless of intervention type a 'leading from the front' approach to implementation will likely enhance intervention success. While the results pertain to flu vaccination among HCWs, the components identified here may be relevant to public health campaigns regarding COVID-19 vaccination.

Service needs of young people affected by adverse childhood experiences (ACEs): A systematic review of UK qualitative evidence.

BACKGROUND: Adverse Childhood Experiences (ACEs) such as, physical and sexual abuse, neglect, or living in a household with domestic violence or substance misuse, can have negative impacts on mental and physical health across the lifecourse. A deeper understanding of the kinds of services that people affected by ACEs feel they need to overcome these negative impacts is required. REVIEW QUESTION: How do people affected by ACEs between the ages of 3 to 18 experience support and services in the UK? What are their needs relating to services and support? METHODS: Systematic review of qualitative evidence. We harvested relevant studies from existing systematic reviews of qualitative evidence located through a search of 18 databases. Included studies needed to be published in or after 2008, conducted in the UK, and report the views of people exposed to ACEs relating to their service needs. We included studies with participants who were affected by ACEs between 3 and 18 years old with no restriction on the age at which they accessed services. RESULTS: We identified 71 reviews from which we harvested 238 references on title and abstract screening. Following full text screening and quality and relevance appraisal we included 20 studies. Each of the included studies focussed on a specific ACE population. Almost half focused on young people who were fostered, looked-after or leaving care. No studies focussed on parental incarceration or divorce. Young people value emotional and practical support. Service providers were most valued for displaying empathy, being non-judgemental, and being active listeners. Supportive relationships, especially with adults, are a key factor in feeling understood. CONCLUSIONS: People affected by ACEs describe the importance of stability and continuity in the support they receive. These factors are important for allowing necessary time to overcome obstacles and build up trust. Research often frames response to ACE in terms of short term individual psychological outcomes but these findings highlight the importance of focussing on wider social factors to encourage meaningful engagement with services.