Letting kids play their CARDs (Comfort, Ask, Relax, Distract) to help cope with needle-related fear and pain: Results from user testing.

This study examined perceptions of children and parents about a new web-based CARD (Comfort, Ask, Relax, Distract) game that teaches children how to cope with needle-related pain and fear. A convenience sample of 15 child-parent dyads (children, 6-12 years) participated. Children played the game on a handheld device while being virtually monitored. Activity tracking revealed most children engaged with multiple components. Children reported they understood the game, it was easy to play, they learned coping strategies and believed they could implement them. Children reported lower fear of needles after playing. Parents liked the simplicity and variety of game activities. Most children and parents reported they would use the game or its coping strategies for future needles and would recommend the game. In summary, children and parents found the CARD web game acceptable and appropriate. Future studies can evaluate its effectiveness when integrated into upcoming needle procedures like COVID-19 vaccinations.

Integration of CARD (Comfort Ask Relax Distract) for COVID-19 community pharmacy vaccination in children: Effect on implementation outcomes.

Introduction: Community pharmacists report that providing vaccinations can be challenging, particularly if the vaccine recipient is a child, because of heightened levels of fear. The objective of this study was to determine acceptability and feasibility of the CARD (Comfort Ask Relax Distract) system as a vaccination delivery framework for children receiving COVID-19 vaccinations in a community pharmacy setting. CARD incorporates evidence-based interventions that reduce fear and immunization stress-related responses in vaccine recipients and was demonstrated to be effective and feasible in other vaccination settings providing vaccinations to children and adults. Methods: This mixed-methods study involved 5 independent pharmacies (with 6 vaccinators) offering COVID-19 vaccinations to children between 5 and 11 years of age. Vaccinating staff and implementation leads from the pharmacy organization participated in a small-scale CARD implementation project (before-and-after design). Afterwards, they filled in quantitative surveys and provided qualitative feedback about their perceptions and experiences in focus group discussions. Qualitative data were analyzed deductively, using the Consolidated Framework for Implementation Research (CFIR). Results: The study was conducted between January 16 and March 20, 2022. Across both quantitative and qualitative measures, vaccinating staff reported positive attitudes about CARD and alignment with their professional roles. They reported that CARD reduced children's fear and improved the vaccination experiences in children and parents and for themselves. Vaccinators reported increased confidence due to CARD. They reported compatibility of CARD interventions within their practice and that it was time neutral. They maintained use of some interventions after the study. They also provided suggestions and shared concerns about fidelity and future feasibility of continuing various components of the program. Conclusion: CARD was demonstrated to be acceptable and feasible by vaccinators performing vaccinations in children in community pharmacies.

Experiences of community pharmacists administering COVID-19 vaccinations: A qualitative study.

Background: Throughout the COVID-19 pandemic, community pharmacists have played an important role in the provision of patient care, including the delivery of COVID-19 vaccines. The additional workload and related demands arising from these extended services might affect worklife burnout. This qualitative study explored the experiences of Canadian community pharmacists in providing COVID-19 vaccines during the COVID-19 pandemic. Methods: Eighteen community pharmacists across 10 provinces were asked about vaccination processes and perceptions about their role in separate, virtual semistructured interviews. Interviews were transcribed verbatim and analyzed using a deductive approach using the Areas of Worklife Burnout framework, with pharmacists' self-reported descriptions of their activities summarized using the Association of Faculties of Pharmacy of Canada's (AFPC) professional competencies framework. Results: Participants identified aspects of their role that were rewarding and challenging. Some challenges included lack of control, increased workload, inadequate communication, unfair treatment and conflicting values. They described being able to meet challenges and demonstrating resiliency via adaptability, developing communities and valuing their contribution to ending the COVID-19 pandemic. Self-identified AFPC competencies contributing to their ability to manage their worklife included care-provider, professional, leader-manager, collaborator and scholar. Conclusion: Pharmacists accepted their additional responsibility of managing COVID-19 vaccines during the COVID-19 pandemic. However, they expressed some challenges with this role. To ensure sustainability of these services, prioritizing adequate resources, work processes and efficient communication with all relevant stakeholder groups, including public health, government and corporate leaders, is recommended for the future. Can Pharm J (Ott) 2023;156(Suppl):xx-xx.

CARD (Comfort Ask Relax Distract) for community pharmacy vaccinations in children: Effect on immunization stress-related responses and satisfaction.

Introduction: CARD (Comfort Ask Relax Distract) is a vaccine delivery program demonstrated to reduce pain, fear and associated immunization stress-related responses (ISRR) in children undergoing vaccinations at school. This study evaluated CARD's clinical impact when integrated into community pharmacy-based pediatric vaccinations. Methods: This was a before-and-after CARD implementation study in 5 independent pharmacies offering COVID-19 vaccinations to children aged 5-11 years. No changes were made to practices in the "before" phase. CARD interventions were integrated in the "after" phase (e.g., children prepared a coping plan using a checklist, distraction toolkits were placed in waiting and vaccination spaces, vaccinations were performed with privacy, needles were obscured). Children self-reported ISRR, including fear, pain and dizziness during vaccination, and both children and parents/caregivers (herein, parents) compared the child's experience to their last needle (better, same, worse). In the "after" phase, parents and children reported how much CARD helped (not at all, a little bit, a moderate amount, a lot). Results: The study was conducted between January 16 and March 20, 2022. Altogether, 152 children participated (71 before and 81 after CARD); demographic characteristics did not differ. Children's self-reported fear was lower after CARD, when assessed continuously (2.5 vs 3.7 out of 10; p = 0.02) or dichotomously, using a cut-off of 0 vs >0 (58% vs 80%; p = 0.01). Pain was lower when assessed dichotomously (<2 vs ≥2; p = 0.03). There was no difference in dizziness. After CARD, children and parents reported more positive experiences compared to the child's last needle (p = 0.01, both analyses) and more children and parents reported that distraction and child participation in the process were helpful (p < 0.001, both analyses). Overall, 92% of children and 91% of parents said CARD helped. Conclusion: CARD reduced children's fear and improved vaccination experiences for children and parents when integrated in community pharmacy-based vaccinations.

Community pharmacists' perceptions of the CARD (Comfort Ask Relax Distract) system for use during vaccinations.

Introduction: We explored Canadian community pharmacists' perceptions of the CARD (Comfort Ask Relax Distract) system, a vaccine delivery framework that integrates evidence-based interventions that reduce immunization stress-related responses (ISRRs). The objective was to introduce CARD to pharmacists and obtain their feedback to guide future implementation efforts for community pharmacy-based vaccinations. Methods: Eighteen pharmacists across all provinces participated in one-on-one moderated virtual interviews. A semistructured interview guide was used to guide the discussion and included questions about experiences with coronavirus disease 2019 (COVID-19) vaccine administration and perceptions of CARD as a framework for vaccination delivery in the pharmacy. In this report, we focus on feedback about CARD. Interviews were audio-recorded and transcribed verbatim and deductively coded using the Consolidated Framework for Implementation Research (CFIR). Results: The study was conducted from May 28 to August 16, 2021. Pharmacists' responses were categorized in 3 CFIR domains: intervention characteristics, inner setting and characteristics of individuals. Overall, pharmacists were receptive towards CARD and thought it filled a current gap in practice, particularly for childhood vaccinations. Pharmacists reported learning techniques to make vaccinations more comfortable for their clients. They provided feedback on how specific interventions could be adapted for their practice (e.g., dissemination of client-directed education via appointment booking portals, provision of distraction items in waiting and vaccinating spaces). Discussion: This study provided preliminary evidence that pharmacists found CARD acceptable and appropriate for community pharmacy-based vaccinations. The data collected from this study were used to inform a small-scale implementation project with CARD during COVID-19 vaccine administration in children aged 5 to 11 years.

COVID-19 Vaccination Delivery in Long-Term-Care using the CARD (Comfort Ask Relax Distract) System: Mixed Methods study of Implementation Drivers.

Objectives: CARD (comfort, ask, relax, distract) is a vaccine delivery framework that includes interventions to improve the patient's experience. CARD has not been previously implemented in long-term care (LTC) settings. This study evaluated drivers to implementation for COVID-19 vaccinations in an LTC facility. Methods: Postimplementation interpretive evaluation including qualitative interviews and quantitative surveys with eight participants. The Consolidated Framework for Implementation Research (CFIR) was used for analysis. Adverse reactions to vaccinations and CARD interventions, including local reactogenicity and systemic reactions, were abstracted from medical charts of residents. Results: Eight CFIR constructs emerged. Staff perceived CARD was complex because it added steps to vaccination delivery. Motivated to meet residents' needs, a receptive implementation climate of support among staff led to using strategies within CARD, such as administering topical anesthetics and omitting alcohol skin antisepsis prior to injections. Having an effective network like the residents council positively influenced implementation by allowing residents to voice their opinions. Facilitators to implementation included staff knowledge and beliefs and staff's commitment to their organization, which was focused on person-centered care. Barriers included lack of available resources (inadequate staffing), insufficient communication between management and staff and lack of awareness of CARD, and external policies not aligned with CARD. Chart reviews conducted for 93 vaccinated residents corroborated perceptions of vaccination and CARD intervention safety, revealing a low rate of local and systemic adverse reactions and no cases of skin infection. Discussion: We identified positive and negative implementation drivers. Future research is recommended to expand the strategies employed and involve residents more directly.

Objectifs: Le système CARD (confort, aide, relaxation, distraction) est un cadre d'administration de vaccins qui comprend des interventions pour amèliorer l'expérience du patient. Le système CARD n'a pas été mis en œuvre précédemment dans les établissements de soins de longue durée. Cette étude a évalué les facteurs de sa mise en œuvre pour la vaccination contre la COVID-19 dans un établissement de soins de longue durée.Méthodes: Évaluation interprétative après la mise en œuvre, y compris des entretiens qualitatifs et des enquêtes quantitatives auprès de huit participants. Le Cadre consolidé pour la recherche sur la mise en œuvre (CFIR) a été utilisé pour l'analyse. Les effets indésirables à la vaccination et aux interventions CARD, y compris la réactogénicité locale et les réactions systémiques, ont été extraites des dossiers médicaux des résidentsRésultats: Huit construits du CFIR ont émergé. Le personnel a perçu que le système CARD était complexe car il ajoutait des étapes à la vaccination. Motivé à répondre aux besoins des résidents, un climat de mise en œuvre réceptif suscitant le soutien du personnel a conduit à l'utilisation de stratégies propres au système CARD, telles que l'administration d'anesthésiques topiques et l'omission de l'antisepsie cutanée à l'alcool avant les injections. Le fait d'avoir un réseau efficace comme le conseil des résidents a influencé positivement la mise en œuvre en permettant à ces derniers d'exprimer leurs opinions. Les facilitateurs de la mise en œuvre comprenaient les connaissances et les croyances du personnel et l'engagement de celui-ci envers l'organisation, qui mettait l'accent sur les soins centrés sur la personne. Les obstacles comprenaient le manque de disponibilité des ressources (effectifs insuffisants), l'insuffisance de la communication entre la direction et le personnel et le manque de connaissances au sujet de CARD, de même que les politiques externes non alignées avec le système CARD. Un examen des dossiers effectué pour 93 résidents vaccinés a corroboré les perceptions de la sécurité de la vaccination et de l'intervention CARD tout en révélant un faible taux d'effets indésirables locaux et systémiques et aucun cas d'infection cutanée.Discussion: Nous avons identifié des facteurs de mise en œuvre positifs et négatifs. Des recherches futures sont recommandées pour élargir les stratégies utilisées et impliquer plus directement les résidents.

Integrating the CARD (Comfort Ask Relax Distract) system in a mass vaccination clinic to improve the experience of individuals during COVID-19 vaccination: a pre-post implementation study.

Many people have negative experiences with vaccination due to stress-related reactions including fear and pain. We used a pre-post study design to evaluate the impact of implementing a modified version of the CARD (Comfort-Ask-Relax-Distract) system on stress-related reactions in individuals aged 12 y or older undergoing COVID-19 vaccinations in mass vaccination clinics. Vaccine recipients reported their level of pain, fear and dizziness during vaccination. Clinic staff reported their attitudes about CARD and use of CARD interventions. CARD improved client symptoms across genders and ages with an average reduction in needle pain, fear and dizziness of 75%, 40% and 44%, respectively. CARD was more effective in younger individuals. Clinic staff reported positive attitudes about CARD and uptake of selected CARD interventions. In summary, the modified CARD system reduced stress-related responses in a general population undergoing COVID-19 vaccinations in a mass vaccination clinic, was feasible and acceptable to staff. Future implementation efforts are recommended that include more diverse cultural contexts and incorporate education of individuals about CARD ahead of time.

Impact of the CARD (Comfort Ask Relax Distract) system on school-based vaccinations: A cluster randomized trial.

BACKGROUND: The CARD (Comfort Ask Relax Distract) system is a vaccine delivery framework that integrates evidence-based interventions to reduce stress-related responses and improve the vaccination experience for children undergoing vaccinations at school. In preliminary studies, CARD was acceptable and effective. The objective was to evaluate CARD in a large, pragmatic trial to confirm its effectiveness in real-world settings. METHODS: Hybrid effectiveness-implementation cluster randomized trial in schools receiving vaccination services from Wellington-Dufferin-Guelph Public Health. Forty schools with grade 7 students (12 years old) were randomized to CARD and control (n = 20/group). Nurses in CARD schools planned clinics with principals and educated students about CARD ahead of time. Principals disseminated information to staff and parents and sent reminders. Vaccination day processes minimized fear and facilitated student self-selected coping strategies. Nurses in control schools followed usual practices, which excluded principal meetings, education, reminders, and systematic integration of fear-reducing or child-selected coping strategies. Outcomes included stress-related symptoms (fear - primary outcome, pain, dizziness, fainting, post-vaccination reactions), use of coping interventions, vaccination uptake, attitudes and implementation outcomes (acceptability, appropriateness, feasibility, fidelity). RESULTS: Altogether, 1919 students were included. Fear and pain were lower in CARD schools: OR 0.65 (95% CI 0.47-0.90) and OR 0.62 (95% CI 0.50-0.77), respectively. No students fainted in CARD schools compared to 0.8% in control (p = 0.02). Dizziness and post-vaccination reactions did not differ. Student-led coping interventions were used more frequently in CARD schools. Vaccination uptake was 76.1% in CARD schools and 72.5% in control schools (OR 1.13 (95% CI 0.85-1.50)). Staff and students had positive attitudes about CARD and implementation outcomes; however, recommendations were made to improve fidelity. DISCUSSION: CARD reduced stress-related responses in students undergoing vaccinations at school and was positively received by students and public health staff. CARD is recommended to improve the quality of vaccination delivery services. TRIAL REGISTRATION: NCT03966300.