A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care

Analysis of the impact of COVID-19 pandemic and response on routine childhood vaccination coverage and equity in Northern Nigeria: a mixed methods study

BACKGROUND

Based on 2021 data, Nigeria had the second largest number of zero-dose children globally estimated at over 2.25 million, concentrated in the northern part of the country due to factors some of which are sociocultural. This study analysed the impact of the COVID-19 pandemic and response on childhood vaccination in Northern Nigeria.

METHODS

Using a mixed methods sequential study design in the most populous northern states of Kaduna and Kano, quantitative routine immunisation data for the period 2018-2021 and qualitative data collected through 16 focus group discussions and 40 key informant interviews were used. An adaptation of the socioecological model was used as a conceptual framework. Mean vaccination coverages and test of statistical difference in childhood vaccination data were computed. Qualitative data were coded and analysed thematically.

RESULTS

Mean Penta 1 coverage declined in Kaduna from 69.88% (SD=21.02) in 2018 to 59.54% (SD=19.14%) by 2021, contrasting with Kano where mean Penta 1 coverage increased from 51.87% (SD=12.61) to 56.32% (SD=17.62%) over the same period. Outreaches and vaccination in urban areas declined for Kaduna state by 10% over the pandemic period in contrast to Kano state where it showed a marginal increase. The two states combined had an estimated 25% of the country's zero-dose burden in 2021. Lockdowns, lack of transport and no outreaches which varied across the states were some of the factors mentioned by participants to have negatively impacted childhood vaccination. Special vaccination outreaches were among the recommendations for ensuring continued vaccination through a future pandemic.

CONCLUSION

While further interrogating the accuracy of denominator estimates for the urban population, incorporating findings into pandemic preparedness and response will ensure uninterrupted childhood vaccination during emergencies. Addressing the identified issues will be critical to achieving and sustaining universal childhood vaccination in Nigeria.

Community Health Workers in Early Childhood Well-Child Care for Medicaid-Insured Children: A Randomized Clinical Trial

Importance

An intervention model (the Parent-focused Redesign for Encounters, Newborns to Toddlers; the PARENT intervention) for well-child care that integrates a community health worker into preventive care services may enhance early childhood well-child care.

Objective

To examine the effectiveness of the PARENT intervention vs usual care for parents with children younger than 2 years of age.

Design, Setting, and Participants

A cluster randomized clinical trial was conducted between March 2019 and July 2022. Of the 1283 parents with a child younger than 2 years of age presenting for a well-child visit at 1 of the 10 clinic sites (2 federally qualified health centers in California and Washington) approached for trial participation, 937 were enrolled.

Intervention

Five clinics implemented the PARENT intervention, which is a team-based approach to care that uses a community health worker in the role of a coach (ie, health educator) as part of the well-child care team to provide comprehensive preventive services, and 5 clinics provided usual care.

Main Outcomes and Measures

There were 2 primary outcomes: score for parent-reported receipt of recommended anticipatory guidance during well-child visits (score range, 0-100) and emergency department (ED) use (proportion with ≥2 ED visits). The secondary outcomes included psychosocial screening, developmental screening, health care use, and parent-reported experiences of care.

Results

Of the 937 parents who were enrolled, 914 remained eligible to participate (n = 438 in the intervention group and n = 476 in the usual care group; 95% were mothers, 73% reported Latino ethnicity, and 63% reported an annual income <$30 000). The majority (855/914; 94%) of the children (mean age, 4.4 months at parental enrollment) were insured by Medicaid. Of the 914 parents who remained eligible and enrolled, 785 (86%) completed the 12-month follow-up interview. Parents of children treated at the intervention clinics (n = 375) reported receiving more anticipatory guidance than the parents of children treated at the usual care clinics (n = 407) (mean score, 73.9 [SD, 23.4] vs 63.3 [SD, 27.8], respectively; adjusted absolute difference, 11.01 [95% CI, 6.44 to 15.59]). There was no difference in ED use (proportion with ≥2 ED visits) between the intervention group (n = 376) and the usual care group (n = 407) (37.2% vs 36.1%, respectively; adjusted absolute difference, 1.2% [95% CI, -5.5% to 8.0%]). The effects of the intervention on the secondary outcomes included a higher amount of psychosocial assessments performed, a greater number of parents who had developmental or behavioral concerns elicited and addressed, increased attendance at well-child visits, and greater parental experiences with the care received (helpfulness of care).

Conclusions and Relevance

The intervention resulted in improvements in the receipt of preventive care services vs usual care for children insured by Medicaid by incorporating community health workers in a team-based approach to early childhood well-child care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03797898.

Clinic-Based Financial Coaching and Missed Pediatric Preventive Care: A Randomized Trial

OBJECTIVES

Poverty is a common root cause of poor health and disrupts medical care. Clinically embedded antipoverty programs that address financial stressors may prevent missed visits and improve show rates. This pilot study evaluated the impact of clinic-based financial coaching on adherence to recommended preventive care pediatric visits and vaccinations in the first 6 months of life.

METHODS

In this community-partnered randomized controlled trial comparing clinic-based financial coaching to usual care among low-income parent-infant dyads attending pediatric preventive care visits, we examined the impact of the longitudinal financial intervention delivered by trained coaches addressing parent-identified, strengths-based financial goals (employment, savings, public benefits enrollment, etc.). We also examined social needs screening and resource referral on rates of missed preventive care pediatric visits and vaccinations through the 6-month well-child visit.

RESULTS

Eighty-one parent-infant dyads were randomized (35 intervention, 46 control); nearly all parents were mothers and more than one-half were Latina. The rate of missed visits among those randomized to clinic-based financial coaching was half that of controls (0.46 vs 1.07 missed of 4 recommended visits; mean difference, 0.61 visits missed; P = .01). Intervention participants were more likely to have up-to-date immunizations each visit (relative risk, 1.26; P = .01) with fewer missed vaccinations by the end of the 6-month preventive care visit period (2.52 vs 3.8 missed vaccinations; P = .002).

CONCLUSIONS

In this pilot randomized trial, a medical-financial partnership embedding financial coaching within pediatric primary care improved low-income families' adherence to recommended visits and vaccinations. Clinic-based financial coaching may improve care continuity and quality in the medical home.

Systematic review on reducing missed opportunities for vaccinations in Latin America

Objectives

To estimate the prevalence of missed opportunities for vaccination (MOV) in Latin America and the effect of interventions targeting health systems, health workers, patients, and communities on MOV.

Methods

Searches were conducted in MEDLINE, EMBASE, CINAHL, and LILACS electronic databases and relevant organizations were contacted, including the Pan American Health Organization (PAHO), to identify studies meeting eligibility criteria. A pair of reviewers identified 27 randomized and non-randomized studies quantifying the effectiveness of any intervention for reducing MOV and 5 studies assessing the rate of MOV in Latin America. Results are reported narratively when criteria to pool results were not met, and the certainty of this evidence was assessed using the GRADE approach.

Results

Evidence suggests the rate of MOV in Latin America ranged from 5% to 37% with a pooled estimate of 17% (95% CI [9, 32]) (low certainty) and that monetary incentives to healthcare teams, training for healthcare teams on how to communicate with patients, and educational interventions for caregivers probably reduce MOV (moderate to very low certainty).

Conclusions

There is insufficient evidence supporting the implementation of any intervention as policy based only on the potential reduction of MOV without considering several factors, including costs, feasibility, acceptability, and equity.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Evaluating the vaccination coverage: validity of household-hold vaccination booklet and caregiver's recall

BACKGROUND

We compared results from household data sources to medical record sources by using data from a vaccination coverage survey.

METHODS

Vaccination coverage (VC) was calculated based on parental recall, household vaccination booklet, and Zhejiang provincial immunization information system (ZJIIS). We evaluated the accuracy of VC based on household sources (vaccination booklet and recall) assuming the medical record was accurate. Concordance, sensitivity, specificity, positive predictive value, and negative predictive value were estimated as well as the Kappa statistic was also used to evaluate the agreement between data sources.

RESULTS

Among the 1,800 children identified in the household survey, all were registered in ZJIIS. VC estimated using the vaccination booklet alone was substantially lower than that based on medical records (net bias 3.4-16.7% in different age groups). VC based on parental recall ranged from 2.5% below (among children aged 1 year) to 16.7% points above (among children aged 6 years) than those based on medical records. Concordance was lowest for card estimates (32.5-45.5%). Sensitivity was <60% for all household sources, except for recall source. Specificity was lowest for recall estimates (14.5-42.6%). Positive predictive value was >75%, while negative predictive value was <50%, for all household sources. Kappa statistics generally indicated poor agreement between household and medical record sources.

CONCLUSIONS

Household-retained vaccination booklets and parental recall were insufficient sources for evaluating the VC. Our findings emphasized the importance of taking interventions to make the vaccination booklet more consistent with the records from medical resource.

The Contribution of Reminder-Recall to Vaccine Delivery Efforts: A Narrative Review

Reminders, alerting patients to the need for vaccines that will be due in the future, and recall messages, informing patients about vaccines that are overdue, have been shown to improve immunization rates for children and adolescents in numerous systematic reviews. Therefore, reminder and recall interventions (R/R) are recommended by the Task Force on Community Preventive Services for increasing immunization rates on the basis of strong evidence. R/R messages can be delivered by mail (letter or postcard), via personal or auto-dialer phone calls, by text or e-mail or via patient-portals and can simply be alerts to action or can include educational material with the aim of motivating patients to seek vaccination. R/R has also been shown to be a relatively low-cost intervention with high cost-effectiveness compared with other recommended strategies. However, although R/R as a strategy is consistently effective and cost-effective overall, there is wide variation in the impact of R/R by 1) modality of how it is delivered, 2) the targeted vaccine, 3) the age group, and 4) whether the R/R is conducted centrally by a health system or Immunization Information System or by individual practices. This narrative review summarizes the literature about effectiveness of R/R within each of these categories. We also discuss limitations of R/R, with a focus on the potential impact of parental vaccine hesitancy in blunting its effectiveness and problems with data integrity, on which R/R relies. We also discuss challenges to sustaining R/R efforts, including potential methods of funding for R/R efforts.

Effective interventions to increase routine childhood immunization coverage in low socioeconomic status communities in developed countries: A systematic review and critical appraisal of peer-reviewed literature

OBJECTIVES

Childhood immunization coverage rates are known to be disproportionate according to population's socioeconomic status (SES). This systematic review examined and appraised quality of interventions deemed effective to increase routine childhood immunization uptake in low SES populations in developed countries.

METHODS

A literature search was conducted using Medline, Embase, CINAHL, EBMR, PsycInfo, PubMed, and Health STAR. We systematically searched and critically appraised articles published between January 1990 and December 2019 using the Effective Public Health Practice Project Quality Assessment tool. This systematic review provides a synthesis of the available evidence for childhood immunization interventions deemed effective for low SES parents or families of children ≤ 5 years of age.

SYNTHESIS

The search yielded 3317 records, of which 2975 studies met the inclusion criteria. From the 100 relevant studies, a total of 40 were included. The majority of effective and strongly rated studies synthesized consisted of multi-component interventions. Such interventions addressed access, community-based mobilization, outreach, appointment reminders, education, clinical tracking and incentives, and were language and health literacy appropriate to support low SES parents. Improving access to low SES parents was deemed effective in the vast majority of strongly rated studies. Incorrect contact information of low SES parents due to increased social mobility (i.e. household moves) rendered reminders ineffective, and therefore, updating contact information should be pursued proactively by front-line healthcare providers. In addition, plain language communication with low SES parents regarding immunization was deemed effective in improving immunization uptake.

CONCLUSION

Comprehensive multi-component interventions including improved access, appointment reminders, education and precision health communication are effective for addressing health inequities in immunization coverage amongst marginalized populations. Most low SES parents still believe that the benefits of immunization outweigh the risks.

Assessing vaccination coverage, timeliness, and its temporal variations among children in a rural area in China

China has achieved high vaccination coverage under the Expanded Program on Immunization (EPI) in children 1-2 years of age. However, a knowledge gap exists regarding vaccination coverage and timeliness for children >2 years of age. As such, this study aimed to estimate coverage and timeliness for all EPI and selected non-EPI vaccines within a rural area of China. Immunization data for 5091 children, born between September 2003 and November 2015, were collected from vaccination cards obtained during sero-surveillance follow-up visits and/or from the Hunan immunization information system. For each dose of both EPI and non-EPI vaccines, vaccination coverage and timeliness were calculated, and temporal variations were examined across birth cohorts. We found coverage for EPI vaccines scheduled for <12 months was 97.1%-99.4%. However, for EPI vaccines scheduled at 6 years coverage was 44.4%-51.7%. The timeliness for EPI vaccines was generally poor, especially for EPI vaccines introduced after 2008 or scheduled for administration at ≥12 months, with a maximum of 35.4% of children vaccinated according to schedule. Despite this, we found increasing trends in vaccination coverage and improvements in timeliness for EPI vaccines. However, for non-EPI vaccines, we found only moderate increases, and in some cases decreases, in vaccination coverage. This study demonstrates the success and improvement of the Chinese immunization program, but also highlights some challenges to be addressed. We recommend that future changes in vaccine practice and policy should primarily focus on improving coverage and timeliness of vaccines introduced after 2008, and/or scheduled for administration ≥12 months.

Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting

OBJECTIVE

To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake.

STUDY DESIGN

Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits.

RESULTS

Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups.

CONCLUSIONS

Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

Participation in an action research project on vaccine services for children: relationship with vaccine delays

Multicomponent interventions are effective in improving vaccine coverage. However, few studies have assessed their effect on timely vaccination. The aim of this study was to compare the proportion of children with vaccine delays at 2- and 12-month visits according to whether or not health centers have participated in an action research project on the organization of vaccination services for 0-5-year-olds. The action research project included a multicomponent intervention and was conducted between 2011 and 2015 in Quebec, Canada. An ecological before/after design was used for this analysis. A total of 264,579 DTaP-IPV-Hib (2-month visits) and 240,541 Men-C-C (12-month visits) vaccine doses were administered during 2011-2012 to 2014-2015 fiscal years, including 19% in 14 participating health centers and the remaining in 78 nonparticipating centers. Vaccine delays demonstrated a more pronounced decreasing trend in participating versus nonparticipating health centers (p < .0001 at 2 and 12 months). Between 2011-2012 and 2014-2015, participating centers managed to eliminate 35% of their vaccine delays at 2-month visits and 33% at 12-month visits, whereas nonparticipating centers eliminated 19% of delays at both visits. Our results are consistent with a positive impact of the multicomponent intervention, despite the fact that it had not specifically aimed at decreasing vaccine delays.

Can vaccination coverage be improved through reducing the missed opportunities for immunization? Results from the evaluation in Zhejiang province, east China

BACKGROUND

To evaluate the missed opportunities for vaccination (MOV) in Zhejiang province by using the global methodology from World Health Organization (WHO).

METHODS

Based on the WHO Planning Guide to Reduce Missed Opportunities for Vaccination (MOV) and Methodology for the Assessment of MOV, 33 health facilities from 11 cities in Zhejiang province were selected. For each health facility, exit investigations for 20 caregivers of children aged 0-23 months and knowledge, attitudes, and practices (KAP) surveys for 10 health workers was implemented. A MOV was determined based on the child's age on the date of investigation, eligibility for various vaccines. The prevalence of MOV was calculated and the risk factors of MOV were explored.

RESULTS

There were 660 completed exit investigations of caregivers of children aged 0-23 months and 330 health worker KAP investigations. Of the 658 children with documented vaccination records, 12.6% were still under-vaccinated. Among these under-vaccinated children, 54.2% still had a MOV. Children's age and their previous vaccination behavior, as well as caregivers' relationship to children and education level had a significant impact on the incidence of MOV.

CONCLUSION

The high proportions of visits with MOV in Zhejiang province suggested that interventions to reduce MOV in health service settings may be a potential quick win for improving coverage and equity. National immunization programs should explore the tailored efforts to improve health worker practices by making better use of existing health service contacts.

Evidence-based strategies to increase vaccination uptake: a review

PURPOSE OF REVIEW

To summarize evidence-based strategies for improving pediatric immunization rates including physician behaviors, clinic and public health processes, community-based and parent-focused interventions, and legal and policy approaches RECENT FINDINGS: Studies continue to show the effectiveness of audit and feedback, provider reminders, standing orders, and reminder/recall to increase immunization rates. Provider communication strategies may improve immunization rates including use of a presumptive approach and motivational interviewing. Centralized reminder/recall (using a state Immunization Information System) is more effective and cost-effective compared to a practice-based approach. Recent work shows the success of text messages for reminder/recall for vaccination. Web-based interventions, including informational vaccine websites with interactive social media components, have shown effectiveness at increasing uptake of pediatric and maternal immunizations. Vaccination requirements for school attendance continue to be effective policy interventions for increasing pediatric and adolescent vaccination rates. Allowance for and ease of obtaining exemptions to vaccine requirements are associated with increased exemption rates.

SUMMARY

Strategies to increase vaccination rates include interventions that directly impact physician behavior, clinic and public health processes, patient behaviors, and policy. Combining multiple strategies to work across different settings and addressing different barriers may offer the best approach to optimize immunization coverage.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

BACKGROUND

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

OBJECTIVES

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

SELECTION CRITERIA

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

AUTHORS' CONCLUSIONS

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Attendance at Well-Child Visits After Reach Out and Read

Attendance at well-child visits (WCVs) is a sine qua non of preventive care. We hypothesized that Reach Out and Read (ROR) would be associated with better WCV attendance. Parents of children 76 to 72 months at 8 clinics who did not yet have ROR reported how many WCVs their child had attended in the previous year; separate samples at the same clinics were interviewed 16 months after the ROR program was instituted. Comparing 267 parents before ROR and 254 after, the percentage who had attended the minimum number of WCVs required by the American Academy of Pediatrics periodicity schedule rose from 67.4% (180/267) to 78.3% (199/254; P < .01). This difference remained significant after controlling for multiple potential confounding factors (estimated odds ratio = 2.1, 95% confidence interval = 1.3-3.5). The largest differences were among Latino children and children of less-educated parents. Programs to enhance early literacy may increase attendance at WCVs among at-risk families.

Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients

Introduction:

Hospitalization provides an ideal opportunity for influenza vaccination, and strategies can enhance existing tools within the electronic medical record (EMR). The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients.

Methods:

We conducted a quality improvement initiative for children aged older than 6 months on medical inpatient teams at a large pediatric tertiary care hospital from September 2014 to March 2015, comprising 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using EMR prompts alone. The provider reminder interventions comprised weekly e-mails indicating inpatient immunization status; vaccination reports; and visual reminders. The family education group intervention consisted of handouts regarding the benefits and safety of influenza vaccination. We measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Data were analyzed using Statistical Process Control Charts and Chi-square tests.

Results:

Among 2,552 patients aged older than 6 months hospitalized during the study period, 1,657 were unimmunized. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%) and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunization status than the control group (61% versus 53%; P = 0.0017). Exposure to the intervention did not impact the length of stay/discharge time.

Conclusions:

Provider reminders including e-mails, visual reminders, and vaccination reports are effective ways of increasing inpatient influenza vaccination rates and are more effective than family education, or EMR prompts alone.

Systematic review of the incremental costs of interventions that increase immunization coverage

Achieving and maintaining high vaccination coverage requires investments, but the costs and effectiveness of interventions to increase coverage remain poorly characterized. We conducted a systematic review of the literature to identify peer-reviewed studies published in English that reported interventions aimed at increasing immunization coverage and the associated costs and effectiveness of the interventions. We found limited information in the literature, with many studies reporting effectiveness estimates, but not providing cost information. Using the available data, we developed a cost function to support future programmatic decisions about investments in interventions to increase immunization coverage for relatively low and high-income countries. The cost function estimates the non-vaccine cost per dose of interventions to increase absolute immunization coverage by one percent, through either campaigns or routine immunization. The cost per dose per percent increase in absolute coverage increased with higher baseline coverage, demonstrating increasing incremental costs required to reach higher coverage levels. Future studies should evaluate the performance of the cost function and add to the database of available evidence to better characterize heterogeneity in costs and generalizability of the cost function.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Assessment of temperatures in the vaccine cold chain in two provinces in Lao People's Democratic Republic: a cross-sectional pilot study

Objective

All childhood vaccines, except the oral polio vaccine, should be kept at 2–8 °C, since the vaccine potency can be damaged by heat or freezing temperature. A temperature monitoring study conducted in 2008–2009 reported challenges in cold chain management from the provincial level downwards. The present cross-sectional pilot study aimed to assess the current status of the cold chain in two provinces (Saravan and Xayabouly) of Lao People’s Democratic Republic between March–April 2016. Two types of temperature data loggers recorded the temperatures and the proportions of time exposed to < 0 or > 8 °C were calculated.

Results

The temperature remained within the appropriate range in the central and provincial storages. However, the vaccines were frequently exposed to > 8 °C in Saravan and < 0 °C in Xayabouly in the district storage. Vaccines were exposed to > 8 °C during the transportation in Saravan and to both > 8 and < 0 °C in Xayabouly. Thus, challenges in managing the cold chain in the district storage and during transportation remain, despite improvements at the provincial storage. A detailed up-to-date nationwide analysis of the current situation of the cold chain is warranted to identify the most appropriate intervention to tackle the remaining challenges.

A systematic review of strategies for reducing missed opportunities for vaccination

BACKGROUND

Missed opportunities for vaccination (MOVs) occur when persons eligible for vaccination visit a health facility and do not get the vaccines they need. We conducted a systematic review to assess effects of interventions for reducing MOVs.

METHODS

We searched PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in April 2017. Three authors independently screened search outputs, reviewed potentially eligible papers, assessed risk of bias, and extracted data; resolving disagreements by consensus. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI) and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

RESULTS

Six studies (five trials and one cohort study) met our inclusion criteria, all conducted in the United States of America. All six studies had various limitations and were classified as having a high risk of bias. We found moderate certainty evidence that the following interventions probably improve vaccination coverage: patient education (RR 1.92, 95% CI 1.38-2.68), patient tracking using community health workers (RR 1.18, 95% CI 1.11-1.25), and patient tracking and provider prompts (RR 1.24, 95% CI 1.18-1.31). In addition, we found low certainty evidence that concurrent interventions targeting health-facility (education, prompts, and audit and feedback) and family settings (phone calls) may increase vaccination coverage (RR 1.25, 95% CI 1.08-1.46).

CONCLUSIONS

The currently available evidence suggests that patient education, patient tracking, outreach sessions, and provider prompts reduce missed opportunities for vaccination and improve vaccination coverage. Rigorous studies are required to confirm these findings and increase the certainty of the current evidence base. WHO is currently coordinating efforts to generate such evidence, especially from low-income and middle-income countries, and it is likely that the data will be available in the next few years.

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Written reminders increase vaccine coverage in Danish children - evaluation of a nationwide intervention using The Danish Vaccination Register, 2014 to 2015

We evaluated a national intervention of sending written reminders to parents of children lacking childhood vaccinations, using the Danish Vaccination Register (DDV). The intervention cohort included the full birth cohort of 124,189 children born in Denmark who reached the age of 2 and 6.5 years from 15 May 2014 to 14 May 2015. The reference cohort comprised 124,427 children who reached the age of 2 and 6.5 years from 15 May 2013 to 14 May 2014. Vaccination coverage was higher in the intervention cohort at 2.5 and 7 years of age. The differences were most pronounced for the second dose of the measles-mumps-rubella vaccine (MMR2) and the diphtheria-tetanus-pertussis-polio vaccine DTaP-IPV4 among the 7-year-olds, with 5.0 percentage points (95% confidence interval (CI): 4.5-5.4) and 6.4 percentage points (95% CI: 6.0-6.9), respectively. Among the 2.5 and 7-year-olds, the proportion of vaccinations in the preceding 6 months was 46% and three times higher, respectively, in the intervention cohort than the reference cohort. This study indicates a marked effect of personalised written reminders, highest for the vaccines given later in the schedule in the older cohort. In addition, the reminders increased awareness about correct registration of vaccinations in DDV.

Interventions to increase pediatric vaccine uptake: An overview of recent findings

Although much is known about factors contributing to variation in pediatric immunization uptake, there is a need for synthesis of effective vaccine promotion strategies. With growing public health concern on how to best sustain high pediatric immunization rates, and improve where the rates are suboptimal, this review offers evidence gathered from several studies on the achievement of these goals. We identified and analyzed reported findings on childhood (primarily ≤ 7 years) immunization outcomes from tested intervention strategies that focused on parents, guardians, and caregivers, as well as providers, clinics/practices, and communities. The findings suggest that targeted and tailored interventions offer substantial possibilities, especially in a combined manner. We describe promising intervention models that have been operationalized with success and provide evidence for scalability across contexts. Moreover, they are sensitive to parents' and providers' needs, are feasibly integrated in daily clinical practice, and account for broader community concerns and issues.

Electronic Immunization Alerts and Spillover Effects on Other Preventive Care

The impact of electronic health record (EHR) immunization clinical alert systems on the delivery of other preventive services remains unknown. We assessed for spillover effects of an EHR immunization alert on delivery of 6 other preventive services, in children 18 to 30 months of age needing immunizations. We conducted a secondary data analysis, with additional primary data collection, of a randomized, historically controlled trial to improve immunization rates with EHR alerts, in an urban, primary care clinic. No significant differences were found in screening for anemia, lead, development, nutrition, and injury prevention counseling in children prompting EHR immunization alerts (n = 129), compared with controls (n = 135). Significant increases in oral health screening in patients prompting EHR alerts (odds ratio = 4.8, 95% CI = 1.8-13.0) were likely due to practice changes over time. An EHR clinical alert system targeting immunizations did not have a spillover effect on the delivery of other preventive services.

Prenatal vaccination education intervention improves both the mothers' knowledge and children's vaccination coverage: Evidence from randomized controlled trial from eastern China

OBJECTIVES

To verify the effectiveness of prenatal vaccination education intervention on improving mother's vaccination knowledge and child's vaccination status in Zhejiang province, eastern China.

METHODS

Pregnant women with ≥ 12 gestational weeks were recruited and randomly assigned into the intervention group and the control group. The intervention group were given a vaccination education session while the control group were not. Two round surveys were performed before and 3 months after the intervention. The vaccination status of child was extracted at 12 months of age from immunization information system. The differences of the vaccination knowledge, the coverage, the completeness and the timeliness of vaccination between 2 groups were evaluated. The effectiveness of vaccination education intervention was assessed, under the control of the other demographic variables.

RESULTS

Among the 1252 participants, 851 subjects replied to the post-survey. Significant improvements of vaccination knowledge between the pre- and the post- survey in the intervention group were observed (Mean ± S.D:1.8 ± 1.1 vs. 3.7 ± 1.2 for vaccines score and 2.7 ± 1.5 vs. 4.8 ± 1.0 for vaccine policy score, respectively). The coverage of fully vaccination was significantly higher in the intervention group (90.0% vs. 82.9%, P<0.01). The timeliness of fully vaccination was significantly higher in the intervention group (51.9% vs. 33.0%, P<0.01). In the intervention group, pregnant women were more likely to be with high score of knowledge (OR = 5.2, 95%CI: 2.6-8.8), and children were more likely to complete the full series of vaccination (OR = 3.4, 95%CI: 2.1-4.8), and children were more likely to complete the full series of vaccination in a timely manner (OR = 2.3, 95%CI: 1.6-3.5).

CONCLUSIONS

Vaccination education in the pregnant women can effectively improve the knowledge regarding immunization and increase the coverage, the completeness and the timeliness of childhood vaccination. Strong partnership needs to be established between the obstetricians and the vaccination staff to improve the performance of NIP.

Use of Preventive Maternal and Child Health Services by Latina Women

Some health indicators for Latinos tend to be more positive than socioeconomic status would predict. Yet, Latina women and their young children use fewer preventive health services and have a higher incidence of preventable diseases than non-Hispanic whites. The Institute of Medicine recently called for intervention research among minority subgroups to end racial and ethnic disparities in health care. To help guide future intervention research, this article presents a critique and synthesis of the peer-reviewed literature on interventions that enroll Latina women into preventive reproductive health services (prenatal care, cervical cancer screening, and child immunizations). Results are presented according to three categories of interventions: improvements within formal health care settings, outreach through lay health advisors ( promotoras) and media, and interventions combining these approaches. An agenda for intervention research is proposed for preventive-care use by this population.

Increasing Coverage of Appropriate Vaccinations: A Community Guide Systematic Economic Review

CONTEXT

Population-level coverage for immunization against many vaccine-preventable diseases remains below optimal rates in the U.S. The Community Preventive Services Task Force recently recommended several interventions to increase vaccination coverage based on systematic reviews of the evaluation literature. The present study provides the economic results from those reviews.

EVIDENCE ACQUISITION

A systematic review was conducted (search period, January 1980 through February 2012) to identify economic evaluations of 12 interventions recommended by the Task Force. Evidence was drawn from included studies; estimates were constructed for the population reach of each strategy, cost of implementation, and cost per additional vaccinated person because of the intervention. Analyses were conducted in 2014.

EVIDENCE SYNTHESIS

Reminder systems, whether for clients or providers, were among the lowest-cost strategies to implement and the most cost effective in terms of additional people vaccinated. Strategies involving home visits and combination strategies in community settings were both costly and less cost effective. Strategies based in settings such as schools and MCOs that reached the target population achieved additional vaccinations in the middle range of cost effectiveness.

CONCLUSIONS

The interventions recommended by the Task Force differed in reach, cost, and cost effectiveness. This systematic review presents the economic information for 12 effective strategies to increase vaccination coverage that can guide implementers in their choice of interventions to fit their local needs, available resources, and budget.

Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: A systematic review and meta-analysis

Vaccination is one of the most effective ways of reducing childhood mortality. Despite global uptake of childhood vaccinations increasing, rates remain sub-optimal, meaning that vaccine-preventable diseases still pose a public health risk. A range of interventions to promote vaccine uptake have been developed, although this range has not specifically been reviewed in early childhood. We conducted a systematic review and meta-analysis of parental interventions to improve early childhood (0-5 years) vaccine uptake. Twenty-eight controlled studies contributed to six separate meta-analyses evaluating aspects of parental reminders and education. All interventions were to some extent effective, although findings were generally heterogeneous and random effects models were estimated. Receiving both postal and telephone reminders was the most effective reminder-based intervention (RD=0.1132; 95% CI=0.033-0.193). Sub-group analyses suggested that educational interventions were more effective in low- and middle-income countries (RD=0.13; 95% CI=0.05-0.22) and when conducted through discussion (RD=0.12; 95% CI=0.02-0.21). Current evidence most supports the use of postal reminders as part of the standard management of childhood immunisations. Parents at high risk of non-compliance may benefit from recall strategies and/or discussion-based forums, however further research is needed to assess the appropriateness of these strategies.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

OBJECTIVES

To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

The 'active ingredients' for successful community engagement with disadvantaged expectant and new mothers: a qualitative comparative analysis

AIMS

To explore which conditions of community engagement are implicated in effective interventions targeting disadvantaged pregnant women and new mothers.

BACKGROUND

Adaptive experiences during pregnancy and the early years are key to reducing health inequalities in women and children worldwide. Public health nurses, health visitors and community midwives are well placed to address such disadvantage, often using community engagement strategies. Such interventions are complex; however, and we need to better understand which aspects of community engagement are aligned with effectiveness.

DESIGN

Qualitative comparative analysis conducted in 2013, of trials data included in a recently published systematic review.

METHODS

Two reviewers agreed on relevant conditions from 24 maternity or early years intervention studies examining four models of community engagement. Effect size estimates were converted into 'fuzzy' effectiveness categories and truth tables were constructed. Using fsQCA software, Boolean minimization identified solution sets. Random effects multiple regression and fsQCA were conducted to rule out risk of methodological bias.

RESULTS/FINDINGS

Studies focused on antenatal, immunization, breastfeeding and early professional intervention outcomes. Peer delivery (consistency 0·83; unique coverage 0·63); and mother-professional collaboration (consistency 0·833; unique coverage 0·21) were moderately aligned with effective interventions. Community-identified health need plus consultation/collaboration in intervention design and leading on delivery were weakly aligned with 'not effective' interventions (consistency 0·78; unique coverage 0·29).

CONCLUSIONS

For disadvantaged new and expectant mothers, peer or collaborative delivery models could be used in interventions. A need exists to design and test community engagement interventions in other areas of maternity and early years care and to further evaluate models of empowerment.

Evaluating community engagement in an academic medical center

From the perspective of academic medical centers (AMCs), community engagement is a collaborative process of working toward mutually defined goals to improve the community's health, and involves partnerships between AMCs, individuals, and entities representing the surrounding community. AMCs increasingly recognize the importance of community engagement, and recent programs such as Prevention Research Centers and Clinical and Translational Science Awards have highlighted community engagement activities. However, there is no standard or accepted metric for evaluating AMCs' performance and impact of community engagement activities.In this article, the authors present a framework for evaluating AMCs' community engagement activities. The framework includes broad goals and specific activities within each goal, wherein goals and activities are evaluated using a health services research framework consisting of structure, process, and outcome criteria. To illustrate how to use this community engagement evaluation framework, the authors present specific community engagement goals and activities of the University of Rochester Medical Center to (1) improve the health of the community served by the AMC; (2) increase the AMC's capacity for community engagement; and (3) increase generalizable knowledge and practices in community engagement and public health.Using a structure-process-outcomes framework, a multidisciplinary team should regularly evaluate an AMC's community engagement program with the purpose of measurably improving the performance of the AMC and the health of its surrounding community.

Improving immunization rates in a hospital-based primary care practice

OBJECTIVE

We implemented a quality improvement initiative aimed at reaching a 95% immunization rate for patients aged 24 months. The setting was a hospital-based pediatric primary care practice in Boston, Massachusetts. We defined immunization as full receipt of the vaccine series as recommended by the Centers for Disease Control and Prevention.

METHODS

The initiative was team-based and structured around 3 core interventions: systematic identification and capture of target patients, use of a patient-tracking registry, and patient outreach and care coordination. We measured monthly overall and modified immunization rates for patients aged 24 months. The modified rate excluded vaccine refusals and practice transfers. We plotted monthly overall and modified immunization rates on statistical process control charts to monitor progress and evaluate impact.

RESULTS

We measured immunization rates for 3298 patients aged 24 months between January 2009 and December 2012. Patients were 48% (n = 1576) female, 77.3% (n = 2548) were African American or Hispanic, and 70.2% (n = 2015) were publicly insured. Using control charts, we established mean overall and modified immunization rates of 90% and 93%, respectively. After implementation, we observed an increase in the mean modified immunization rate to 95%.

CONCLUSIONS

A quality improvement initiative enabled our pediatric practice to increase its modified immunization rate to 95% for children aged 24 months. We attribute the improvement to the incorporation of medical home elements including a multidisciplinary team, patient registry, and care coordination.

Completeness and timeliness of vaccination and determinants for low and late uptake among young children in eastern China

BACKGROUND

We studied completeness and timeliness of vaccination and determinants for low and delayed uptake in children born between 2008 and 2009 in Zhejiang province in eastern China.

METHODS

We used data from a cross-sectional cluster survey conducted in 2011, which included 1146 children born from 1 Jan 2008 to 31 Dec 2009. Various vaccination history, social-demographic factors, attitude and satisfaction toward immunization from caregivers were collected by a standard questionnaire. We restricted to the third dose of HepB, PV, and DPT (HepB3, PV3, and DPT3) as outcome variables for completeness of vaccination and restricted to the first dose of HepB, PV, DPT, and MCV(HepB1, PV1, DPT1, and MCV1) as outcome variables for timeliness of vaccination. The χ(2) test and logistic regression analysis were applied to identify the determinants of completeness and timeliness of vaccination. Survival analysis by the Kaplan-Meier method was performed to present the timeliness vaccination.

RESULTS

Coverage for HepB1, HepB3, PV1, PV3, DPT1, DPT3, and MCV1 was 93.22%, 90.15%, 96.42%, 91.63%, 95.80%, 90.16%, and 92.70%, respectively. Timely vaccination occurred in 501/1146(43.72%) children for HepB1, 520/1146(45.38%) for PV1, 511/1146(44.59%) for DPT1, and 679/1146(59.25%) for MCV1. Completeness of specific vaccines was associated with mother' age, immigration status, birth place of child, maternal education level, maternal occupation status, socio-economic development level of surveyed areas, satisfaction toward immunization service and distance of the house to immunization clinic. Timeliness of vaccination for specific vaccines was associated with mother' age, maternal education level, immigration status, siblings, birth place, and distance of the house to immunization clinic.

CONCLUSION

Despite reasonably high vaccination coverage, we observed substantial vaccination delays. We found specific factors associated with low and/or delayed vaccine uptake. These findings can help to improve strategies such as Reaching Every District (RED), out-reach vaccination services and health education to reach children who remain inadequately protected.

Get screened: a randomized trial of the incremental benefits of reminders, recall, and outreach on cancer screening

BACKGROUND

Rates of breast cancer (BC) and colorectal cancer (CRC) screening are particularly low among poor and minority patients. Multifaceted interventions have been shown to improve cancer-screening rates, yet the relative impact of the specific components of these interventions has not been assessed. Identifying the specific components necessary to improve cancer-screening rates is critical to tailor interventions in resource limited environments.

OBJECTIVE

To assess the relative impact of various components of the reminder, recall, and outreach (RRO) model on BC and CRC screening rates within a safety net practice.

DESIGN

Pragmatic randomized trial.

PARTICIPANTS

Men and women aged 50-74 years past due for CRC screen and women aged 40-74 years past due for BC screening.

INTERVENTIONS

We randomized 1,008 patients to one of four groups: (1) reminder letter; (2) letter and automated telephone message (Letter + Autodial); (3) letter, automated telephone message, and point of service prompt (Letter + Autodial + Prompt); or (4) letter and personal telephone call (Letter + Personal Call).

MAIN MEASURES

Documentation of mammography or colorectal cancer screening at 52 weeks following randomization.

KEY RESULTS

Compared to a reminder letter alone, Letter + Personal Call was more effective at improving screening rates for BC (17.8 % vs. 27.5 %; AOR 2.2, 95 % CI 1.2-4.0) and CRC screening (12.2 % vs. 21.5 %; AOR 2.0, 95 % CI 1.1-3.9). Compared to letter alone, a Letter + Autodial + Prompt was also more effective at improving rates of BC screening (17.8 % vs. 28.2 %; AOR 2.1, 95 % CI 1.1-3.7) and CRC screening (12.2 % vs. 19.6 %; AOR 1.9, 95 % CI 1.0-3.7). Letter + Autodial was not more effective than a letter alone at improving screening rates.

CONCLUSIONS

The addition of a personal telephone call or a patient-specific provider prompt were both more effective at improving mammogram and CRC screening rates compared to a reminder letter alone. The use of automated telephone calls, however, did not provide any incremental benefit to a reminder letter alone.

Measles vaccination coverage estimates from surveys, clinic records, and immune markers in oral fluid and blood: a population-based cross-sectional study

Background

Recent outbreaks of measles and polio in low-income countries illustrate that conventional methods for estimating vaccination coverage do not adequately identify susceptible children. Immune markers of protection against vaccine-preventable diseases in oral fluid (OF) or blood may generate more accurate measures of effective vaccination history, but questions remain about whether antibody surveys are feasible and informative tools for monitoring immunization program performance compared to conventional vaccination coverage indicators. This study compares six indicators of measles vaccination status, including immune markers in oral fluid and blood, from children in rural Bangladesh and evaluates the implications of using each indicator to estimate measles vaccination coverage.

Methods

A cross-sectional population-based study of children ages 12–16 months in Mirzapur, Bangladesh, ascertained measles vaccination (MCV1) history from conventional indicators: maternal report, vaccination card records, ‘card + history’ and EPI clinic records. Oral fluid from all participants (n = 1226) and blood from a subset (n = 342) were tested for measles IgG antibodies as indicators of MCV1 history and compared to conventional MCV1 coverage indicators.

Results

Maternal report yielded the highest MCV1 coverage estimates (90.8%), followed by EPI records (88.6%), and card + history (84.2%). Seroprotection against measles by OF (57.3%) was significantly lower than other indicators, even after adjusting for incomplete seroconversion and assay performance (71.5%). Among children with blood results, 88.6% were seroprotected, which was significantly higher than coverage by card + history and OF serostatus but consistent with coverage by maternal report and EPI records. Children with vaccination cards or EPI records were more likely to have a history of receiving MCV1 than those without cards or records. Despite similar MCV1 coverage estimates across most indicators, within-child agreement was poor for all indicators.

Conclusions

Measles IgG antibodies in OF was not a suitable immune marker for monitoring measles vaccination coverage in this setting. Because agreement between conventional MCV1 indicators was mediocre, immune marker surveillance with blood samples could be used to validate conventional MCV1 indicators and generate adjusted results that can be compared across indicators.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Face to face interventions for informing or educating parents about early childhood vaccination

BACKGROUND

Childhood vaccination (also described as immunisation) is an important and effective way to reduce childhood illness and death. However, there are many children who do not receive the recommended vaccines because their parents do not know why vaccination is important, do not understand how, where or when to get their children vaccinated, disagree with vaccination as a public health measure, or have concerns about vaccine safety.Face to face interventions to inform or educate parents about routine childhood vaccination may improve vaccination rates and parental knowledge or understanding of vaccination. Such interventions may describe or explain the practical and logistical factors associated with vaccination, and enable parents to understand the meaning and relevance of vaccination for their family or community.

OBJECTIVES

To assess the effects of face to face interventions for informing or educating parents about early childhood vaccination on immunisation uptake and parental knowledge.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE (OvidSP) (1946 to July 2012); EMBASE + Embase Classic (OvidSP) (1947 to July 2012); CINAHL (EbscoHOST) (1981 to July 2012); PsycINFO (OvidSP) (1806 to July 2012); Global Health (CAB) (1910 to July 2012); Global Health Library (WHO) (searched July 2012); Google Scholar (searched September 2012), ISI Web of Science (searched September 2012) and reference lists of relevant articles. We searched for ongoing trials in The International Clinical Trials Registry Platform (ICTRP) (searched August 2012) and for grey literature in The Grey Literature Report and OpenGrey (searched August 2012). We also contacted authors of included studies and experts in the field. There were no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster RCTs evaluating the effects of face to face interventions delivered to individual parents or groups of parents to inform or educate about early childhood vaccination, compared with control or with another face to face intervention. Early childhood vaccines are all recommended routine childhood vaccines outlined by the World Health Organization, with the exception of human papillomavirus vaccine (HPV) which is delivered to adolescents.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed database search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed the risk of bias of included studies. We contacted study authors for additional information.

MAIN RESULTS

We included six RCTs and one cluster RCT involving a total of 2978 participants. Three studies were conducted in low- or middle-income countries and four were conducted in high-income countries. The cluster RCT did not contribute usable data to the review. The interventions comprised a mix of single-session and multi-session strategies. The quality of the evidence for each outcome was low to very low and the studies were at moderate risk of bias overall. All these trials compared face to face interventions directed to individual parents with control.The three studies assessing the effect of a single-session intervention on immunisation status could not be pooled due to high heterogeneity. The overall result is uncertain because the individual study results ranged from no evidence of effect to a significant increase in immunisation.Two studies assessed the effect of a multi-session intervention on immunisation status. These studies were also not pooled due to heterogeneity and the result was very uncertain, ranging from a non-significant decrease in immunisation to no evidence of effect.The two studies assessing the effect of a face to face intervention on knowledge or understanding of vaccination were very uncertain and were not pooled as data from one study were skewed. However, neither study showed evidence of an effect on knowledge scores in the intervention group. Only one study measured the cost of a case management intervention. The estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care.The review also considered the following secondary outcomes: intention to vaccinate child, parent experience of intervention, and adverse effects. No adverse effects related to the intervention were measured by any of the included studies, and there were no data on the other outcomes of interest.

AUTHORS' CONCLUSIONS

The limited evidence available is low quality and suggests that face to face interventions to inform or educate parents about childhood vaccination have little to no impact on immunisation status, or knowledge or understanding of vaccination. There is insufficient evidence to comment on the cost of implementing the intervention, parent intention to vaccinate, parent experience of the intervention, or adverse effects. Given the apparently limited effect of such interventions, it may be feasible and appropriate to incorporate communication about vaccination into a healthcare encounter, rather than conduct it as a separate activity.

A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents

OBJECTIVE

To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents.

METHODS

We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end.

RESULTS

Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost $18.78 (mailed) or $16.68 (phone) per adolescent per year to deliver. The cost per additional adolescent fully vaccinated was $463.99 for mailed and $714.98 for telephone; the cost per additional adolescent receiving a preventive visit was $324.75 and $487.03.

CONCLUSIONS

Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits, with modest costs and modest impact.

Barriers to the use of reminder/recall interventions for immunizations: a systematic review

BACKGROUND

Although many studies have demonstrated the benefits of reminder/recall (RR) measures to address patient under-immunization and improve immunization coverage, they are not widely implemented by healthcare providers. We identified providers' perceived barriers to their use from existing literature.

METHODS

We conducted a systematic review of relevant articles published in English between January 1990 and July 2011 that examined the perceptions of healthcare providers regarding barriers to tracking patient immunization history and implementing RR interventions. We searched MEDLINE, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Academic Search Premier, and PsychINFO. Additional strategies included hand-searching the references of pertinent articles and related reviews, and searching keywords in Google Scholar and Google.

RESULTS

Ten articles were included; all described populations in the United States, and examined perceptions of family physicians, pediatricians, and other immunization staff. All articles were of moderate-high methodological quality; the majority (n=7) employed survey methodology. The most frequently described barriers involved the perceived human and financial resources associated with implementing an RR intervention, as well as low confidence in the accuracy of patient immunization records, given the lack of data sharing between multiple immunization providers. Changes to staff workflow, lack of appropriate electronic patient-tracking functionalities, and uncertainty regarding the success of RR interventions were also viewed as barriers to their adoption.

CONCLUSIONS

Although transitioning to electronic immunization records and registries should facilitate the implementation of RR interventions, numerous perceived barriers must still be overcome before the full benefits of these methods can be realized.

Effectiveness and cost of immunization recall at school-based health centers

BACKGROUND AND OBJECTIVE

Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs.

METHODS

During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥ 1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices.

RESULTS

At the end of the demonstration study, 77% of girls had received ≥ 1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥ 1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized.

CONCLUSIONS

SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings.

Effectiveness and net cost of reminder/recall for adolescent immunizations

OBJECTIVE

To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues.

METHODS

We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines.

RESULTS

Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses.

CONCLUSIONS

R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

A multimodal intervention to promote mammography and colorectal cancer screening in a safety-net practice

BACKGROUND

There are limited data regarding interventions designed to improve cancer screening rates in safety-net practices with "real world" patients.

OBJECTIVE

To examine the impact of a multimodal intervention on mammography and colorectal cancer (CRC) screening rates in a safety-net practice caring for underserved patients.

METHODS

At an inner-city family medicine practice, all patients past due for mammography or CRC screening were assigned to receive or not receive a screening promotion intervention based on their medical record number. The 12-month intervention included outreach to patients (tailored letters, automated and personal phone calls) and point-of-care patient and clinician prompts. The trial was registered at clinicaltrials.gov, NCT00818857.

RESULTS

We enrolled 469 participants aged 40 to 74 years, including 28% African Americans, 5% Latinos, 25% with Medicaid, and 10% without any form of insurance. Participants in the intervention group showed statistically significantly higher rates of cancer screening; rates were 41% vs 16.8% for mammography and 28.8% vs 10% for CRC screening. These findings were confirmed in multivariable analysis. Similar relative improvements in screening were seen across race, ethnicity, socioeconomic status, and insurance groups.

DISCUSSION

A multimodal intervention shows promise for improving rates of mammography and colorectal cancer screening within a safety-net practice. Further study will identify the most cost-effective components of the intervention.

Primary care strategies to improve childhood immunisation uptake in developed countries: systematic review

Objectives

To conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries.

Design

Systematic review.

Setting

Developed countries

Participants

Preschool children who were due, or overdue, one or more of their routine primary immunisations.

Main outcome measures

Increase in the proportion of the target population up to date with standard recommended universal vaccinations.

Results

Forty-six studies were included for analysis, published between 1980 and 2009. Twenty-six studies were randomized controlled trials, 11 were before and after trials, and nine were controlled intervention trials. Parental reminders showed a statistically significant increase in immunisation rates in 34% of included intervention arms. These effects were reported with both generic and specific reminders and with all methods of reminders and recall. Strategies aimed at immunisation providers were also shown to improve immunisation rates with a median change in immunisation rates of 7% when reminders were used, 8% when educational programmes were used and 19% when feedback programmes were used.

Conclusion

General practitioners are uniquely positioned to influence parental decisions on childhood immunisation. A variety of strategies studied in primary care settings have been shown to improve immunisation rates, including parental and healthcare provider reminders.

Increasing inner-city adult influenza vaccination rates: a randomized controlled trial

OBJECTIVES

In a population of seniors served by urban primary care centers, we evaluated the effect of the practice-based intervention on influenza immunization rates and disparities in vaccination rates by race/ethnicity and insurance status.

METHODS

A randomized controlled trial during 2003-2004 tested patient tracking/recall/outreach and provider prompts on improving influenza immunization rates. Patients aged > or = 65 years in six large inner-city primary care practices were randomly allocated to study or control group. Influenza immunization coverage was measured prior to enrollment and on the end date.

RESULTS

At study end, immunization rates were greater for the intervention group than for the control group (64% vs. 22%, p < 0.0001). When controlling for other factors, the intervention group was more than six times as likely to receive influenza vaccine. The intervention was effective across gender, race/ ethnicity, age, and insurance subgroups. Among the intervention group, 3.5% of African Americans and 3.2% of white people refused influenza immunization.

CONCLUSIONS

Patient tracking/recall/outreach and provider prompts were intensive but successful approaches to increasing seasonal influenza immunization rates among this group of inner-city seniors.

Validity of parent-reported vaccination status for adolescents aged 13-17 years: National Immunization Survey-Teen, 2008

OBJECTIVE

The validity of parent-reported adolescent vaccination histories has not been assessed. This study evaluated the validity of parent-reported adolescent vaccination histories by a combination of immunization card and recall, and by recall only, compared with medical provider records.

METHODS

We analyzed data from the 2008 National Immunization Survey-Teen. Parents of adolescents aged 13-17 years reported their child's vaccination history either by immunization card and recall (n = 3,661) or by recall only (n = 12,822) for the hepatitis B (Hep B), measles-mumps-rubella (MMR), varicella (VAR), tetanus-diphtheria/tetanus-diphtheria-acellular pertussis (Td/ Tdap), meningococcal conjugate (MCV4), and quadrivalent human papillomavirus (HPV4) (for girls only) vaccines. We validated parental report with medical records.

RESULTS

Among the immunization card/recall group, vaccines with > 20% false-positive reports included MMR (32.3%) and Td/Tdap (36.9%); vaccines with > 20% false-negative reports included VAR (35.2%), MCV4 (36.0%), and Tdap (41.9%). Net bias ranged from -25.0 to -0.1 percentage points. Kappa values ranged from 0.22 to 0.92. Among the recall-only group, vaccines with > 20% false-positive reports included Hep B (33.9%), MMR (61.4%), VAR (26.2%), and Td/Tdap (60.6%); vaccines with > 20% false-negative reports included Hep B (58.9%), MMR (33.7%), VAR (51.6%), Td/Tdap (25.5%), Tdap (50.3%) MCV4 (63.0%), and HPV4 (20.5%). Net bias ranged from -46.0 to 0.5 percentage points. Kappa values ranged from 0.03 to 0.76.

CONCLUSIONS

Validity of parent-reported vaccination histories varies by type of report and vaccine. For recently recommended vaccines, false-negative rates were substantial and higher than false-positive rates, resulting in net underreporting of vaccination rates by both the immunization card/recall and recall-only groups. Provider validation of parent-reported vaccinations is needed for valid surveillance of adolescent vaccination coverage.

Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology

OBJECTIVES

Lay health workers (LHWs) are used in many settings to increase immunisation uptake among children. However, little is known about the effectiveness of these interventions. The objective of this review was to assess the effects of LHW interventions on childhood immunisation uptake.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index and Archive, AMED, POPLINE and WHOLIS, reference lists of included papers and relevant reviews, and contacted the authors of relevant papers. We selected randomised and non-randomised controlled trials, controlled before-after studies, and interrupted time series of any intervention delivered by LHWs and designed to increase childhood immunisation uptake. Two authors independently extracted data using a standard form and assessed risk of bias and evidence quality.

FINDINGS

We identified twelve studies, ten of which were randomised controlled trials. Seven studies were conducted among economically disadvantaged populations in high-income countries. Five studies were from low- and middle-income countries. In ten studies, LHWs promoted childhood immunisation. In two studies, LHWs vaccinated children themselves. In most of the studies, the control group populations received no intervention or standard care. Most of the studies showed that LHWs increased immunisation coverage. However, study settings were diverse, allowing us to carry out only one meta-analysis including four studies.

CONCLUSION

LHWs could make an important contribution to achieving the Millennium Development Goal for child health. However, more high-quality studies are needed, particularly from LMICs. More studies are also needed to assess the effects of using LHWs to vaccinate children themselves.

Related factors of age-appropriate immunization among urban-rural children aged 24-35 months in a 2005 population-based survey in Nonsan, Korea

PURPOSE

This study was aimed to determine the status and related factors of age-appropriate immunization among urban-rural children aged 24-35 months in a 2005 population-based survey in Nonsan, Korea.

MATERIALS AND METHODS

We conducted household survey and provider check using questionnaire and checklist to obtain data on immunization status for children, aged 24-35 months. Age-appropriate immunization was defined as status of receiving the fourth diphtheria-tetanus-pertussis (4 DTP), 3 Polio, the first measles-mumps-rubella (1 MMR) doses, and the 4 : 3 : 1 series.

RESULTS

Age-appropriate immunization rates were 51.7% for 4 DPT, 88.0% for 3 Polio, 87.9% for 1 MMR, and 50.3% for the 4 : 3 : 1 series. First-born children, lower perceived barrier scores, and higher perception of immunization data were significantly related to age-appropriate immunization.

CONCLUSION

The findings indicated that age-appropriate immunization rate could be improved by implementing reminder/recall service and providing the knowledge about immunization. Identification and consideration related factors would improve immunization rate and age-appropriate immunization.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Immunization milestones: a more comprehensive picture of age-appropriate vaccination

A challenge facing immunization registries is developing measures of childhood immunization coverage that contain more information for setting policy than present vaccine series up-to-date (UTD) rates. This study combined milestone analysis with provider encounter data to determine when children either do not receive indicated immunizations during medical encounters or fail to visit providers. Milestone analysis measures immunization status at key times between birth and age 2, when recommended immunizations first become late. The immunization status of a large population of children in the Oregon ALERT immunization registry and in the Oregon Health Plan was tracked across milestone ages. Findings indicate that the majority of children went back and forth with regard to having complete age-appropriate immunizations over time. We also found that immunization UTD rates when used alone are biased towards relating non-UTD status to a lack of visits to providers, instead of to provider visits on which recommended immunizations are not given.