Patient reminder and patient recall systems to improve immunization rates

SMS-reminder for vaccination in Africa: research from published, unpublished and grey literature

Immunization for children against vaccine-preventable diseases is one of the most important health intervention method in the world, both in terms of its health impact and cost-effectiveness. Through EPI and various other programs such as the Decades of Vaccines, immunization has been improving the health of children around the world. However, this progress falls short of global immunization targets of the Global Vaccine Action Plan (GVAP). Furthermore, the African region still lags behind in immunization, and suffers from a high proportion of vaccine preventable diseases as a result. Reminders and recall for vaccination have been shown to improve health care-seeking behaviours, and have been recommended for application in routine and supplemental measles immunization activities. With mobile phones becoming more accessible in Africa, SMS vaccine reminder system has been proposed as a convenient and easily scalable way to inform caregivers of the disease and the importance of immunization, to address any concerns related to immunization safety, and to remind them of vaccination schedules and campaigns. There have been 6 published articles and 1 unpublished article on the effect of SMS reminder system for immunization in Africa. The studies done has shown that SMS vaccination reminder has led to improvements in vaccination uptakes in various metrics, whether is through the increase in vaccination coverage, decrease in dropout rates, increase in completion rate, or decrease in delay for vaccination.

A review of measles control in Kenya, with focus on recent innovations

Despite the existence of a highly effective measles vaccine and the decrease in worldwide deaths from measles by more than 79% from the 2000 baseline levels, measles today remains one of the leading causes of vaccine-preventable deaths in the world. The African region is a key player in the global fight against measles. Africa has made tremendous progress in its effort to immunize children and to control the disease, increasing its regional measles vaccination coverage from 56% in 2001 to 85% in 2010. The Republic of Kenya has been a strong follower of the World Health Assembly and Measles Elimination 2020 resolutions, which aims to eliminate measles from the country. Since the beginning of the 21st century, Kenya has faced many challenges, but also aid, in the form of new innovations, in their fight against measles. In 2002, Kenya started its first SIA using A-D syringes, and from 2003-2005, GAVI funded injection safety support (INS) to Kenya, as an effort to scale-up safe injection in sub-Saharan Africa. In 2016, the Kenya introduced Measles-Rubella (MR) combined vaccine in its nationwide SIA campaign, after recognizing that rubella is a disease that must be controlled along with measles. In 2009 and 2012 SIAs, Red Cross volunteers conducted H2H visits to promote immunization as well as document information from the community with regards to immunization, including the current coverage, to campaign management levels. Case-based surveillance, using real-time PCR, measles-specific IgM detection and Epi-link were used to confirm and map measles infection during outbreaks. Alternative serosurveys such as Dried Blood Spot and Urine sample surveys were also tested in Kenya. In 2013 and 2016, two studies were also conducted in Kenya on the use of SMS reminder system for routine immunization. These studies, which showed SMS to significantly improve the vaccination coverage, paved way for use of SMS in a larger scale in Kenya.

Research on subgroups is not research on equity attributes: Evidence from an overview of systematic reviews on vaccination

BACKGROUND

Equity remains a priority in the international health development agenda. However, major inequities in vaccination coverage jeopardise the achievement of the Sustainable Development Goals. We aim at comprehensively describing how research has addressed equity issues related to vaccination.

METHODS

We carried out an overview of systematic reviews (SRs) that explicitly explored the effects of interventions to improve vaccination in any context; for any vaccine and, in any language. We followed standard research synthesis methods to systematically search for SR, assess them for inclusion and extracting relevant data, particularly on vaccination related outcomes. To gather evidence on equity issues addressed in the SR, we used the PROGRESS-plus framework.

FINDINGS

Our search obtained 2,003 hits which resulted in 54 included SRs, published between 1994 and 2014. The quality of SRs was generally poor, with less than half complying with most of the quality criteria. Reported vaccines included, by order of frequency, influenza and Expanded Programme on Immunisation vaccines. The types of interventions more frequently reported were related to vaccination delivery strategies, financial support and information, education and communication. Most of the SRs suggested effects favouring intervention groups as opposed to comparison groups. The most frequently reported equity attribute was 'place of residence' and the least reported equity attributes were sexual orientation and religion. Very few estimates of effects actually measured differences or changes between groups having those attributes and all of them referred to the place of residence. No data was found about reducing equity gaps for vulnerable groups or minorities, or attributes such as sexual orientation, education or specific religious groups.

CONCLUSIONS

Although research on vulnerable populations as a subgroup is abundant, it fails to report on the interventions that will actually reduce inequities and consider how redistribution of health care resources could shrink the gap between the privileged and most vulnerable groups including minorities. Research, if aiming at being responsive to global health policy trends, needs to report not only on specific attributes but also on how a better redistribution of health care resources could contribute to alleviating the unjust situation of the most vulnerable populations.

Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma

BACKGROUND

Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services including immunisation. To improve immunisation rates, it is necessary to understand what helps and hinders individuals in these communities in taking up immunisations. This study had two aims. 1. Investigate the views of Travellers in the UK on the barriers and facilitators to acceptability and uptake of immunisations and explore their ideas for improving immunisation uptake; 2. Examine whether and how these responses vary across and within communities, and for different vaccines (childhood and adult).

METHODS

This was a qualitative, cross-sectional interview study informed by the Social Ecological Model. Semi-structured interviews were conducted with 174 Travellers from six communities: Romanian Roma, English Gypsy/Irish Travellers (Bristol), English Gypsy (York), Romanian/Slovakian Roma, Scottish Show people (Glasgow) and Irish Traveller (London). The focus was childhood and selected adult vaccines. Data were analysed using the Framework approach.

RESULTS

Common accounts of barriers and facilitators were identified across all six Traveller communities, similar to those documented for the general population. All Roma communities experienced additional barriers of language and being in a new country. Men and women described similar barriers and facilitators although women spoke more of discrimination and low literacy. There was broad acceptance of childhood and adult immunisation across and within communities, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough and described barriers to booking and attending immunisation. Cultural concerns about antenatal vaccines and HPV vaccination were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified as barriers across different communities. Trustful relationships with health professionals were important and continuity of care valued.

CONCLUSIONS

The experience of many Travellers in this study, and the context through which they make health decisions, is changing. This large study identified key issues that should be considered when taking action to improve uptake of immunisations in Traveller families and reduce the persistent inequalities in coverage.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20019630 .

Immunization information systems in Canada: Attributes, functionality, strengths and challenges. A Canadian Immunization Research Network study

OBJECTIVES

Canada does not have a national immunization registry. Diverse systems to record vaccine uptake exist, but these have not been systematically described. Our objective was to describe the immunization information systems (IISs) and non-IIS processes used to record childhood and adolescent vaccinations, and to outline the strengths and limitations of the systems and processes.

METHODS

We collected information from key informants regarding their provincial, territorial or federal organization's surveillance systems for assessing immunization coverage. Information collection consisted of a self-administered questionnaire and a follow-up interview. We evaluated systems against attributes derived from the literature using content analysis.

RESULTS

Twenty-six individuals across 16 public health organizations participated over the period of April to August 2015. Twelve of Canada's 13 provinces and territories (P/Ts) and two organizations involved in health service delivery for on-reserve First Nations people participated. Across systems, there were differences in data collection processes, reporting capabilities and advanced functionality. Commonly cited challenges included timeliness and data completeness of records, particularly for physician-administered immunizations. Privacy considerations and the need for data standards were stated as challenges to the goal of information sharing across P/T systems. Many P/Ts have recently implemented new systems and, in some cases, legislation to improve timeliness and/or completeness.

CONCLUSION

Considerable variability exists among IISs and non-IIS processes used to assess immunization coverage in Canada. Although some P/Ts have already pursued legislative or policy initiatives to address the completeness and timeliness of information, many additional opportunities exist in the information technology realm.

Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence

BACKGROUND

Childhood vaccination is an effective way to prevent serious childhood illnesses, but many children do not receive all the recommended vaccines. There are various reasons for this; some parents lack access because of poor quality health services, long distances or lack of money. Other parents may not trust vaccines or the healthcare workers who provide them, or they may not see the need for vaccination due to a lack of information or misinformation about how vaccinations work and the diseases they can prevent.Communication with parents about childhood vaccinations is one way of addressing these issues. Communication can take place at healthcare facilities, at home or in the community. Communication can be two-way, for example face-to-face discussions between parents and healthcare providers, or one-way, for instance via text messages, posters or radio programmes. Some types of communication enable parents to actively discuss vaccines and their benefits and harms, as well as diseases they can prevent. Other communication types simply give information about vaccination issues or when and where vaccines are available. People involved in vaccine programmes need to understand how parents experience different types of communication about vaccination and how this influences their decision to vaccinate.

OBJECTIVES

The specific objectives of the review were to identify, appraise and synthesise qualitative studies exploring: parents' and informal caregivers' views and experiences regarding communication about childhood vaccinations and the manner in which it is communicated; and the influence that vaccination communication has on parents' and informal caregivers' decisions regarding childhood vaccination.

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-process and Other Non-Index Citations (Ovid SP), Embase (Ovid), CINAHL (EbscoHOST), and Anthropology Plus (EbscoHost) databases for eligible studies from inception to 30 August 2016. We developed search strategies for each database, using guidelines developed by the Cochrane Qualitative Research Methods Group for searching for qualitative evidence as well as modified versions of the search developed for three related reviews of effectiveness. There were no date or geographic restrictions for the search.

SELECTION CRITERIA

We included studies that utilised qualitative methods for data collection and analysis; focused on the views and experiences of parents and informal caregivers regarding information about vaccination for children aged up to six years; and were from any setting globally where information about childhood vaccinations was communicated or distributed.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, using a three-step sampling frame. We conducted a thematic analysis using a constant comparison strategy for data extraction and synthesis. We assessed our confidence in the findings using the GRADE-CERQual approach. High confidence suggests that it is highly likely that the review finding is a reasonable representation of the phenomenon of interest, while very low confidence indicates that it is not clear whether the review finding is a reasonable representation of it. Using a matrix model, we then integrated our findings with those from other Cochrane reviews that assessed the effects of different communication strategies on parents' knowledge, attitudes and behaviour about childhood vaccination.

MAIN RESULTS

We included 38 studies, mostly from high-income countries, many of which explored mothers' perceptions of vaccine communication. Some focused on the MMR (measles, mumps, rubella) vaccine.In general, parents wanted more information than they were getting (high confidence in the evidence). Lack of information led to worry and regret about vaccination decisions among some parents (moderate confidence).Parents wanted balanced information about vaccination benefits and harms (high confidence), presented clearly and simply (moderate confidence) and tailored to their situation (low confidence in the evidence). Parents wanted vaccination information to be available at a wider variety of locations, including outside health services (low confidence) and in good time before each vaccination appointment (moderate confidence).Parents viewed health workers as an important source of information and had specific expectations of their interactions with them (high confidence). Poor communication and negative relationships with health workers sometimes impacted on vaccination decisions (moderate confidence).Parents generally found it difficult to know which vaccination information source to trust and challenging to find information they felt was unbiased and balanced (high confidence).The amount of information parents wanted and the sources they felt could be trusted appeared to be linked to acceptance of vaccination, with parents who were more hesitant wanting more information (low to moderate confidence).Our synthesis and comparison of the qualitative evidence shows that most of the trial interventions addressed at least one or two key aspects of communication, including the provision of information prior to the vaccination appointment and tailoring information to parents' needs. None of the interventions appeared to respond to negative media stories or address parental perceptions of health worker motives.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several review findings. Further research, especially in rural and low- to middle-income country settings, could strengthen evidence for the findings where we had low or very low confidence. Planners should consider the timing for making vaccination information available to parents, the settings where information is available, the provision of impartial and clear information tailored to parental needs, and parents' perceptions of health workers and the information provided.

Hispanic mothers' beliefs regarding HPV vaccine series completion in their adolescent daughters

Rates of human papillomavirus (HPV) vaccine series completion among adolescent Hispanic females in Texas in 2014 (∼39%) lag behind the Healthy People 2020 goal (80%). This qualitative study identifies Hispanic mothers' salient behavioral, normative and control beliefs regarding having their adolescent daughters complete the vaccine series. Thirty-two mothers of girls (aged 11-17) that had received at least one dose of the HPV vaccine, completed in-depth interviews. Six girls had received one dose of the HPV vaccine, 10 girls had received two doses, and 16 girls had received all three doses. The questions elicited salient: (i) experiential and instrumental attitudes (behavioral beliefs); (ii) supporters and non-supporters (normative beliefs) and (iii) facilitators and barriers (control beliefs). Directed content analysis was employed to select the most salient beliefs. Mothers: (i) expressed salient positive feelings (e.g. good, secure, happy and satisfied); (ii) believed that completing the series resulted in positive effects (e.g. protection, prevention); (iii) believed that the main supporters were themselves, their daughter's father and doctor with some of their friends not supporting series completion and (iv) believed that vaccine affordability, information, transportation, ease of scheduling and keeping vaccination appointments and taking their daughter's immunization card to appointments were facilitators. This study represents the first step in building theory-based framework of vaccine series completion for this population. The beliefs identified provide guidance for health care providers and intervention developers.

Latina and Black/African American Women's Perspectives on Cancer Screening and Cancer Screening Reminders

INTRODUCTION

Racial and ethnic disparities continue to exist in cancer screening rates, especially among US Latina and Black/African American populations. We conducted six focus groups among 41 women from these communities in order to better understand their preferences about cancer screening reminders and the motivators and deterrents they face in obtaining recommended breast, cervical, and colon cancer screening.

METHODS

Using self-reported patient race/ethnicity from electronic medical records of a large, integrated health care system in Seattle, we recruited women ages 30-60 to participate in one of five 2-hour focus groups. Using verbatim transcripts from these discussions, we conducted a qualitative analysis to identify common themes.

RESULTS

The focus group participants were primarily strong endorsers and utilizers of recommended breast, cervical, and colon cancer screening services. Insurance and belief in preventive care were the most common motivators that they cited in obtaining cancer screening. However, they still reported multiple barriers to getting recommended cancer screening for themselves and community members, including lack of time, conflicting information about screening intervals, distrust in the health care system, and a lack of understanding of the benefits of preventive care.

CONCLUSIONS

Efforts to improve understanding about the benefits of cancer screening, clarify cancer screening guideline recommendations, increase cultural competency among health care professionals, and expand the times and locations where cancer screening is available are all options that may improve cancer screening rates among Latinas and Black/African American women.

A human papillomavirus vaccination program for low-income postpartum women

BACKGROUND

Effective interventions are needed to address the low rate of human papillomavirus (HPV) vaccination in the United States, particularly among girls and women 16-26 years old. Counseling and offering the vaccine to postpartum patients could be an effective strategy to increase uptake among young women who did not complete the 3-dose series at an earlier age.

OBJECTIVE

The purpose of this evaluation was to assess the effectiveness of a multicomponent program designed for postpartum women that used patient navigators (PNs) and reminders for follow-up visits to improve uptake and completion of the HPV vaccine series.

STUDY DESIGN

As part of standard care, patients ≤26 years of age from Galveston County, Texas, who delivered an infant from November 2012 through June 2014 at a public hospital were counseled and offered the HPV vaccine postpartum. PNs assisted with scheduling follow-up injections during postpartum or well-child visits. A program evaluation was conducted after 20 months.

RESULTS

Of 1038 patients approached, only 161 (15.5%) had previously completed the vaccine series. Of the 877 patients who had not completed the series, 661 (75.4%) received at least 1 dose postpartum, with 575 patients receiving their first dose and 86 receiving their second or third doses. By April 2015, initiation rates had increased as a result of this program from 25.4% before the program was initiated to 80.8% and completion rates from 15.5-65.1%. Missed appointments for injections were less likely among those who received text message reminders and more likely among those with ≥2 prior pregnancies. Those who were Hispanic or had received an influenza vaccination in the last year were more likely to initiate and complete the series through this program. Patients who missed ≥1 follow-up appointments were less likely to complete the vaccine series.

CONCLUSION

Offering the HPV vaccine postpartum dramatically increased initiation rates among postpartum patients. PN and text messages ensured that a high percentage completed all 3 doses.

Effectiveness of a smartphone app on improving immunization of children in rural Sichuan Province, China: a cluster randomized controlled trial

Background

The aim of this study was to assess the effectiveness of an EPI smartphone application (EPI app) on improving vaccination coverage in rural Sichuan Province, China.

Methods

This matched-pair cluster randomized controlled study included 32 village doctors, matched in 16 pairs, and took place from 2013 to 2015. Village doctors in the intervention group used the EPI app and reminder text messages while village doctors in the control group used their usual procedures and text messages. The primary outcome was full vaccination coverage with all five vaccines (1 dose of BCG, 3 doses of hepatitis B, 3 doses of OPV, 3 doses of DPT and 1 dose of measles vaccine), and the secondary outcome was coverage with each dose of the five individual vaccines. We also conducted qualitative interviews with village doctors to understand perceptions on using the EPI app and how this changed their vaccination work.

Results

The full vaccination coverage increased statistically significant from baseline to end-line in both the intervention (67 % [95 % CI:58-75 %] to 84 % [95 % CI:76-90 %], P = 0.028) and control group (71 % [95 % CI:62-79 %] to 82 % [95 % CI:74-88 %], P = 0.014). The intervention group had higher increase in full vaccination coverage from baseline to end-line compared to the control group (17 % vs 10 %), but this was not statistically significant (P = 0.164). Village doctors found it more convenient to use the EPI app to manage child vaccination and also reported saving time by looking up information of caregivers and contacting caregivers for overdue vaccinations quicker. However, village doctors found it hard to manage children who migrated out of the counties.

Conclusions

This study showed that an app and text messages can be used by village doctors to improve full vaccination coverage, though no significant increase in vaccination coverage was found when assessing the effect of the app on its own. Village doctors using EPI app reported having improved their working efficiency of managing childhood vaccination. Future studies should be conducted to evaluate the impact of more integrated approach of mHealth intervention on child immunization.

Trial registration

Chinese Clinical Trials Registry (ChiCTR): ChiCTR-TRC-13003960, registered on December 6, 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3549-0) contains supplementary material, which is available to authorized users.

Sharing success - understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease

BACKGROUND

Rheumatic fever (RF) and rheumatic heart disease (RHD) cause considerable morbidity and mortality amongst Australian Aboriginal and Torres Strait Islander populations. Secondary antibiotic prophylaxis in the form of 4-weekly benzathine penicillin injections is the mainstay of control programs. Evidence suggests, however, that delivery rates of such prophylaxis are poor.

METHODS

This qualitative study used semi-structured interviews with patients, parents/care givers and health professionals, to explore the enablers of and barriers to the uptake of secondary prophylaxis. Data from participant interviews (with 11 patients/carers and 11 health practitioners) conducted in four far north Queensland sites were analyzed using the method of constant comparative analysis.

RESULTS

Deficits in registration and recall systems and pain attributed to injections were identified as barriers to secondary prophylaxis uptake. There were also varying perceptions regarding responsibility for ensuring injection delivery. Enablers of secondary prophylaxis uptake included positive patient-healthcare provider relationships, supporting patient autonomy, education of patients, care givers and healthcare providers, and community-based service delivery.

CONCLUSION

The study findings provide insights that may facilitate enhancement of secondary prophylaxis delivery systems and thereby improve uptake of secondary prophylaxis for RF/RHD.

Impact of an SMS advice programme on maternal and newborn health in rural China: study protocol for a quasi-randomised controlled trial

INTRODUCTION

Expectant mothers in low-income and middle-income countries often lack access to vital information about pregnancy, preparation for birth and best practices when caring for their newborn. Innovative solutions are needed to bridge this knowledge gap and dramatically improve maternal and neonatal health in these settings. This study aims to evaluate the impact of an innovative text messaging intervention on maternal and neonatal health outcomes.

METHODS AND ANALYSIS

This study offers expectant mothers in rural China a package of free short messages via cell phone regarding pregnancy and childbirth. These messages are tailored to each mother's gestational week. It is hypothesised that delivering these short advice messages to pregnant women can improve maternal and newborn health. The study uses factorial quasi-randomisation to compare psychological, behavioural and health outcomes between 4 groups: 2 groups receiving different sets of short message interventions (ie, good household prenatal practices and healthcare seeking), a group receiving both interventions and a control group. Treatment assignment occurs at the individual level. The primary outcome is newborn health, measured by appropriateness of weight for gestational age. Secondary outcomes include severe neonatal and maternal morbidity as well as psychological and behavioural measures. This study has enrolled pregnant women who attend county maternal and child health centres for their prenatal visits.

DISCUSSION

This pilot is the first large-scale effort to build a comprehensive evidence base on the impact of prenatal text messages via cell phone on maternal and newborn health outcomes in China. The study has broad implications for public health policy in China and the implementation of mobile health interventions in low-resource settings around the world.

ETHICS

This study was approved by the Ethics Committee of the School of Medicine at Xi'an Jiaotong University on 18 January 2013.

TRIAL REGISTRATION NUMBER

NCT02037087; Pre-results.

A qualitative evaluation to explore the suitability, feasibility and acceptability of using a 'celebration card' intervention in primary care to improve the uptake of childhood vaccinations

BACKGROUND

Childhood vaccination remains a primary mechanism for reducing the burden of infectious disease. In the United Kingdom, as in many countries, a sustained effort is required to ensure that vaccination targets are met to afford protection to the whole population from vaccine preventable disease. The Celebrate and Protect programme is a collaborative partnership developed to improve the uptake of childhood vaccination across a number of boroughs within London through the use of a celebration card to encourage attendance for vaccination and enhance relationships between general practices and the parents/carers of children.

METHODS

This study was undertaken to assess the suitability, feasibility and acceptability of the Celebrate and Protect programme across nine boroughs in London. Data were collected either from telephone interviews (n = 24) or from focus groups (n = 31). A total of 55 key informants were included in the study, representing strategic, commissioning or policy leads, healthcare professionals and primary care teams delivering vaccinations and parents/carers of children under five.

RESULTS

The analysis of data identified that whilst parents/carers saw the celebration card positively this raised the issue of 'vaccine hesitancy' and the lack of information that parents/carers have to make informed decisions about vaccination. Similarly, healthcare professionals viewed the programme positively and felt that it was deliverable within existing resources although they raised wider questions about on-going sustainability and about quantitative data collection. In relation to the collaboration between primary care and a pharmaceutical company in developing the Celebrate and Protect programme, it was generally felt that, provided appropriate governance is in place, it was a pragmatic approach in which the benefits outweighed any perceived disadvantages.

DISCUSSION

The Celebrate and Protect programme was seen as an innovative collaborative programme to engage with parents and carers of children in order to improve relationships between service users and providers and subsequently increase vaccination uptake. The analysis demonstrates that that the celebration card is suitable for its purpose, acceptable to both healthcare professionals and to parents/carers of children and the Celebrate and Protect programme has been able to deliver its aims.

CONCLUSION

Whilst the delivery of the 'celebration card' intervention in primary met its objectives there are some outstanding issues in terms of the sustainability of the initiative and the ability to demonstrate quantitative improvements in vaccination uptake rates.

Interventions for improving coverage of childhood immunisation in low- and middle-income countries

BACKGROUND

Immunisation is a powerful public health strategy for improving child survival, not only by directly combating key diseases that kill children but also by providing a platform for other health services. However, each year millions of children worldwide, mostly from low- and middle-income countries (LMICs), do not receive the full series of vaccines on their national routine immunisation schedule. This is an update of the Cochrane review published in 2011 and focuses on interventions for improving childhood immunisation coverage in LMICs.

OBJECTIVES

To evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in LMICs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 4, part of The Cochrane Library. www.cochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 12 May 2016); MEDLINE In-Process and Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 12 May 2016); CINAHL 1981 to present, EbscoHost (searched 12 May 2016); Embase 1980 to 2014 Week 34, OvidSP (searched 2 September 2014); LILACS, VHL (searched 2 September 2014); Sociological Abstracts 1952 - current, ProQuest (searched 2 September 2014). We did a citation search for all included studies in Science Citation Index and Social Sciences Citation Index, 1975 to present; Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 2 July 2016). We also searched the two Trials Registries: ICTRP and ClinicalTrials.gov (searched 5 July 2016) SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT), non-RCTs, controlled before-after studies, and interrupted time series conducted in LMICs involving children aged from birth to four years, caregivers, and healthcare providers.

DATA COLLECTION AND ANALYSIS

We independently screened the search output, reviewed full texts of potentially eligible articles, assessed risk of bias, and extracted data in duplicate; resolving discrepancies by consensus. We then conducted random-effects meta-analyses and used GRADE to assess the certainty of evidence.

MAIN RESULTS

Fourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community-based health education (three studies), facility-based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).We found moderate-certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria-tetanus-pertussis vaccines (DTP3: risk ratio (RR) 1.68, 95% confidence interval (CI) 1.09 to 2.59). We also found low-certainty evidence that facility-based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low-certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low-certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low-certainty evidence). Home visits to identify non-vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low-certainty evidence). There was low-certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).

AUTHORS' CONCLUSIONS

Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well-conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

Can mobile technologies improve on-time vaccination? A study piloting maternal use of ImmunizeCA, a Pan-Canadian immunization app

Mobile applications have the potential to influence vaccination behavior, including on-time vaccination. We sought to determine whether the use of a mobile immunization app was associated with the likelihood of reporting on-time vaccination in a cohort of 50 childbearing women. In this pilot study, we describe participant reported app use, knowledge, attitudes or beliefs regarding pediatric vaccination and technology readiness index (TRI) scores. To explore if app use is associated with change in attitudes, beliefs or behavior, participants were instructed complete a baseline survey at recruitment then download the app. A follow up survey followed 6-months later, reexamining concepts from the first survey as well as collecting participant TRI scores. Changes in Likert scores between pre and post survey questions were compared and multivariate logistic regression was used to assess the relationship between TRI score and select survey responses. Thirty-two percent of participants perceived that the app made them more likely to vaccinate on time. We found some individuals' attitudes toward vaccines improved, some became less supportive and in others there was no change. The mean participant TRI score was 3.25(IQR 0.78) out of a maximum score of 5, indicating a moderate level of technological adoption among the study cohort population. While the app was well received, these preliminary results showed participant attitudes toward vaccination moved dichotomously. Barriers to adoption remain in both usability and accessibility of mobile solutions, which are in part dependent on the user's innate characteristics such as technology readiness.

Improving Rates of Influenza Vaccination Through Electronic Health Record Portal Messages, Interactive Voice Recognition Calls and Patient-Enabled Electronic Health Record Updates: Protocol for a Randomized Controlled Trial

BACKGROUND

Clinical decision support (CDS), including computerized reminders for providers and patients, can improve health outcomes. CDS promoting influenza vaccination, delivered directly to patients via an electronic health record (EHR) patient portal and interactive voice recognition (IVR) calls, offers an innovative approach to improving patient care.

OBJECTIVE

To test the effectiveness of an EHR patient portal and IVR outreach to improve rates of influenza vaccination in a large multispecialty group practice in central Massachusetts.

METHODS

We describe a nonblinded, randomized controlled trial of EHR patient portal messages and IVR calls designed to promote influenza vaccination. In our preparatory phase, we conducted qualitative interviews with patients, providers, and staff to inform development of EHR portal messages with embedded questionnaires and IVR call scripts. We also provided practice-wide education on influenza vaccines to all physicians and staff members, including information on existing vaccine-specific EHR CDS. Outreach will target adult patients who remain unvaccinated for more than 2 months after the start of the influenza season. Using computer-generated randomization and a factorial design, we will assign 20,000 patients who are active users of electronic patient portals to one of the 4 study arms: (1) receipt of a portal message promoting influenza vaccines and offering online appointment scheduling; (2) receipt of an IVR call with similar content but without appointment facilitation; (3) both (1) and (2); or (4) neither (1) nor (2) (usual care). We will randomize patients without electronic portals (10,000 patients) to (1) receipt of IVR call or (2) usual care. Both portal messages and IVR calls promote influenza vaccine completion. Our primary outcome is percentage of eligible patients with influenza vaccines administered at our group practice during the 2014-15 influenza season. Both outreach methods also solicit patient self-report on influenza vaccinations completed outside the clinic or on barriers to influenza vaccination. Self-reported data from both outreach modes will be uploaded into the EHR to increase accuracy of existing provider-directed EHR CDS (vaccine alerts).

RESULTS

With our proposed sample size and using a factorial design, power calculations using baseline vaccination rate estimates indicated that 4286 participants per arm would give 80% power to detect a 3% improvement in influenza vaccination rates between groups (α=.05; 2-sided). Intention-to-treat unadjusted chi-square analyses will be performed to assess the impact of portal messages, either alone or in combination with the IVR call, on influenza vaccination rates. The project was funded in January 2014. Patient enrollment for the project described here completed in December 2014. Data analysis is currently under way and first results are expected to be submitted for publication in 2016.

CONCLUSIONS

If successful, this study's intervention may be adapted by other large health care organizations to increase vaccination rates among their eligible patients.

CLINICALTRIAL

ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277 (Archived by WebCite at http://www.webcitation.org/6fbLviHLH).

Appointment reminder systems are effective but not optimal: results of a systematic review and evidence synthesis employing realist principles

Missed appointments are an avoidable cost and resource inefficiency which impact upon the health of the patient and treatment outcomes. Health care services are increasingly utilizing reminder systems to manage these negative effects. This study explores the effectiveness of reminder systems for promoting attendance, cancellations, and rescheduling of appointments across all health care settings and for particular patient groups and the contextual factors which indicate that reminders are being employed sub-optimally. We used three inter-related reviews of quantitative and qualitative evidence. Firstly, using pre-existing models and theories, we developed a conceptual framework to inform our understanding of the contexts and mechanisms which influence reminder effectiveness. Secondly, we performed a review following Centre for Reviews and Dissemination guidelines to investigate the effectiveness of different methods of reminding patients to attend health service appointments. Finally, to supplement the effectiveness information, we completed a review informed by realist principles to identify factors likely to influence non-attendance behaviors and the effectiveness of reminders. We found consistent evidence that all types of reminder systems are effective at improving appointment attendance across a range of health care settings and patient populations. Reminder systems may also increase cancellation and rescheduling of unwanted appointments. "Reminder plus", which provides additional information beyond the reminder function may be more effective than simple reminders (ie, date, time, place) at reducing non-attendance at appointments in particular circumstances. We identified six areas of inefficiency which indicate that reminder systems are being used sub-optimally. Unless otherwise indicated, all patients should receive a reminder to facilitate attendance at their health care appointment. The choice of reminder system should be tailored to the individual service. To optimize appointment and reminder systems, health care services need supportive administrative processes to enhance attendance, cancellation, rescheduling, and re-allocation of appointments to other patients.

SMS text message reminders to improve infant vaccination coverage in Guatemala: A pilot randomized controlled trial

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A novel SMS vaccine reminder platform was created in a LMIC.

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SMS vaccine reminders were proven feasible to implement in a LMIC.

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SMS vaccine reminders were acceptable to use in a LMIC with high user satisfaction.

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SMS vaccine reminders have the potential for widespread scalability at low cost.

Background

Patient reminder systems are an evidence-based way to improve childhood vaccination rates but are difficult to implement in low- and middle-income countries (LMICs). Short Message Service (SMS) texts may offer a potential low-cost solution, especially in LMICs where mobile phones are becoming more ubiquitous.

Objective

To determine if an SMS-based vaccination reminder system aimed at improving completion of the infant primary immunization series is feasible and acceptable in Guatemala.

Methods

A pilot randomized controlled trial was conducted at two public health clinics in Guatemala City. Infants aged 8–14 weeks presenting for the first dose of the primary immunization series were enrolled in March–April 2013. Participants randomized into the intervention received three SMS reminders one week before the second and third dose. A follow-up acceptability survey was administered to both groups.

Results

The participation rate was 86.8% (321/370); 8 did not own a cell phone and 12 could not use SMS. 96.9% of intervention parents were sent at least one SMS reminder prior to visit 2 and 96.3% prior to visit 3. Both intervention and usual care participants had high rates of vaccine and visit completion, with a non-statistically significant higher percentage of children in the intervention completing both visit 2 (95.0% vs. 90.1%, p = .12) and visit 3 (84.4% vs. 80.7%, p = .69). More intervention vs. usual care parents agreed that SMS reminders would be helpful for remembering appointments (p < .0001), agreed to being interested in receiving future SMS reminders (p < .0001), and said that they would be willing to pay for future SMS reminders (p = .01).

Conclusion

This proof of concept evaluation showed that a new application of SMS technology is feasible to implement in a LMIC with high user satisfaction. Larger studies with modifications in the SMS system are needed to determine effectiveness (Clinical Trial Registry NCT01663636).

Parental Choice of Recall Method for HPV Vaccination: A Pragmatic Trial

OBJECTIVES

Completion rates for the human papillomavirus vaccine (HPV) series among adolescents remain low. Effectiveness of recall with parents choosing the method (preference-based recall) for increasing HPV series completion is unstudied. Within a cluster-randomized trial, we examined effectiveness of preference-based recall compared with usual care for increasing series completion and the association of recall choices with completion.

METHODS

All Kaiser Permanente Colorado pediatric practices (n = 7) were randomized to intervention (n = 4) or control (n = 3) by using covariate-constrained randomization. From January to June 2013, parents at intervention practices whose adolescents received HPV 1 were asked the recall method they preferred for subsequent doses and if they also wanted their child reminded. Completion rates were assessed 1 year after HPV 1.

RESULTS

At intervention practices, 374 (43%) of 867 patients were enrolled; 39% preferred text, 18% e-mail, 9% auto-dialer, and 34% 2-methods; 19% chose to have adolescent also recalled. Intervention adolescents were more likely to complete (63% vs 38%) than were controls (adjusted risk ratio 1.47 [1.38-1.57]) and less likely to be late in completing the series (45% vs 57%, P = .02). Rates of completion were similar between different recall methods, but significantly higher for those preferring e-mail and phone compared withother methods (90% vs 60%. P = .008). Completion rates were similar for adolescents who also received recalls (62%) versus those who did not (63%).

CONCLUSIONS

Preference-based recall was effective in increasing HPV series completion rates, with point estimates substantially higher than for most published studies of reminder/recall.

Text messaging reminders for influenza vaccine in primary care: a cluster randomised controlled trial (TXT4FLUJAB)

OBJECTIVES

(1) To develop methods for conducting cluster randomised trials of text messaging interventions utilising routine electronic health records at low cost; (2) to assess the effectiveness of text messaging influenza vaccine reminders in increasing vaccine uptake in patients with chronic conditions.

DESIGN

Cluster randomised trial with general practices as clusters.

SETTING

English primary care.

PARTICIPANTS

156 general practices, who used text messaging software, who had not previously used text message influenza vaccination reminders. Eligible patients were aged 18-64 in 'at-risk' groups.

INTERVENTIONS

Practices were randomly allocated to either an intervention or standard care arm in the 2013 influenza season (September to December). Practices in the intervention arm were asked to send a text message influenza vaccination reminder to their at-risk patients under 65. Practices in the standard care arm were asked to continue their influenza campaign as planned.

BLINDING

Practices were not blinded. Analysis was performed blinded to practice allocation.

MAIN OUTCOME MEASURES

Practice-level influenza vaccine uptake among at-risk patients aged 18-64 years.

RESULTS

77 practices were randomised to the intervention group (76 analysed, n at-risk patients=51,121), 79 to the standard care group (79 analysed, n at-risk patients=51,136). The text message increased absolute vaccine uptake by 2.62% (95% CI -0.09% to 5.33%), p=0.058, though this could have been due to chance. Within intervention clusters, a median 21.0% (IQR 10.2% to 47.0%) of eligible patients were sent a text message. The number needed to treat was 7.0 (95% CI -0.29 to 14.3).

CONCLUSIONS

Patient follow-up using routine electronic health records is a low cost method of conducting cluster randomised trials. Text messaging reminders are likely to result in modest improvements in influenza vaccine uptake, but levels of patients being texted need to markedly increase if text messaging reminders are to have much effect.

TRIAL REGISTRATION NUMBER

ISRCTN48840025.

Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review

BACKGROUND

Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents.

METHODS

Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose.

RESULTS

Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis.

CONCLUSIONS

Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial

Background

Despite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50 % of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families.

Methods/Design

We will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families’ healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby’s health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital.

We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care.

Discussion

This study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia.

Trial Registration

Australian New Zealand Clinical Trials Registry

Registration number: ACTRN12615000976583 

Date registered: 17 September 2015

Using Digital Technology to Engage and Communicate with Patients: A Survey of Patient Attitudes

BACKGROUND

As primary care moves toward a system of population health management, providers will need to engage patients outside traditional office-based interactions.

OBJECTIVE

We assessed patient attitudes regarding technology use to communicate with their primary care team or to engage with other patients outside typical office settings. Design/Participants/Main Measures We conducted a national survey using GfK KnowledgePanel(®) to examine attitudes on the use of digital technology (email, text messaging, and social media such as Facebook and Twitter) to communicate with primary care teams about health behavior goals and test results. We also assessed attitudes toward the use of digital technologies to engage with other patients in activities such as peer coaching.

KEY RESULTS

Of the 5119 panel members invited to participate, 3336 completed the survey (response rate, 65.2 %). Among respondents, more than half (58 %) reported using Facebook, and nearly two-thirds (64.1 %) used text messaging. Overall, few participants were willing to communicate about health goals via social media (3.1 %) or text messaging (13.3 %), compared to email (48.8 %) or phone (75.5 %) (results were similar for communication about test results). Among those that used text messaging, race/ethnicity was the only factor independently associated with greater support for text messaging [African American (OR 1.44; 95 % CI, 1.01-2.06) and Hispanic (OR 1.8; 95 % CI, 1.25-2.59)] in multivariate models. Participants interested in engaging in peer coaching through Facebook (11.7 %) were more likely to be younger (p < 0.0001), female (p < 0.001), and a racial/ethnic minority (African American, non-Hispanic or Hispanic, p < 0.0004).

CONCLUSIONS

Despite regular use of new digital technology such as text messaging and social media, few participants supported using these tools for communicating with their physicians' practice. Participants were most supportive of using email for communication. Contrary to previous studies, among users of technology, low socioeconomic status and racial/ethnic minorities were equally or more likely to support use.

Influenza Vaccination: A Cross-Sectional Survey of Knowledge, Attitude and Practices among the Lebanese Adult Population

BACKGROUND

Influenza is a common preventable infectious disease associated with high mortality and morbidity. Vaccination is the most cost-effective measure to prevent influenza, yet the vaccine uptake is known to be low. No previous studies have assessed the rate of seasonal influenza vaccination use among the Lebanese population, nor examined the knowledge and attitudes towards the influenza vaccine.

METHODS

A cross-sectional survey was performed in 30 pharmacies randomly selected across Lebanon. A 19-item questionnaire was used to record influenza vaccination status, knowledge and attitudes towards the influenza vaccine among the Lebanese general population.

RESULTS

The survey response rate was 93%. Among the 640 study participants, the overall 2014-2015 seasonal influenza vaccination rate was 27.6%. The majority of participants (72.4%) reported irregular uptake of the vaccine. Results of the multivariate analysis revealed that elderly people (OR = 2.25, CI = 1.08-4.71), with higher education (OR = 1.42, CI = 1.09-1.84), higher physical activity (OR significantly higher than 1 for all categories), and chronic respiratory disease (OR = 3.24, CI = 1.58-6.62) were more regularly vaccinated, while those who visit the doctor "only when needed" (OR = 0.55, CI = 0.34-0.88) and those who consume more than seven drinks/week (OR = 0.24, CI = 0.09-0.65) were less regularly vaccinated. When introducing knowledge and attitude variables to the model, "thinking that the vaccine was not needed" was the only correlate that demonstrated a significant inverse association with regular influenza vaccination (OR = 0.15; p = 0.017).

CONCLUSIONS

Suboptimal vaccination rates exist among the Lebanese ambulatory adult population. Clear misinformation on the importance of regular influenza immunization is also highlighted. This evidence underscores a compelling need to raise public awareness regarding the efficacy of the influenza vaccine.

Did you get your shots? Experimental evidence on the role of reminders

Many families fail to vaccinate their children despite the supply of these services at no cost. This study tests whether personal reminders can increase demand for vaccination. A field experiment was conducted in rural Guatemala in which timely reminders were provided to families whose children were due for a vaccine. The six-month intervention increased the probability of vaccination completion by 2.2 percentage points among all children in treatment communities. Moreover, for children in treatment communities who were due to receive a vaccine, and whose parents were expected to be reminded about that due date, the probability of vaccination completion increased by 4.6 percentage points. The cost of an additional child with complete vaccination due to the intervention is estimated at about $7.50.

Promoting HPV Vaccination in Safety-Net Clinics: A Randomized Trial

OBJECTIVES

Evaluate effects of a multicomponent intervention (human papillomavirus [HPV] vaccine-specific brochure and recalls) on HPV vaccination and secondarily examine if race/ethnicity moderates effects.

METHODS

Unvaccinated girls aged 11 to 18 years attending 4 safety-net pediatric clinics and their parent/guardian (n = 814 dyads) were randomized to (1) active comparison (general adolescent vaccine brochure), or (2) intervention consisting of a HPV vaccine-specific brochure, telephone recalls to parents who declined, and recalls to patients overdue for doses 2 and 3. HPV 1-dose and 3-dose coverages were assessed via electronic health records 12 months after randomization. Multivariate logistic regressions estimated adjusted odds and marginal predicted vaccine coverage by study arm and race/ethnicity.

RESULTS

Intent-to-treat analyses found no main effect of the HPV vaccine-specific brochure on 1-dose coverage (42.0% vs 40.6%); however, secondary analyses found race/ethnicity was a significant moderator such that the intervention was effective only for Hispanic individuals (adjusted odds ratio [AOR] 1.43; 95% confidence interval [CI] 1.02-2.02), and not effective for black individuals (AOR 0.64; 95% CI 0.41-1.13). Recalls to parents who declined the vaccine during the index visit were not effective, but recalls to patients overdue for doses 2 and 3 were effective at increasing 3-dose coverage regardless of race/ethnicity (AOR 1.99; 95% CI 1.16-3.45).

CONCLUSIONS

Educational materials describing only the HPV vaccine were effective for Hispanic but not black individuals. Future research should test mechanisms that may mediate intervention effects for different racial/ethnic groups, such as different informational needs or vaccine schemas (experiences, beliefs, norms).

Effectiveness and Cost of Bidirectional Text Messaging for Adolescent Vaccines and Well Care

OBJECTIVE

To evaluate the effectiveness and cost of bidirectional short messaging service in increasing rates of vaccination and well child care (WCC) among adolescents.

METHODS

We included all adolescents needing a recommended adolescent vaccine (n = 4587) whose parents had a cell-phone number in 5 private and 2 safety-net pediatric practices. Adolescents were randomized to intervention (n = 2228) or control (n = 2359). Parents in the intervention group received up to 3 personalized short messaging services with response options 1 (clinic will call to schedule), 2 (parent will call clinic), or STOP (no further short messaging service). Primary outcomes included completion of all needed services, WCC only, all needed vaccinations, any vaccination, and missed opportunity for vaccination.

RESULTS

Intervention patients were more likely to complete all needed services (risk ratio [RR] 1.31, 95% confidence interval [CI] 1.12-1.53), all needed vaccinations (RR 1.29, 95% CI 1.12-1.50), and any vaccination (RR 1.36, 95% CI 1.20-1.54). Seventy-five percent of control patients had a missed opportunity versus 69% of intervention (P = .002). There was not a significant difference for WCC visits. Responding that the clinic should call to schedule ("1") was associated with the highest effect size for completion of all needed services (RR 1.89, 95% CI 1.41-2.54). Net cost ranged from $855 to $3394 per practice.

CONCLUSIONS

Bidirectional short messaging service to parents was effective at improving rates for all adolescent vaccinations and for all needed services, especially among parents who responded they desired a call from the practice.

Text message reminders do not improve hepatitis B vaccination rates in an Australian sexual health setting

OBJECTIVE

To evaluate the impact of text message reminders (short messaging service (SMS)) on hepatitis B virus (HBV) vaccination completion among high risk sexual health center attendees.

MATERIALS AND METHODS

In September 2008, Sydney Sexual Health Centre implemented an SMS reminder system. The authors assessed the impact of the reminder system on HBV vaccination rates among patients who initiated a course. The authors used a chi-square test and multivariate logistic regression to determine if SMS reminders were associated with second and third dose vaccine completion, compared with patients prior to the intervention.

RESULTS

Of patients sent SMS reminders in 2009 (SMS group), 54% (130/241) received 2 doses and 24% (58/241) received 3 doses, compared to 56% (258/463) (P = 0.65) and 30% (141/463) (P = 0.07) in the pre-SMS group (2007), respectively. Findings did not change after adjusting for baseline characteristics significantly different between study groups. There were no significant differences in completion rates among people who injected drugs, HIV-negative gay and bisexual men (GBM), and HIV-positive GBM. Among sex workers, travelers, and people who reported sex overseas, second and third dose completion rates were significantly lower in the SMS group compared to the pre-SMS group. In the SMS group, 18% of those who only had one dose attended the clinic within 1-18 months and 30% of those who had 2 doses attended in 6-18 months, but vaccination was missed.

DISCUSSION

SMS reminders did not increase second or third vaccine dose completion in this population.

CONCLUSION

Clinician prompts to reduce missed opportunities and multiple recall interventions may be needed to increase HBV vaccination completion in this high risk population.

Electronic and postal reminders for improving immunisation coverage in children: protocol for a systematic review and meta-analysis

INTRODUCTION

Worldwide, suboptimal immunisation coverage causes the deaths of more than one million children under five from vaccine-preventable diseases every year. Reasons for suboptimal coverage are multifactorial, and a combination of interventions is needed to improve compliance with immunisation schedules. One intervention relies on reminders, where the health system prompts caregivers to attend immunisation appointments on time or re-engages caregivers who have defaulted on scheduled appointments. We undertake this systematic review to investigate the potential of reminders using emails, phone calls, social media, letters or postcards to improve immunisation coverage in children under five.

METHODS AND ANALYSIS

We will search for published and unpublished randomised controlled trials and non-randomised controlled trials in PubMed, Scopus, CINAHL, CENTRAL, Science Citation Index, WHOLIS, Clinicaltrials.gov and the WHO International Clinical Trials Platform. We will conduct screening of search results, study selection, data extraction and risk-of-bias assessment in duplicate, resolving disagreements by consensus. In addition, we will pool data from clinically homogeneous studies using random-effects meta-analysis; assess heterogeneity of effects using the χ(2) test of homogeneity; and quantify any observed heterogeneity using the I(2) statistic.

ETHICS AND DISSEMINATION

This protocol does not need approval by an ethics committee because we will use publicly available data, without directly involving human participants. The results will provide updated evidence on the effects of electronic and postal reminders on immunisation coverage, and we will discuss the applicability of the findings to low and middle-income countries. We plan to disseminate review findings through publication in a peer-reviewed journal and presentation at relevant conferences. In addition, we will prepare a policymaker-friendly summary using a validated format (eg, SUPPORT Summary) and disseminate this through social media and email discussion groups.

REVIEW REGISTRATION NUMBER

PROSPERO registration number CRD42014012888.

Vaccination of adolescents with chronic medical conditions: Special considerations and strategies for enhancing uptake

Adolescents with chronic medical conditions (CMCs), a growing population worldwide, possess a wide array of preventive health care needs. Vaccination is strongly recommended for the vast majority of these adolescents given their increased risk of vaccine preventable infection and associated complications. Not only should they receive routine vaccines, but some also require additional vaccines. Despite these guidelines, evidence suggests that adolescents with CMCs often fail to receive needed vaccines. Many factors contribute to this under-immunization, including lack of knowledge among parents and providers and suboptimal coordination of primary and subspecialty care. This review describes current vaccination recommendations for these adolescents as well as recent data related to infection risk, vaccine efficacy and safety, vaccination coverage, and the unique multilevel factors impacting uptake in this population. It also discusses strategies for improving coverage levels and reducing missed vaccination opportunities, with a particular focus on technology-based interventions.

National Immunization Program: Computerized System as a tool for new challenges

The scope and coverage of the Brazilian Immunization Program can be compared with those in developed countries because it provides a large number of vaccines and has a considerable coverage. The increasing complexity of the program brings challenges regarding its development, high coverage levels, access equality, and safety. The Immunization Information System, with nominal data, is an innovative tool that can more accurately monitor these indicators and allows the evaluation of the impact of new vaccination strategies. The main difficulties for such a system are in its implementation process, training of professionals, mastering its use, its constant maintenance needs and ensuring the information contained remain confidential. Therefore, encouraging the development of this tool should be part of public health policies and should also be involved in the three spheres of government as well as the public and private vaccination services.

Improving adherence to national recommendations for zoster vaccination through simple interventions

OBJECTIVE

In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers.

METHODS

General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey.

RESULTS

Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey.

CONCLUSIONS

Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.

The Role of eHealth in Optimizing Preventive Care in the Primary Care Setting

Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world’s morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.

Barriers to childhood immunisation: Findings from the Longitudinal Study of Australian Children

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A known group of under-immunising parents in Australia are conscientious objectors.

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However we found that most under-immunising parents do not disagree with immunisation.

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These parents experience a heterogeneous range of barriers to immunisation.

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Eg low social contact, psychological distress, large families, child health concerns.

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Tailored interventions are required to address these varying needs.

Objectives

To examine barriers to childhood immunisation experienced by parents in Australia.

Design

Cross-sectional analysis of secondary data.

Setting

Nationally representative Longitudinal Study of Australian Children (LSAC).

Participants

Five thousand one hundred seven infants aged 3–19 months in 2004.

Main outcome measure

Maternal report of immunisation status: incompletely or fully immunised.

Results

Overall, 9.3% (473) of infants were incompletely immunised; of these just 16% had mothers who disagreed with immunisation. Remaining analyses focussed on infants whose mother did not disagree with immunisation (N = 4994) (of whom 8% [398] were incompletely immunised).

Fifteen variables representing potential immunisation barriers and facilitators were available in LSAC; these were entered into a latent class model to identify distinct clusters (or ‘classes’) of barriers experienced by families. Five classes were identified: (1) ‘minimal barriers’, (2) ‘lone parent, mobile families with good support’, (3) ‘low social contact and service information; psychological distress’, (4) ‘larger families, not using formal childcare’, (5) ‘child health issues/concerns’. Compared to infants from families experiencing minimal barriers, all other barrier classes had a higher risk of incomplete immunisation. For example, the adjusted risk ratio (RR) for incomplete immunisation was 1.51 (95% confidence interval: 1.08–2.10) among those characterised by ‘low social contact and service information; psychological distress’, and 2.47 (1.87–3.25) among ‘larger families, not using formal childcare’.

Conclusions

Using the most recent data available for examining these issues in Australia, we found that the majority of incompletely immunised infants (in 2004) did not have a mother who disagreed with immunisation. Barriers to immunisation are heterogeneous, suggesting a need for tailored interventions.

Evaluating the implementation of the 13-valent pneumococcal vaccine supplementary dose program in Australian primary health care settings

BACKGROUND

The availability of new pneumococcal conjugate vaccines covering a broader range of serotypes, has seen many countries introduce these into their national immunisation program. When transitioning from 7-valent to 13-valent pneumococcal conjugate vaccines, Australia is one of a small number of countries that included a supplementary dose of the 13-valent pneumococcal conjugate vaccine to offer protection against additional serotypes to an expanded age group of children. An evaluation of the implementation and uptake of the 13-valent pneumococcal conjugate vaccine supplementary dose was undertaken in two local health districts (LHDs) in New South Wales, Australia.

METHODS

A self-administered postal survey of immunisation providers in the Northern New South Wales and Mid North Coast LHDs. Trends in vaccine ordering were examined. Coverage was assessed using data from the Australian Childhood Immunisation Register (ACIR).

RESULTS

Of the 177 surveys sent, 125 were returned (70%). Almost all providers (96%) were aware of the 13vPCV supplementary dose program though took an opportunistic approach to program promotion and parental reminders. Supplementary doses of 13vPCV were ordered for 37% of the eligible cohort, mostly in the program's first six months. Coverage as recorded on the ACIR was 27%, though was lower in older children and those not due for scheduled childhood vaccines. Of the children who received the 13vPCV supplementary dose, 3% received it at the same time as vaccines due at 12-months of age, and 44% at the time of those due at 18-months of age.

CONCLUSION

Despite the high awareness of the program, reported coverage was lower than that for other PCV supplementary dose programs in Australia and internationally. This may be influenced by providers' largely opportunistic approach to implementation, under-reporting to the ACIR or vaccine uptake. Lessons learned from this evaluation are relevant for future time-limited childhood vaccination programs. Prior to commencement, providers should be informed about the importance of catch-up/supplementary vaccination for their patients and their active role in promoting this. They should also receive program information before parents. An understanding of parental reasons for non-receipt of time-limited childhood vaccines and evaluation of the effect of aligning supplementary (or catch up) vaccination programs with the NIP schedule would be useful to inform future programs.

Experiences, perceptions and preferences of mothers towards childhood immunization reminder/recall in Ibadan, Nigeria: a cross-sectional study

INTRODUCTION

Immunization reminder/recall system is proven as one of the effective ways of improving immunization rates. Prior to the development and implementation of an immunization reminder/recall system intervention, we explored the experiences, preferences and perceptions towards childhood immunization reminder/recall among 614 mothers of infants in Ibadan, Nigeria.

METHODS

A cross-sectional health facility-based survey utilizing a semi-structured questionnaire was conducted in four Primary Health Care centers. Descriptive statistics were computed using SPSS. Logistic models were used to investigate the relationships with specific outcomes.

RESULTS

Only 3.9% had ever heard of immunization reminder/recall and 1.5% had ever received one. However, 97.9% were willing to record their cellphone numbers in the clinics for immunization reminder/recall and 95.1% were willing to receive. Their preferred communication modes were cell phone calls (57.6%) or text messages/SMS (35.6%). Only 2.2% preferred home-visits and 0.4%, e-mails. About 4% were not willing to receive any form of immunization reminder/recall. Mothers with post-secondary education were more likely to prefer SMS than other mothers (OR 2.3, 95% CI 1.7-3.3, p.

CONCLUSION

This study provided critical baseline data for designing a reminder/recall intervention for routine childhood immunization in the study communities. The findings may serve as a guide for public health professionals in designing reminder/recall strategies to improve childhood immunization.

Adult immunization schedule. The general practitioner's perspective and new tools for a better practice

Vaccine-preventable disease significantly contributes to the morbidity and mortality of adults worldwide. The rates of vaccination against influenza, pneumococcal disease and tetanus in adults and in high-risk group of people are far from the optimal coverage as suggested by Minister of Health. General Practitioners (GPs) can contribute to increase immunization in adults and in elderly people because these age groups attend frequently the surgery of their family doctors for reasons related to their chronic diseases. The GPs, on their side, can proactively involve patients through informatics tools that supply lists of specific patients and electronic alerts in patient records.

Effectiveness of short message services reminder on childhood immunization programme in Kadoma, Zimbabwe - a randomized controlled trial, 2013

BACKGROUND

Globally, non-attendance for immunization appointments remains a challenge to healthcare providers. A review of the 2011 immunization coverage for Kadoma City, Zimbabwe was 74% for Oral Polio Vaccine (OPV), Pneumococcal and Pentavalent antigens. The immunization coverage was less than 90%, which is the target for Kadoma City. Adoption of short message services (SMS) reminders has been shown to enhance attendance in some medical settings. The study was conducted to determine the effectiveness of SMS reminders on immunization programme for Kadoma City.

METHODS

A randomized controlled trial was conducted at Kadoma City clinics in Zimbabwe. Women who delivered and were residents of Kadoma City were recruited into the study. In the intervention group, SMS reminders were sent at 6, 10 and 14 weeks in addition to routine health education. In the non-intervention no SMS reminders were used, however routine health education was offered. Data were collected using interviewer administered questionnaire. Data were analyzed using Epi Info 7™, where frequencies, means, risk ratios and risk differences were generated.

RESULTS

A total of 304 participants were recruited, 152 for the intervention group and 152 for the non-intervention group. The immunization coverage at 6 weeks was 97% in the intervention group and 82% in the non-intervention group (p < 0.001). At 14 weeks immunization coverage was 95% for intervention and 75% for non-intervention group (p < 0.001). Those who did not delay receiving immunization at 14 weeks was 82% for the intervention and 8% for non-intervention group. Median delay for intervention was 0 days (Q1 = 0; Q3 = 0) and 10 days (Q1 = 6; Q3 = 17) for non-intervention group. The risk difference (RD) for those who received SMS reminders than those in the non intervention group was 16.3% (95% CI: 12.5-28.0) at 14 weeks.

CONCLUSION

Immunization coverage in the intervention group was significantly higher than in non-intervention group. Overall increase in immunization coverage can be attributed to use of SMS.

TRIAL REGISTRATION

ISRCTN70918594 . Registration Date: 28 August 2014.

The influence of partial public reimbursement on vaccination uptake in the older population: a cross-sectional study

Background

Flu vaccination is recommended annually for high risk groups. However, in Ireland, free access to vaccination is not universal for those in high risk groups; the vaccine and consultation are only free for those with a medical card, a means tested scheme. Few private health insurance policies cover the cost of attendance for vaccination in general practice. The aim was to examine the influence of this reimbursement policy on vaccination coverage among older adults.

Methods

Cross-sectional wave 1 data from The Irish Longitudinal Study on Ageing (TILDA) were analysed (2009–2011). TILDA is a nationally representative prospective cohort study of adults aged ≥50, sampled using multistage stratified clustered sampling. Self-reported entitlement to healthcare was categorised as 1) medical card only 2) private health insurance only, 3) both and 4) neither. The outcome was responses to ‘have you ever had a flu shot’. Multivariate logistic regression was used, adjusting for age and need.

Results

68.6% of those defined as clinically high-risk received the flu vaccination in the past (95% CI = 67-71%). Those with a medical card were almost twice as likely to have been vaccinated, controlling for age and chronic illness (OR = 1.9, 95% CI = 1.5-2.5, p = <0.001).

Conclusions

Having a medical card increased the likelihood of being vaccinated, independent of age and need. The mismatch between vaccination guidelines and reimbursement policy is creating unequal access to recommended services among high risk groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1356-7) contains supplementary material, which is available to authorized users.

Financial incentives for increasing uptake of HPV vaccinations: a randomized controlled trial

OBJECTIVE

Uptake of human papillomavirus (HPV) vaccinations by 17- to 18-year-old girls in England is below (<35%) target (80%). This trial assesses (a) the impact of financial incentives on uptake and completion of an HPV vaccination program, and (b) whether impacts are moderated by participants' deprivation level. It also assesses the impact of incentives on decision quality to get vaccinated, as measured by attitudes toward the vaccination and knowledge of its consequences.

METHOD

One thousand 16- to 18-year-old girls were invited to participate in an HPV vaccination program: 500 previously uninvited, and 500 unresponsive to previous invitations. Girls randomly received either a standard invitation letter or a letter including the offer of vouchers worth £ 45 (€ 56; $73) for undergoing 3 vaccinations. Girls attending their first vaccination appointment completed a questionnaire assessing decision quality to be vaccinated. Outcomes were uptake of the first and third vaccinations and decision quality.

RESULTS

The intervention increased uptake of the first (first-time invitees: 28.4% vs. 19.6%, odds ratio [OR] = 1.63, 95% confidence interval [CI; 1.08, 2.47]; previous nonattenders: 23.6% vs. 10.4%, OR = 2.65, 95% CI [1.61, 4.38]) and third (first-time invitees: 22.4% vs. 12%, OR = 2.15, 95% CI [1.32, 3.50]; previous nonattenders: 12.4% vs. 3%, OR = 4.28, 95% CI [1.92, 9.55]) vaccinations. Impacts were not moderated by deprivation level. Decision quality was unaffected by the intervention.

CONCLUSIONS

Although the intervention increased completion of HPV vaccinations, uptake remained lower than the national target, which, in addition to cost effectiveness and acceptability issues, necessitates consideration of other ways of achieving it.

How can screening colonoscopy be optimized?

Since the implementation of screening programmes, both the incidence and mortality of colorectal cancer have been decreasing. The choice of the preferred screening tool, however, is divergent and the adherence to screening programmes in most countries is still low. Cancer detection tests such as the guaiac faecal occult blood test (gFOBT) and the immunohistochemical FOBT (iFOBT) achieve higher acceptance than endoscopy. The sensitivity and specificity of iFOBT are higher than those of gFOBT, but gFOBT is cheaper and easier to perform. Endoscopic screening, which represents cancer prevention tests, has higher sensitivity for premalignant lesions than gFOBT and iFOBT and enables diagnosis and therapy in one single procedure. Since screening colonoscopy and sigmoidoscopy are invasive procedures with potentially severe adverse events, the highest possible quality must be provided. High-tech equipment, experience, training, quality control programmes, excellent bowel preparation and low adverse event rates are pivotal. Alternative screening tools such as CT colonography, barium enema CT and multitarget stool DNA tests have not been established as routine screening tools to date.

Interventions aimed at communities to inform and/or educate about early childhood vaccination

BACKGROUND

A range of strategies are used to communicate with parents, caregivers and communities regarding child vaccination in order to inform decisions and improve vaccination uptake. These strategies include interventions in which information is aimed at larger groups in the community, for instance at public meetings, through radio or through leaflets. This is one of two reviews on communication interventions for childhood vaccination. The companion review focuses on face-to-face interventions for informing or educating parents.

OBJECTIVES

To assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE and five other databases up to July 2012. We searched for grey literature in the Grey Literature Report and OpenGrey. We also contacted authors of included studies and experts in the field. There were no language, date or settings restrictions.

SELECTION CRITERIA

Individual or cluster-randomised and quasi-randomised controlled trials, interrupted time series (ITS) and repeated measures studies, and controlled before-and-after (CBA) studies. We included interventions aimed at communities and intended to inform and/or educate about vaccination in children six years and younger, conducted in any setting. We defined interventions aimed at communities as those directed at a geographic area, and/or interventions directed to groups of people who share at least one common social or cultural characteristic. Primary outcomes were: knowledge among participants of vaccines or vaccine-preventable diseases and of vaccine service delivery; child immunisation status; and unintended adverse effects. Secondary outcomes were: participants' attitudes towards vaccination; involvement in decision-making regarding vaccination; confidence in the decision made; and resource use or cost of intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed risk of bias in all included studies.

MAIN RESULTS

We included two cluster-randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.The trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine-preventable diseases among intervention participants (adjusted mean difference 0.121, 95% confidence interval (CI) 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (risk ratio (RR) 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (diptheria, pertussis and tetanus) (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted mean difference 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision-making regarding childhood vaccination (adjusted mean difference 0.043, 95% CI -0.009 to 0.097).The studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.

AUTHORS' CONCLUSIONS

This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.'

Reminder systems to improve patient adherence to tuberculosis clinic appointments for diagnosis and treatment

BACKGROUND

People with active tuberculosis (TB) require six months of treatment. Some people find it difficult to complete treatment, and there are several approaches to help ensure completion. One such system relies on reminders, where the health system prompts patients to attend for appointments on time, or re-engages people who have missed or defaulted on a scheduled appointment.

OBJECTIVES

To assess the effects of reminder systems on improving attendance at TB diagnosis, prophylaxis, and treatment clinic appointments, and their effects on TB treatment outcomes.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, Cochrane Effective Practice and Organization of Care Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, SCI-EXPANDED, SSCI, mRCT, and the Indian Journal of Tuberculosis without language restriction up to 29 August 2014. We also checked reference lists and contacted researchers working in the field.

SELECTION CRITERIA

Randomized controlled trials (RCTs), including cluster RCTs and quasi-RCTs, and controlled before-and-after studies comparing reminder systems with no reminders or an alternative reminder system for people with scheduled appointments for TB diagnosis, prophylaxis, or treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the included trials. We compared the effects of interventions by using risk ratios (RR) and presented RRs with 95% confidence intervals (CIs). Also we assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Nine trials, including 4654 participants, met our inclusion criteria. Five trials evaluated appointment reminders for people on treatment for active TB, two for people on prophylaxis for latent TB, and four for people undergoing TB screening using skin tests. We classified the interventions into 'pre-appointment' reminders (telephone calls or letters prior to a scheduled appointment) or 'default' reminders (telephone calls, letters, or home visits to people who had missed an appointment).For people being treated for active TB, clinic attendance and TB treatment completion were higher in people receiving pre-appointment reminder phone-calls (clinic attendance: 66% versus 50%; RR 1.32, 95% CI 1.10 to 1.59, one trial (USA), 615 participants, low quality evidence; TB treatment completion: 100% versus 88%; RR 1.14, 95% CI 1.02 to 1.27, one trial (Thailand), 92 participants, low quality evidence). Clinic attendance and TB treatment completion were also higher with default reminders (letters or home visits) (clinic attendance: 52% versus 10%; RR 5.04, 95% CI 1.61 to 15.78, one trial (India), 52 participants, low quality evidence; treatment completion: RR 1.17, 95% CI 1.11 to 1.24, two trials (Iraq and India), 680 participants, moderate quality evidence).For people on TB prophylaxis, clinic attendance was higher with a policy of pre-appointment phone-calls (63% versus 48%; RR 1.30, 95% CI 1.07 to 1.59, one trial (USA), 536 participants); and attendance at the final clinic was higher with regular three-monthly phone-calls or nurse visits (93% versus 65%, one trial (Spain), 318 participants).For people undergoing screening for TB, three trials of pre-appointment phone-calls found little or no effect on the proportion of people returning to clinic for the result of their skin test (three trials, 1189 participants, low quality evidence), and two trials found little or no effect with take home reminder cards (two trials, 711 participants). All four trials were conducted among healthy volunteers in the USA.

AUTHORS' CONCLUSIONS

Policies of sending reminders to people pre-appointment, and contacting people who miss appointments, seem sensible additions to any TB programme, and the limited evidence available suggests they have small but potentially important benefits. Future studies of modern technologies such as short message service (SMS) reminders would be useful, particularly in low-resource settings.

Partnering with middle school students to design text messages about HPV vaccination

Human papillomavirus (HPV) vaccination is routinely recommended for U.S. adolescents ages 11 to 12 years, yet vaccine coverage remains low. Text message HPV immunization reminders to parents have been effective with increasing uptake, but text messages directly to adolescents in order to increase HPV vaccination uptake are unknown. The purpose of this study was to examine the acceptability of text messages about HPV vaccination and message preferences among adolescents. Middle school students (n = 43) assisted in designing text messages to promote HPV vaccine among their peers. Through seven focus groups and two in-class surveys, we assessed students' knowledge of HPV vaccine, use of texting, and preferences for text messages and sources. The average age of participants was 13 years, and all were White (17 males, 26 females) in this rural setting. More than 70% used text messaging with a cell phone. The text message with the best composite score (M = 2.33, SD = 0.72) for likeability, trustworthiness, and motivation to seek more information was a gain frame emphasizing reduction in HPV infection if vaccinated against HPV. Text messages with lower scores emphasized threats of disease if not vaccinated. Participants (68%) preferred doctors as their information source. Text messaging to adolescents may be a strategy to improve HPV knowledge and vaccination.

Vaccination management and vaccination errors: a representative online-survey among primary care physicians

BACKGROUND

Effective immunizations require a thorough, multi-step process, yet few studies comprehensively addressed issues around vaccination management.

OBJECTIVES

To assess variations in vaccination management and vaccination errors in primary care.

METHODS

A cross sectional, web-based questionnaire survey was performed among 1157 primary physicians from North Rhine-Westphalia, Germany: a representative 10% random sample of general practitioners (n = 946) and all teaching physicians from the University Duisburg-Essen (n = 211). Four quality aspects with three items each were included: patient-related quality (patient information, patient consent, strategies to increase immunization rates), vaccine-related quality (practice vaccine spectrum, vaccine pre-selection, vaccination documentation), personnel-related quality (recommendation of vaccinations, vaccine application, personnel qualification) and storage-related quality (storage device, temperature log, vaccine storage control). For each of the four quality aspects, "good quality" was reached if all three criteria per quality aspect were fulfilled. Good vaccination management was defined as fulfilling all twelve items. Additionally, physicians' experiences with errors and nearby-errors in vaccination management were obtained.

RESULTS

More than 20% of the physicians participated in the survey. Good vaccination management was reached by 19% of the practices. Patient-related quality was good in 69% of the practices, vaccine-related quality in 73%, personnel-related quality in 59% and storage-related quality in 41% of the practices. No predictors for error reporting and good vaccination management were identified.

CONCLUSIONS

We identified good results for vaccine- and patient-related quality but need to improve issues that revolve around vaccine storage.

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.

Age-specific strategies for immunization reminders and recalls: a registry-based randomized trial

BACKGROUND

Although previous studies have found reminder/recall to be effective in increasing immunization rates, little guidance exists regarding the specific ages at which it is optimal to send reminder/recall notices.

PURPOSE

To assess the relative effectiveness of centralized reminder/recall strategies targeting age-specific vaccination milestones among children in urban areas during June 2008-June 2009.

METHODS

Three reminder/recall strategies used capabilities of the Michigan Care Improvement Registry (MCIR), a statewide immunization information system: a 7-month recall strategy, a 12-month reminder strategy, and a 19-month recall strategy. Eligible children were randomized to notification (intervention) or no notification groups (control). Primary study outcomes included MCIR-recorded immunization activity (administration of ≥1 new dose, entry of ≥1 historic dose, entry of immunization waiver) within 60 days following each notification cycle.

RESULTS

A total of 10,175 children were included: 2,072 for the 7-month recall, 3,502 for the 12-month reminder, and 4,601 for the 19-month recall. Immunization activity was similar between notification versus no notification groups at both 7 and 12 months. Significantly more 19-month-old children in the recall group (26%) had immunization activity compared to their counterparts who did not receive a recall notification (19%).

CONCLUSIONS

Although recall notifications can positively affect immunization activity, the effect may vary by targeted age group. Many 7- and 12-month-olds had immunization activity following reminder/recall; however, levels of activity were similar irrespective of notification, suggesting that these groups were likely to receive medical care or immunization services without prompting.