Put the below in your own words into 1-2 paragraphs for the main conclusion and 1-2 paragraphs for the clinical application.

Put the below in your own words into 1-2 paragraphs for the main conclusion and 1-2 paragraphs for the clinical application

Main conclusion:

The following is one example of a main conclusion and clinical applicability to assist you in formulating your take home message for the dissemination assignment. The details in these descriptions are intentionally detailed for your consideration. Do not include this level of detail in the dissemination assignment.

HPV study:

The Healthy People 2020 HPV vaccination goal of 80% of all United States adolescents[KG1] is not being met with current practices (citation). With insufficient vaccination, reduction in HPV-related disease and cancers will not be optimized (citation). A clinical practice guideline and two research articles were appraised to evaluate the effectiveness of strategies to improve HPV vaccination. Among these, the evidence is insufficient and rates weak to moderate in its quality (citation 1; citation 2; citation 3, appraisal tool 1, appraisal tool 2, appraisal tool 3).

Using criteria from the AGREE II guideline appraisal tool, the clinical practice guideline rated low to moderate in quality (citation 1; citation 2). This guideline failed to rate the supplemental evidence using the GRADE criteria, included many studies funded by vaccine manufacturers as well as potential conflicts of interest among the authors, and did not present specific strategies to increase vaccine[KG2] [KG3] uptake. The guideline questions, methods and search strategies were strong.

The moderately-rated randomized controlled trial studied the use of digital information to improve HPV vaccination rates. It had a strong cluster randomized design with blinding of participants, but suffered from serious methodological concerns (citation 1, citation 2). Due to logistical barriers, only 25% of eligible patients were given the intervention. Out of 1596 participants, only 141 received the enhanced education. However, among these, vaccine uptake improved by three times compared with the control group. Additionally, the potential for bias and over inflation of the effect size could have occurred via several avenues: selection bias by the medical assistants, researcher bias by knowing which patients received the intervention, and[KG4] conflicts of interest including researcher affiliation with vaccine and technology manufacturers.

The third article rated strong, a qualitative study that aimed to elicit understanding of the reasons mothers accepted or denied HPV vaccination for their adolescent children (citation 1, citation 2). Strengths included strong theoretical constructs, ample participant quotations imparting a felt message of each of the qualitative themes, and robust methods, analysis, and results. Weaknesses included questionable saturation of themes, lack of reporting of the influence of the researcher on the researcher, and omission of a specific qualitative method and philosophy. The results imply that clinicians may be able to increase HPV vaccination[KG5] [KG6] rates through addressing knowledge deficits, creating urgency, and reducing missed opportunities and logistical barriers. Qualitative research rates low on the hierarchy of evidence, as it does not study interventions, but offers useful guidance in understanding participant perspectives, which could guide targeted conversations that could improve clinical outcomes (citation).

In summary, this limited collection of evidence is not strong enough to support implementing the results into clinical practice without an exhaustive review of strategies to improve HPV vaccine rates among diverse populations and settings. Intuitively, it is[KG7] likely the evidence will support targeted education efforts with clinician encouragement, as well as addressing caregiver barriers to improve HPV vaccination.

Clinical Application (Example 1)

The advanced[KG8] -practice nurse has been charged with a quality improvement project to reach the Healthy People 2020 goal of 80% HPV vaccination for children (citation) at the clinic. Although the limited evidence from the literature appraisal and synthesis is not sufficient to implement a wide-scale intervention project, the APRN has received support to continue with the necessary steps to implement an evidence-based project to increase vaccine uptake. The APRN has shared the results that limited and imperfect evidence[KG9] supports HPV vaccine uptake. This evidence includes targeted educational interventions, increased clinician support

and sense of urgency, working through caregiver barriers, and reducing missed opportunities (citation 1, 2, 3).

Before implementation of a particular strategy, the APRN will complete an exhaustive review of the evidence on strategies to improve vaccine uptake. The APRN is intrigued by the results from a randomized controlled trial showing digital education substantially increased[KG10] HPV vaccination and would like to implement this strategy in the clinic. The APRN submitted a proposal and received a substantial grant to purchase multi-purpose electronic tablets that will contain a variety of evidence-based interactive and educational products, including HPV vaccination. The grant included a pre-intervention phase to resolve barriers that emerged from the literature including logistical, cultural, moral and/or religious, and cost (citation 1, 2, 3). Specific interventions for caregivers who are reluctant to vaccinate will be addressed. With implementation, caregivers and their children will be offered opportunities to express the support or concerns about vaccination within a shared-decision making model, in an environment of respect, using open-ended questions (citation). Results will be measured, and ongoing plans to improve and sustain the project goals, as well as disseminate the results will occur (citation[KG11] [KG12] ).

Example 2:

The limited body of evidence suggests that counseling on the importance[KG13] of starting an HPV vaccination series for adolescent males who are not sexually active is essential. Through the use of technology to shift family attitudes toward the HPV vaccine as well as identifying health behavior intention and action trends, the clinician could significantly increase[KG14] HPV vaccination uptake, thereby decreasing HPV-related illnesses and cancer (citation 1, citation 2). If the parent was experiencing high decisional conflict, the identification of specific health intention and behavior beliefs through discussion may aid in positive health behavior action being taken through implementation of individualized educational interventions (citation). Essentially, this would enable the clinician to better equip oneself with tools and technology that would more adequately address specific thinking and behavioral patterns related to vaccination (citation). The plan of care needs to be individualized with consideration of familial[KG15] values and beliefs especially regarding the sensitive subject of adolescence and sexual activity (citation).

Although each family is allowed the right to self-determination regarding health decisions and choices, it is essential that an informed education is provided through various pathways for individual understanding to be achieved (citation). Starting an open conversation with the patient and family would allow for shared decision making to occur while allowing for the clinician to educate appropriately given the current evidence. An ongoing literature review will assure[KG16] that the best and most complete evidence base will continue to inform and structure future care (Citation).

[KG1]Brief introduction grounds the reader and outlines the purpose. Citations include statistical support, the three articles, and the three appraisal tools.

[KG2]These are only a few of the strengths and weaknesses from the AGREE II tool. You may find others are more important. The writer relates the guideline back to the topic (vaccine uptake strategies), not irrelevant information that does not apply to the PICO or the clinical scenario. The citations are the AGREE II tool and the guideline. The consensus is that this guideline was poorly constructed, and did not find it had much to offer in answering the PICO.

[KG3]

[KG4]You may have a different takeaway from this article. It is important to note some of the most important strengths and weaknesses. The consensus is that this article rated moderate. Some of you thought it was poorly constructed and would not use it to inform care. That is ok, provided you support those views using appraisal concepts.

[KG5]Most of you agreed on the appraisal points from this article. The main area of difficulty was deciding how to use the results to guide care – that seems to be the hardest part of implementing qualitative research.

[KG6]

[KG7]Summary statement wraps up the main conclusion.

Always important to state more literature review is needed (NOT necessarily more research – we don’t know at this point until an exhaustive review is complete).

[KG8]This example takes a system-wide approach to solving the clinical problem, and it works very well.

[KG9]There is no discussion of the studies or the results, or the appraisal points in this section

But the key takeaways are included in the plan.

[KG10]The project includes the steps of EBP but sticks to a succinct application for this project without going into a lot of detail.

[KG11]

[KG12]

[KG13]This example pertains to the case scenario, and it also works very well. Note there is “limited” evidence

[KG14]Nice integration of the CPG, the RCT, and the qual. Study here.

[KG15]ARPN philosophy of respect, individualism, and holistic principles are appreciated

[KG16]More incorporation of the qual. Study.