Patient reminder and patient recall systems to improve immunization rates

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

INTRODUCTION

The UK government recommends that at least 75% of people aged under 64 with certain conditions receive an annual influenza vaccination. Primary care practices often fall short of this target and strategies to increase vaccine uptake are required. Text messaging reminders are already used in 30% of practices to remind patients about vaccination, but there has been no trial addressing their effectiveness in increasing influenza vaccine uptake in the UK. The aims of the study are (1) to develop the methodology for conducting cluster randomised trials of text messaging interventions utilising routine electronic health records and (2) to assess the effectiveness of using a text messaging influenza vaccine reminder in achieving an increase in influenza vaccine uptake in patients aged 18-64 with chronic conditions, compared with standard care.

METHODS AND ANALYSIS

This cluster randomised trial will recruit general practices across three settings in English primary care (Clinical Practice Research Datalink, ResearchOne and London iPLATO text messaging software users) and randomise them to either standard care or a text messaging campaign to eligible patients. Flu vaccine uptake will be ascertained using routinely collected, anonymised electronic patient records. This protocol outlines the proposed study design and analysis methods.

ETHICS AND DISSEMINATION

This study will determine the effectiveness of text messaging vaccine reminders in primary care in increasing influenza vaccine uptake, and will strengthen the methodology for using electronic health records in cluster randomised trials of text messaging interventions. This trial was approved by the Surrey Borders Ethics Committee (13/LO/0872). The trial results will be disseminated at national conferences and published in a peer-reviewed medical journal. The results will also be distributed to the Primary Care Research Network and to all participating general practices.

TRIAL REGISTRATION NUMBER

This study is registered at controlled-trials.com ISRCTN48840025, July 2013.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Improving preterm infants' immunisation status: a follow-up audit

AIM

Preterm infants are at increased risk of vaccine preventable diseases. An audit in 2007 identified suboptimal immunisation status of preterm infants. The aim of this study was to complete the 'audit loop', reviewing preterm infants' immunisation status at a single tertiary paediatric hospital.

METHODS

A retrospective follow-up immunisation audit was conducted at The Royal Children's Hospital, Melbourne, neonatal unit. The 'audit loop' included a preterm infants' reminder sticker and feedback of the original audit findings to Royal Children's Hospital health-care professionals. Immunisation status was determined using the Australian Childhood Immunisation Register record for all admitted preterm infants born <32 weeks gestation (July 2008-June 2009).

RESULTS

Conducted in March 2011, the median age of participants (n = 57) was 2.5 years (range 1.7-3.1 years). Forty-four per cent (25/57) had a history of chronic lung disease, 86% (49/57) were <1500 g and 42% (24/57) <28 weeks gestation. The majority (96% (55/57)) were up to date with routine immunisations at 12 months of age. There was a 2.4-fold increase, compared with the original audit, for receipt of the additional recommended hepatitis B vaccine at 12 months of age, as well as influenza vaccine in infants with chronic lung disease.

CONCLUSION

This study showed that a simple reminder combined with education strategies can improve vaccine delivery in special risk groups such as preterm infants.

Vaccination coverage and its determinants among migrant children in Guangdong, China

Background

Guangdong province attracted more than 31 million migrants in 2010. But few studies were performed to estimate the complete and age-appropriate immunization coverage and determine risk factors of migrant children.

Methods

1610 migrant children aged 12–59 months from 70 villages were interviewed in Guangdong. Demographic characteristics, primary caregiver’s knowledge and attitude toward immunization, and child’s immunization history were obtained. UTD and age-appropriate immunization rates for the following five vaccines and the overall series (1:3:3:3:1 immunization series) were assessed: one dose of BCG, three doses of DTP, OPV and HepB, one dose of MCV. Risk factors for not being UTD for the 1:3:3:3:1 immunization series were explored.

Results

For each antigen, the UTD immunization rate was above 71%, but the age-appropriate immunization rates for BCG, HepB, OPV, DPT and MCV were only 47.8%, 45.1%, 47.1%, 46.8% and 37.2%, respectively. The 1st dose was most likely to be delayed within them. For the 1:3:3:3:1 immunization series, the UTD immunization rate and age-appropriate immunization rate were 64.9% and 12.4% respectively. Several factors as below were significantly associated with UTD immunization. The primary caregiver’s determinants were their occupation, knowledge and attitude toward immunization. The child’s determinants were sex, Hukou, birth place, residential buildings and family income.

Conclusions

Alarmingly low immunization coverage of migrant children should be closely monitored by NIISS. Primary caregiver and child’s determinants should be considered when taking measures. Strategies to strengthen active out-reach activities and health education for primary caregivers needed to be developed to improve their immunization coverage.

Novel immunization reminder/recall approaches: rural and urban differences in parent perceptions

OBJECTIVE

To assess the following among parents of young children: (1) preferences about the source of immunization reminder/recall (R/R) messages, (2) the degree of acceptability of different R/R modalities, and (3) factors that influence preferences, including rural and urban characteristics.

METHODS

We conducted a survey among parents of children 19 to 35 months old who needed ≥1 immunization according to the Colorado Immunization Information System (CIIS). Equal numbers of urban and rural respondents were randomly selected. Up to 4 surveys were mailed to each parent who had a valid address.

RESULTS

After removing invalid addresses, the response rate was 55% (334 of 607). Half of parents (49.7%) had no preference about whether the public health department or their child's doctor sent reminders. Urban parents were more likely to prefer R/R come from their child's doctor (46.7%) compared to rural parents (33.7%), P = .003. Mail was the preferred R/R method (57.7%), then telephone (17.0%), e-mail (12.7%), and text message (10.7%). Although not preferred, 60.1% reported it would be acceptable to receive R/R by e-mail and 46.2% by text message. Factors associated with preferring to receive R/R from their child's doctor were urban residence and educational level of college graduate or greater.

CONCLUSIONS

A large portion of parents are willing to be reminded about vaccinations by their health department rather than their child's provider and via novel modalities, such as e-mail or text messaging. Urbanicity and higher educational level were associated with preferring that R/R come from a provider.

Pharmacy-based Immunization in Rural Communities Strategy (PhICS): A community cluster-randomized trial

BACKGROUND

Influenza is a major cause of morbidity and mortality in Canada, with up to 7000 influenza-related deaths occurring every year. The elderly and individuals with chronic diseases are at increased risk for influenza-related morbidity and mortality.

METHODS

We conducted a 2-year, community cluster-randomized trial targeting elderly people and at-risk groups to assess the effectiveness of pharmacy-based influenza vaccination clinics on influenza vaccination rates. Small rural communities in interior and northern British Columbia were randomly allocated to the intervention or control. In the intervention communities, pharmacy-based influenza vaccination clinics were held and were promoted to eligible patients using personalized invitations from the pharmacists, invitations distributed opportunistically by a pharmacist to eligible patients presenting to pharmacies during the flu season and community-wide promotion using posters and the local media. The main outcome measure was a difference in the mean influenza vaccination rates. The immunization rates were calculated using the number of immunizations given in each community divided by the population size estimated from the census data.

RESULTS

Baseline influenza immunization rates in the population ≥65 years of age were the same in the control (n = 10, mean 85.6% [SD 16.6]) and intervention (n = 14, mean 83.8% [SD 16.3]) communities in 2009 (p = 0.79). In 2010, the mean influenza immunization rate was 56.9% (SD 28.0) in the control communities (n = 15) and 80.1% (SD 18.4) in the intervention communities (n = 14) (p = 0.01) for those ≥65 years of age. However, in 2010, for those 2 to 64 years with chronic medical conditions, the immunization rates were lower in the intervention communities (mean 16.3% [SD 7.1]) compared with the control communities (mean 21.2% [SD 5.8]) (p = 0.04).

CONCLUSION

Clinics were feasible and well attended and they resulted in increased vaccination rates for elderly residents. In contrast, vaccination rates in the younger population with comorbidities remained low and unchanged.

Assessing vaccination coverage in infants, survey studies versus the Flemish immunisation register: achieving the best of both worlds

Infant immunisation coverage in Flanders, Belgium, is monitored through repeated coverage surveys. With the increased use of Vaccinnet, the web-based ordering system for vaccines in Flanders set up in 2004 and linked to an immunisation register, this database could become an alternative to quickly estimate vaccination coverage. To evaluate its current accuracy, coverage estimates generated from Vaccinnet alone were compared with estimates from the most recent survey (2012) that combined interview data with data from Vaccinnet and medical files. Coverage rates from registrations in Vaccinnet were systematically lower than the corresponding estimates obtained through the survey (mean difference 7.7%). This difference increased by dose number for vaccines that require multiple doses. Differences in administration date between the two sources were observed for 3.8-8.2% of registered doses. Underparticipation in Vaccinnet thus significantly impacts on the register-based immunisation coverage estimates, amplified by underregistration of administered doses among vaccinators using Vaccinnet. Therefore, survey studies, despite being labour-intensive and expensive, currently provide more complete and reliable results than register-based estimates alone in Flanders. However, further improvement of Vaccinnet's completeness will likely allow more accurate estimates in the nearby future.

High uptake of HPV immunisation in Scotland--perspectives on maximising uptake

In September 2008, Scotland introduced a national human papillomavirus (HPV) immunisation programme with bivalent HPV vaccine, to prevent cervical cancer. This school-based programme routinely vaccinates girls aged between 12 and 13 years. A catch-up campaign, running over three years, also began at this time, offering vaccination to all girls aged 13 years to under 18 years old. The HPV immunisation campaign presented challenges due to this vaccine being targeted to girls in school and older girls who had left school. Following a long and comprehensive planning process, this campaign was successfully implemented across Scotland, delivering high vaccine uptake of 91.4% for three doses of vaccine in the first year (September 2008 to August 2009) for the routine cohort and 90.1% in the second year (September 2009 to August 2010) for the routine cohort. We describe the planning process, challenges and implementation strategies employed to achieve this high uptake.

Recommendations for a national agenda to substantially reduce cervical cancer

PURPOSE

Prophylactic human papillomavirus (HPV) vaccines and new HPV screening tests, combined with traditional Pap test screening, provide an unprecedented opportunity to greatly reduce cervical cancer in the USA. Despite these advances, thousands of women continue to be diagnosed with and die of this highly preventable disease each year. This paper describes the initiatives and recommendations of national cervical cancer experts toward preventing and possibly eliminating this disease.

METHODS

In May 2011, Cervical Cancer-Free America, a national initiative, convened a cervical cancer summit in Washington, DC. Over 120 experts from the public and private sector met to develop a national agenda for reducing cervical cancer morbidity and mortality in the USA.

RESULTS

Summit participants evaluated four broad challenges to reducing cervical cancer: (1) low use of HPV vaccines, (2) low use of cervical cancer screening, (3) screening errors, and (4) lack of continuity of care for women diagnosed with cervical cancer. The summit offered 12 concrete recommendations to guide future national and local efforts toward this goal.

CONCLUSIONS

Cervical cancer incidence and mortality can be greatly reduced by better deploying existing methods and systems. The challenge lies in ensuring that the array of available prevention options are accessible and utilized by all age-appropriate women-particularly minority and underserved women who are disproportionately affected by this disease. The consensus was that cervical cancer can be greatly reduced and that prevention efforts can lead the way towards a dramatic reduction in this preventable disease in our country.

The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children

INTRODUCTION

In the Saskatoon Health Region (Saskatchewan), only 67.4% of children overall are fully immunized for measles, mumps and rubella (MMR) at 24 months of age, with only 43.7% of low-income children fully immunized.

METHODS

Parents of children who were behind in MMR immunizations were contacted to determine knowledge about, beliefs toward and barriers to immunization. The effectiveness of a telephone reminder system in improving immunization rates in a health region compared with a control health region was determined. Finally, the effectiveness of telephone reminders versus telephone reminders combined with home visits in improving child immunization coverage rates in low-income neighbourhoods was compared.

RESULTS

The survey was completed by 629 parents (69% response rate). Of those, 81.8% were not aware that their child was behind in immunizations. In the Saskatoon Health Region, the MMR immunization coverage increased from 67.4% to 74.0% in the first year of intervention (rate ratio = 1.10; 95% CI 1.08 to 1.12). All four neighbourhood groupings (three urban by income and one rural) had relative increases ranging from 9% to 11%. The control health region observed an immunization coverage increase from 66.5% to 69.2% in the first year (rate ratio = 1.04; 95% CI 1.01 to 1.07). The three low-income neighbourhoods with only telephone reminders had an immunization coverage rate of 48.7% (95% CI 39.5% to 57.8%). The three low-income neighbourhoods that received a telephone reminder and home visit had an immunization coverage rate of 60.5% (95% CI 52.5% to 68.6%).

CONCLUSION

Telephone reminder systems have some benefit in increasing child immunization coverage rates.

Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates

OBJECTIVE

To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs).

DESIGN

Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system.

SETTING

Southwestern Ontario.

PARTICIPANTS

A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives.

INTERVENTIONS

The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services.

MAIN OUTCOME MEASURES

The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months.

RESULTS

Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services.

CONCLUSION

The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.

Population-based versus practice-based recall for childhood immunizations: a randomized controlled comparative effectiveness trial

OBJECTIVES

We compared the effectiveness and cost-effectiveness of population-based recall (Pop-recall) versus practice-based recall (PCP-recall) at increasing immunizations among preschool children.

METHODS

This cluster-randomized trial involved children aged 19 to 35 months needing immunizations in 8 rural and 6 urban Colorado counties. In Pop-recall counties, recall was conducted centrally using the Colorado Immunization Information System (CIIS). In PCP-recall counties, practices were invited to attend webinar training using CIIS and offered financial support for mailings. The percentage of up-to-date (UTD) and vaccine documentation were compared 6 months after recall. A mixed-effects model assessed the association between intervention and whether a child became UTD.

RESULTS

Ten of 195 practices (5%) implemented recall in PCP-recall counties. Among children needing immunizations, 18.7% became UTD in Pop-recall versus 12.8% in PCP-recall counties (P < .001); 31.8% had documented receipt of 1 or more vaccines in Pop-recall versus 22.6% in PCP-recall counties (P < .001). Relative risk estimates from multivariable modeling were 1.23 (95% confidence interval [CI] = 1.10, 1.37) for becoming UTD and 1.26 (95% CI = 1.15, 1.38) for receipt of any vaccine. Costs for Pop-recall versus PCP-recall were $215 versus $1981 per practice and $17 versus $62 per child brought UTD.

CONCLUSIONS

Population-based recall conducted centrally was more effective and cost-effective at increasing immunization rates in preschool children.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Notification about influenza vaccination in Belgium: a descriptive study of how people want to be informed

BACKGROUND

Influenza causes a substantial socioeconomic burden. In Belgium, only 54% of the target group receives an annual vaccination. Patient reminder/recall systems are effective in improving vaccination rates in primary care, but little is known about patients' preferences on notification of influenza vaccination.

AIMS

To evaluate whether general practice patients wish to be notified of the possibility of receiving influenza immunisation, and how.

METHODS

In January 2008, 750 questionnaires were handed out to all consecutive patients aged >18 years in three Belgian general practices. Main outcome measures were the percentage wanting to be notified, demographic and medical factors influencing the information needs of the patients and the specific way in which patients wanted to be notified.

RESULTS

About 80% of respondents wanted to be notified of the possibility of influenza vaccination. Logistic regression analysis showed that those who had previously been vaccinated particularly wished to be notified, both in the total population (OR 4.45; 95% CI 2.87 to 6.90; p<0.0001) and in the subgroup of high-risk individuals (OR 9.05; 95% CI 4.47 to 18.33; p<0.0001). More than 85% of the participants wanted to be informed by their family physician, mostly during a consultation regardless of the reason for the encounter. The second most preferred option was a letter sent by the family physician enclosing a prescription.

CONCLUSIONS

The majority of general practice patients want to be notified of the possibility of influenza vaccination. More than 85% of participants who wanted to be notified preferred to receive this information from their family physician, mostly by personal communication during a regular visit. However, since a large minority preferred to be addressed more proactively (letter, telephone call, e-mail), GPs should be encouraged to combine an opportunistic approach with a proactive one.

Annual Report to the Nation on the Status of Cancer, 1975-2009, featuring the burden and trends in human papillomavirus(HPV)-associated cancers and HPV vaccination coverage levels

Background

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updates on cancer incidence and death rates and trends in these outcomes for the United States. This year’s report includes incidence trends for human papillomavirus (HPV)–associated cancers and HPV vaccination (recommended for adolescents aged 11–12 years).

Methods

Data on cancer incidence were obtained from the CDC, NCI, and NAACCR, and data on mortality were obtained from the CDC. Long- (1975/1992–2009) and short-term (2000–2009) trends in age-standardized incidence and death rates for all cancers combined and for the leading cancers among men and among women were examined by joinpoint analysis. Prevalence of HPV vaccination coverage during 2008 and 2010 and of Papanicolaou (Pap) testing during 2010 were obtained from national surveys.

Results

Death rates continued to decline for all cancers combined for men and women of all major racial and ethnic groups and for most major cancer sites; rates for both sexes combined decreased by 1.5% per year from 2000 to 2009. Overall incidence rates decreased in men but stabilized in women. Incidence rates increased for two HPV-associated cancers (oropharynx, anus) and some cancers not associated with HPV (eg, liver, kidney, thyroid). Nationally, 32.0% (95% confidence interval [CI] = 30.3% to 33.6%) of girls aged 13 to 17 years in 2010 had received three doses of the HPV vaccine, and coverage was statistically significantly lower among the uninsured (14.1%, 95% CI = 9.4% to 20.6%) and in some Southern states (eg, 20.0% in Alabama [95% CI = 13.9% to 27.9%] and Mississippi [95% CI = 13.8% to 28.2%]), where cervical cancer rates were highest and recent Pap testing prevalence was the lowest.

Conclusions

The overall trends in declining cancer death rates continue. However, increases in incidence rates for some HPV-associated cancers and low vaccination coverage among adolescents underscore the need for additional prevention efforts for HPV-associated cancers, including efforts to increase vaccination coverage.

Improving immunization delivery using an electronic health record: the ImmProve project

OBJECTIVE

Though an essential pediatric preventive service, immunizations are challenging to deliver reliably. Our objective was to measure the impact on pediatric immunization rates of providing clinicians with electronic health record-derived immunization prompting.

METHODS

Operating in a large, urban, hospital-based pediatric primary care clinic, we evaluated 2 interventions to improve immunization delivery to children ages 2, 6, and 13 years: point-of-care, patient-specific electronic clinical decision support (CDS) when children overdue for immunizations presented for care, and provider-specific bulletins listing children overdue for immunizations.

RESULTS

Overall, the proportion of children up to date for a composite of recommended immunizations at ages 2, 6, and 13 years was not different in the intervention (CDS active) and historical control (CDS not active) periods; historical immunization rates were high. The proportion of children receiving 2 doses of hepatitis A immunization before their second birthday was significantly improved during the intervention period. Human papillomavirus (HPV) immunization delivery was low during both control and intervention periods and was unchanged for 13-year-olds. For 14-year-olds, however, 4 of the 5 highest quarterly rates of complete HPV immunization occurred in the final year of the intervention. Provider-specific bulletins listing children overdue for immunizations increased the likelihood of identified children receiving catch-up hepatitis A immunizations (hazard ratio 1.32; 95% confidence interval 1.12-1.56); results for HPV and the composite of recommended immunizations were of a similar magnitude but not statistically significant.

CONCLUSIONS

In our patient population, with high baseline uptake of recommended immunizations, electronic health record-derived immunization prompting had a limited effect on immunization delivery. Benefit was more clearly demonstrated for newer immunizations with lower baseline uptake.

HPV vaccination of boys in primary care practices

OBJECTIVE

In October 2011, the Advisory Committee on Immunization Practices (ACIP) recommended the quadrivalent human papillomavirus vaccine (HPV4) for the routine immunization schedule for 11- to 12-year-old boys. Before October 2011, HPV4 was permissively recommended for boys. We conducted a study in 2010 to provide data that could guide efforts to implement routine HPV4 immunization in boys. Our objectives were to describe primary care physicians': 1) knowledge and attitudes about human papillomavirus (HPV)-related disease and HPV4, 2) recommendation and administration practices regarding HPV vaccine in boys compared to girls, 3) perceived barriers to HPV4 administration in boys, and 4) personal and practice characteristics associated with recommending HPV4 to boys.

METHODS

We conducted a mail and Internet survey in a nationally representative sample of pediatricians and family medicine physicians from July 2010 to September 2010.

RESULTS

The response rate was 72% (609 of 842). Most physicians thought that the routine use of HPV4 in boys was justified. Although it was permissively recommended, 33% recommended HPV4 to 11- to 12-year-old boys and recommended it more strongly to older male adolescents. The most common barriers to HPV4 administration were related to vaccine financing. Physicians who reported recommending HPV4 for 11- to 12-year-old boys were more likely to be from urban locations, perceive that HPV4 is efficacious, perceive that HPV-related disease is severe, and routinely discuss sexual health with 11- to 12-year-olds.

CONCLUSIONS

Although most physicians support HPV4 for boys, physician education and evidence-based tools are needed to improve implementation of a vaccination program for males in primary care settings.

Characteristics of 5-year-olds who catch-up with MMR: findings from the UK Millennium Cohort Study

OBJECTIVES

To examine predictors of partial and full measles, mumps and rubella (MMR) vaccination catch-up between 3 and 5 years.

DESIGN

Secondary data analysis of the nationally representative Millennium Cohort Study (MCS).

SETTING

Children born in the UK, 2000-2002.

PARTICIPANTS

751 MCS children who were unimmunised against MMR at age 3, with immunisation information at age 5.

MAIN OUTCOME MEASURES

Catch-up status: unimmunised (received no MMR), partial catch-up (received one MMR) or full catch-up (received two MMRs).

RESULTS

At age 5, 60.3% (n=440) children remained unvaccinated, 16.1% (n=127) had partially and 23.6% (n=184) had fully caught-up. Children from families who did not speak English at home were five times as likely to partially catch-up than children living in homes where only English was spoken (risk ratio 4.68 (95% CI 3.63 to 6.03)). Full catch-up was also significantly more likely in those did not speak English at home (adjusted risk ratio 1.90 (1.08 to 3.32)). In addition, those from Pakistan/Bangladesh (2.40 (1.38 to 4.18)) or 'other' ethnicities (such as Chinese) (1.88 (1.08 to 3.29)) were more likely to fully catch-up than White British. Those living in socially rented (1.86 (1.34 to 2.56)) or 'Other' (2.52 (1.23 to 5.18)) accommodations were more likely to fully catch-up than home owners, and families were more likely to catch-up if they lived outside London (1.95 (1.32 to 2.89)). Full catch-up was less likely if parents reported medical reasons (0.43 (0.25 to 0.74)), a conscious decision (0.33 (0.23 to 0.48)), or 'other' reasons (0.46 (0.29 to 0.73)) for not immunising at age 3 (compared with 'practical' reasons).

CONCLUSIONS

Parents who partially or fully catch-up with MMR experience practical barriers and tend to come from disadvantaged or ethnic minority groups. Families who continue to reject MMR tend to have more advantaged backgrounds and make a conscious decision to not immunise early on. Health professionals should consider these findings in light of the characteristics of their local populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions to improve influenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta-analysis

PURPOSE

Influenza and pneumococcal vaccination rates remain below national targets. We systematically reviewed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults.

METHODS

We included randomized and nonrandomized studies with a concurrent control group. We estimated pooled odds ratios using random effects models, and used the Downs and Black tool to assess the quality of included studies.

RESULTS

Most studies involved elderly primary care patients. Interventions were associated with improvements in the rates of any vaccination (111 comparisons in 77 studies, pooled odds ratio [OR] = 1.61, 95% CI, 1.49-1.75), and influenza (93 comparisons, 65 studies, OR = 1.46, 95% CI, 1.35-1.57) and pneumococcal (58 comparisons, 35 studies, OR = 2.01, 95% CI, 1.72-2.3) vaccinations. Interventions that appeared effective were patient financial incentives (influenza only), audit and feedback (influenza only), clinician reminders, clinician financial incentives (influenza only), team change, patient outreach, delivery site changes (influenza only), clinician education (pneumococcus only), and case management (pneumococcus only). Patient outreach was more effective if personal contact was involved. Team changes were more effective where nurses administered influenza vaccinations independently. Heterogeneity in some pooled odds ratios was high, however, and funnel plots showed signs of potential publication bias. Study quality varied but was not associated with outcomes.

CONCLUSIONS

Quality improvement interventions, especially those that assign vaccination responsibilities to nonphysician personnel or that activate patients through personal contact, can modestly improve vaccination rates in community-dwelling adults. To meet national policy targets, more-potent interventions should be developed and evaluated.

Trends in HPV vaccine initiation among adolescent females in North Carolina, 2008-2010

BACKGROUND

To better target future immunization efforts, we assessed trends and disparities in human papillomavirus (HPV) vaccine initiation among female adolescents in North Carolina over 3 years.

METHODS

We analyzed data from a stratified random sample of 1,427 parents who, between 2008 and 2010, completed two linked telephone surveys: the Behavioral Risk Factor Surveillance System and the Child Health Assessment and Monitoring Program surveys. Weighted analyses examined HPV vaccine initiation for girls ages 11 to 17 years.

RESULTS

HPV vaccine initiation increased modestly over time (2008, 34%; 2009, 41%; 2010, 44%). This upward trend was present within 11 subpopulations of girls, including those who lived in rural areas, were of minority (non-black/non-white) race, or had not recently received a preventive check-up. Looking at differences between groups, HPV vaccine initiation was less common among girls who attended private versus public school, were younger, or lacked a recent check-up. However, the latter difference narrowed over time. The low level of initiation among girls without recent check-ups increased substantially (from 11% to 41%), whereas initiation among girls with recent visits improved little (from 39% to 44%, P(interaction) = 0.007).

CONCLUSIONS

Although HPV vaccine initiation improved among several groups typically at higher risk for cervical cancer, the lack of progress among girls with recent check-ups suggests that missed opportunities for administration have hampered broader improvements.

IMPACT

Achieving widespread coverage of HPV vaccine will require redoubled efforts to vaccinate adolescents during routine care.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.

Non-participation in population-based disease prevention programs in general practice

BACKGROUND

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

METHODS

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

RESULTS

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

CONCLUSIONS

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

Non-participation in population-based disease prevention programs in general practice

Background

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

Methods

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

Results

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

Conclusions

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

A community-based randomized trial of postcard mailings to increase dental utilization among low-income children

PURPOSE

Increasing awareness about the importance of preventive dental care among low-income families has been considered to be key to overcoming nonfinancial access to care barriers for children. The purpose of this randomized, controlled trial was to measure the impact of postcard mailings on dental utilization by low-income children through a dental society program designed to increase access to dental care.

METHODS

Five thousand eight hundred and seven low-income 2- to 4-year-olds were randomly assigned to 1 of 3 groups: (1) Group 1 (n=2,014) received postcards containing information on how to enroll in the Yakima County Access to Baby and Child Dentistry program; (2) Group 2 (n=2,014) received the enrollment information as well as additional information on the availability of fluoride varnish and the need to visit the dentist by the age of 1-year-old; and (3) Group 3 (n=1,779) did not receive postcards.

RESULTS

Preventive services utilization rates were not different among the groups: 61% for Group 1, 62% for Group 2, and 60% for Group 3, although rates were high for a Medicaid population.

CONCLUSIONS

Postcard mailings did not significantly increase utilization of preventive dental services. Other strategies to increase utilization of preventive oral health measures are needed.

Advances in childhood immunisation in South Africa: where to now? Programme managers' views and evidence from systematic reviews

Background

The Expanded Programme on Immunisation (EPI) is one of the most powerful and cost-effective public health programmes to improve child survival. We assessed challenges and enablers for the programme in South Africa, as we approach the 2015 deadline for the Millennium Development Goals.

Methods

Between September 2009 and September 2010 we requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. We collated their responses and searched for systematic reviews on the effectiveness of the proposed solutions; in the Health Systems Evidence, Cochrane Library, and PubMed electronic databases. We screened the search outputs, selected systematic reviews, extracted data, and assessed the quality of included reviews (using AMSTAR) and the quality of the evidence (using GRADE) in duplicate; resolving disagreements by discussion and consensus.

Results

Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes, respectively. The findings from reliable systematic reviews indicate that interactive educational meetings, audit and feedback, and supportive supervision improve healthcare worker performance. Structured and interactive communication tools probably increase parents’ understanding of immunisation; and reminders and recall, use of community health workers, conditional cash transfers, and mass media interventions probably increase immunisation coverage. Finally, a national social health insurance scheme is a potential EPI financing mechanism; however, given the absence of high-quality evidence of effects, its implementation should be pilot-tested and the impacts and costs rigorously monitored.

Conclusion

In line with the Millennium Development Goals, we have to ensure that our children’s right to health, development and survival is respected, protected and promoted. EPI is central to this vision. We found numerous promising strategies for improving EPI performance in South Africa. However, their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation. The strength of our approach comes from having a strong framework for interventions before looking for systematic reviews. Without a framework, we would have been driven by what reviews have been done and what is easily researchable; rather than the values and preferences of key immunisation stakeholders.

Mobile phone messaging reminders for attendance at healthcare appointments

BACKGROUND

Missed appointments are a major cause of inefficiency in healthcare delivery, with substantial monetary costs for the health system, leading to delays in diagnosis and appropriate treatment. Patients' forgetfulness is one of the main reasons for missed appointments, and reminders may help alleviate this problem. Modes of communicating reminders for appointments to patients include face-to-face communication, postal messages, calls to landlines or mobile phones, and mobile phone messaging. Mobile phone messaging applications such as Short Message Service (SMS) and Multimedia Message Service (MMS) could provide an important, inexpensive delivery medium for reminders for healthcare appointments.

OBJECTIVES

To assess the effects of mobile phone messaging reminders for attendance at healthcare appointments. Secondary objectives include assessment of patients' and healthcare providers' evaluation of the intervention; costs; and possible risks and harms associated with the intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2009, Issue 2), MEDLINE (OvidSP) (January 1993 to June 2009), EMBASE (OvidSP) (January 1993 to June 2009), PsycINFO (OvidSP) (January 1993 to June 2009), CINAHL (EbscoHOST) (January 1993 to June 2009), LILACS (January 1993 to June 2009) and African Health Anthology (January 1993 to June 2009). We also reviewed grey literature (including trial registers) and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised controlled trials (QRCTs), controlled before-after (CBA) studies, or interrupted time series (ITS) studies with at least three time points before and after the intervention. We included studies assessing mobile phone messaging as reminders for healthcare appointments. We only included studies in which it was possible to assess effects of mobile phone messaging independent of other technologies or interventions.  

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies against the inclusion criteria, with any disagreements resolved by a third review author. Study design features, characteristics of target populations, interventions and controls, and results data were extracted by two review authors and confirmed by a third author. Primary outcomes of interest were rate of attendance at healthcare appointments. We also considered health outcomes as a result of the intervention, patients' and providers' evaluation of the intervention, perceptions of safety, costs, and potential harms or adverse effects. As the intervention characteristics and outcome measures were similar across included studies, we conducted a meta-analysis to estimate an overall effect size.

MAIN RESULTS

We included four randomised controlled trials involving 3547 participants. Three studies with moderate quality evidence showed that mobile text message reminders improved the rate of attendance at healthcare appointments compared to no reminders (risk ratio (RR) 1.10 (95% confidence interval (CI) 1.03 to 1.17)). One low quality study reported that mobile text message reminders with postal reminders, compared to postal reminders, improved rate of attendance at healthcare appointments (RR 1.10 (95% CI 1.02 to 1.19)). However, two studies with moderate quality of evidence showed that mobile phone text message reminders and phone call reminders had a similar impact on healthcare attendance (RR 0.99 (95% CI 0.95 to 1.03). The costs per attendance of mobile phone text message reminders were shown to be lower compared to phone call reminders. None of the included studies reported outcomes related to harms or adverse effects of the intervention, nor health outcomes or user perception of safety related to the intervention.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that mobile phone text message reminders are more effective than no reminders, and low quality evidence that text message reminders with postal reminders are more effective than postal reminders alone. Further, according to the moderate quality evidence we found, mobile phone text message reminders are as effective as phone call reminders. Overall, there is limited evidence on the effects of mobile phone text message reminders for appointment attendance, and further high-quality research is required to draw more robust conclusions.

Parent opinions about use of text messaging for immunization reminders

Background

Adherence to childhood immunization schedules is a function of various factors. Given the increased use of technology as a strategy to increase immunization coverage, it is important to investigate how parents perceive different forms of communication, including traditional means and text-message reminders.

Objective

To examine current forms of communication about immunization information, parents’ satisfaction levels with these communication modes, perceived barriers and benefits to using text messaging, and the ideal content of text messages for immunization reminders.

Methods

Structured interviews were developed and approved by two Institutional Review Boards. A convenience sample of 50 parents was recruited from two local pediatric clinics. The study included a demographics questionnaire, the shortened form of the Test of Functional Health Literacy for Adults (S-TOFHLA), questions regarding benefits and barriers of text communication from immunization providers, and preferred content for immunization reminders. Content analyses were performed on responses to barriers, benefits, and preferred content (all Cohen’s kappas > 0.70).

Results

Respondents were mostly female (45/50, 90%), white non-Hispanic (31/50, 62%), between 20–41 years (mean = 29, SD 5), with one or two children (range 1–9). Nearly all (48/50, 96%) had an S-TOFHLA score in the “adequate” range. All parents (50/50, 100%) engaged in face-to-face contact with their child’s physician at appointments, 74% (37/50) had contact via telephone, and none of the parents (0/50, 0%) used email or text messages. Most parents were satisfied with the face-to-face (48/50, 96%) and telephone (28/50, 75%) communication. Forty-nine of the 50 participants (98%) were interested in receiving immunization reminders by text message, and all parents (50/50, 100%) were willing to receive general appointment reminders by text message. Parents made 200 comments regarding text-message reminders. Benefits accounted for 63.5% of comments (127/200). The remaining 37.5% (73/200) regarded barriers; however, no barriers could be identified by 26% of participants (13/50). Parents made 172 comments regarding preferred content of text-message immunization reminders. The most frequently discussed topics were date due (50/172, 29%), general reminder (26/172, 26%), and child’s name (21/172, 12%).

Conclusions

Most parents were satisfied with traditional communication; however, few had experienced any alternative forms of communication regarding immunizations. Benefits of receiving text messages for immunization reminders far outweighed the barriers identified by parents. Few barriers identified were text specific. Those that were, centered on cost if parents did not have unlimited texting plans.

Individual and contextual factors associated with low childhood immunisation coverage in sub-Saharan Africa: a multilevel analysis

Background

In 2010, more than six million children in sub-Saharan Africa did not receive the full series of three doses of the diphtheria-tetanus-pertussis vaccine by one year of age. An evidence-based approach to addressing this burden of un-immunised children requires accurate knowledge of the underlying factors. We therefore developed and tested a model of childhood immunisation that includes individual, community and country-level characteristics.

Method and Findings

We conducted multilevel logistic regression analysis of Demographic and Health Survey data for 27,094 children aged 12–23 months, nested within 8,546 communities from 24 countries in sub-Saharan Africa. According to the intra-country and intra-community correlation coefficient implied by the estimated intercept component variance, 21% and 32% of the variance in unimmunised children were attributable to country- and community-level factors respectively. Children born to mothers (OR 1.35, 95%CI 1.18 to 1.53) and fathers (OR 1.13, 95%CI 1.12 to 1.40) with no formal education were more likely to be unimmunised than those born to parents with secondary or higher education. Children from the poorest households were 36% more likely to be unimmunised than counterparts from the richest households. Maternal access to media significantly reduced the odds of children being unimmunised (OR 0.94, 95%CI 0.94 to 0.99). Mothers with health seeking behaviours were less likely to have unimmunised children (OR 0.56, 95%CI 0.54 to 0.58). However, children from urban areas (OR 1.12, 95% CI 1.01 to 1.23), communities with high illiteracy rates (OR 1.13, 95% CI 1.05 to 1.23), and countries with high fertility rates (OR 4.43, 95% CI 1.04 to 18.92) were more likely to be unimmunised.

Conclusion

We found that individual and contextual factors were associated with childhood immunisation, suggesting that public health programmes designed to improve coverage of childhood immunisation should address people, and the communities and societies in which they live.

Completion of the human papillomavirus vaccine series among insured females between 2006 and 2009

BACKGROUND

Completion of the human papillomavirus (HPV) vaccine in a large percentage of young females is an important goal to prevent anogenital cancers associated with HPV. The current study examined whether the percentage of insured women who complete the vaccine series has changed across time, and how provider type and age at initiation affects rates of completion.

METHODS

This retrospective cohort study used administrative data from a private insurance company. The study included 271,976 females in whom the HPV vaccine series was initiated and who had been continuously enrolled in their respective insurance plan for 365 days after vaccine initiation. Multivariate logistic regression was used to determine the odds of completing the vaccine series within 365 days after initiation.

RESULTS

Females aged 13 years to 18 years, 19 years to 26 years, and ≥ 27 years were found to be less likely than those ages 9 years to 12 years to complete their HPV vaccine series. Obstetricians/gynecologists were more likely to administer vaccines to completers than pediatricians, whereas clinics, nurses, family care practitioners, and specialists were less likely to administer initial vaccines to completers compared with pediatricians. The results of the current study also found that females aged 9 years to 12 years and 13 years to 18 years had lower odds of completing the HPV vaccine series for each subsequent year compared with those aged 19 years to 26 years and ≥ 27 years.

CONCLUSIONS

Among insured females in the United States, the percentage of females who complete the HPV vaccine series is dropping over time, especially among younger females, who are specifically targeted to receive the vaccine. Physicians need to stress the importance of completing all 3 vaccinations to their patients.

Coverage for the entire population: tackling immunization rates and disparities in Saskatoon Health Region

OBJECTIVE

Our objective was to determine the effectiveness of an intervention, the Immunization Reminders Project, in terms of a) improving vaccination coverage rates for measles, mumps and rubella (MMR) among 2-year-olds and b) ameliorating geographical disparities in early childhood immunization coverage.

TARGET POPULATION

All 14-month-old and 20-month-old children in Saskatoon Health Region who were overdue for their immunizations.

SETTING

Saskatoon Health Region (SHR).

INTERVENTION

The intervention involved calling the parents/caregivers of the children in the target population with a reminder about immunizations. After five telephone calls and if the parent/caregiver could not be reached, a letter was mailed to the last known address. If there was no response to the letter, a reminder home visit was attempted for families residing in the low-income neighbourhoods in Saskatoon. Since January 2009, all reminders for families not residing in the low-income neighbourhoods in Saskatoon are made through mailed letters.

OUTCOMES

After the introduction of the Immunization Reminders Project, coverage rates among 2-year-olds for MMR increased significantly overall and in most geographical areas examined. Disparities between geographical subgroups appeared to be declining, but not significantly.

CONCLUSION

A universal approach to early childhood immunization can likely contribute to increases in coverage rates, but there is still room for improvement in SHR. These findings have prompted additional practice and policy changes.

Improving the quality of immunization delivery to an at-risk population: a comprehensive approach

OBJECTIVE

Immunization quality improvement (QI) interventions are rarely tested as multicomponent interventions within the context of a theoretical framework proven to improve outcomes. Our goal was to study a comprehensive QI program to increase immunization rates for underserved children that relied on recommendations from the Centers for Disease Control and Prevention's Task Force on Community Preventive Services and the framework of the Chronic Care Model.

METHODS

QI activities occurred from September 2007 to May 2008 at 6 health centers serving a low-income, minority population in Washington, DC. Interventions included family reminders, education, expanding immunization access, reminders and feedback for providers, and coordination of activities with community stakeholders. We determined project effectiveness in improving the 4:3:1:3:3:1:3 vaccination series (4 diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 measles-mumps-rubella vaccine, 3 Haemophilus influenzae type b vaccines, 3 hepatitis B vaccines, 1 varicella vaccine, and three 7-valent pneumococcal conjugate vaccines) compliance.

RESULTS

We found a 16% increase in immunization rates overall and a 14% increase in on-time immunization by 24 months of age. Improvement was achieved at all 6 health centers and maintained beyond 18 months.

CONCLUSION

We were able to implement a comprehensive immunization QI program that was sustainable over time.

The impact of missed opportunities on seasonal influenza vaccination coverage for healthy young children

OBJECTIVE

To estimate the impact of missed opportunities on influenza vaccination coverage among 6- through 23-month-old children who sought medical care during the 2004-2005 influenza season.

DESIGN

Retrospective cohort study.

SETTING

Fifty-two primary care practice sites located in Rochester, New York, Nashville, Tennessee, and Cincinnati, Ohio.

PARTICIPANTS

Children 6 through 23 months of age. METHODS/OUTCOME MEASURE: Charts were reviewed and data collected on influenza vaccinations, type of health care visit (well child or other), and presence of illness symptoms. Missed opportunity was defined as a practice visit by an eligible child during influenza season, when vaccine was available, but during which the child did not receive an influenza vaccination. Vaccine was assumed to be available between the first and last dates influenza vaccination was recorded at that practice. Each child was classified as fully vaccinated, partially vaccinated, or unvaccinated.

RESULTS

Data were analyzed for 1724 children, 6 through 23 months of age. Most children (62.0%) had at least 1 missed opportunity during this period. Among children with any missed opportunities, 12.8% were fully and 29.8% were partially vaccinated. Overall, 33.6% of the missed opportunities occurred during well child visits and 66.4% during other types of visits; 75% occurred when no other vaccines were given. Eliminating all missed opportunities would have increased full vaccination coverage from 30.3% to 49.9%.

CONCLUSIONS

Missed opportunities for influenza vaccination are frequent. Reducing missed opportunities could significantly increase influenza vaccination rates and should be a goal in each practice.

Informatics technology mimics ecology: dense, mutualistic collaboration networks are associated with higher publication rates

Information technology (IT) adoption enables biomedical research. Publications are an accepted measure of research output, and network models can describe the collaborative nature of publication. In particular, ecological networks can serve as analogies for publication and technology adoption. We constructed network models of adoption of bioinformatics programming languages and health IT (HIT) from the literature.

We selected seven programming languages and four types of HIT. We performed PubMed searches to identify publications since 2001. We calculated summary statistics and analyzed spatiotemporal relationships. Then, we assessed ecological models of specialization, cooperativity, competition, evolution, biodiversity, and stability associated with publications.

Adoption of HIT has been variable, while scripting languages have experienced rapid adoption. Hospital systems had the largest HIT research corpus, while Perl had the largest language corpus. Scripting languages represented the largest connected network components. The relationship between edges and nodes was linear, though Bioconductor had more edges than expected and Perl had fewer. Spatiotemporal relationships were weak. Most languages shared a bioinformatics specialization and appeared mutualistic or competitive. HIT specializations varied. Specialization was highest for Bioconductor and radiology systems. Specialization and cooperativity were positively correlated among languages but negatively correlated among HIT. Rates of language evolution were similar. Biodiversity among languages grew in the first half of the decade and stabilized, while diversity among HIT was variable but flat. Compared with publications in 2001, correlation with publications one year later was positive while correlation after ten years was weak and negative.

Adoption of new technologies can be unpredictable. Spatiotemporal relationships facilitate adoption but are not sufficient. As with ecosystems, dense, mutualistic, specialized co-habitation is associated with faster growth. There are rapidly changing trends in external technological and macroeconomic influences. We propose that a better understanding of how technologies are adopted can facilitate their development.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Text4Health: impact of text message reminder-recalls for pediatric and adolescent immunizations

OBJECTIVES

We conducted 2 studies to determine the impact of text message immunization reminder-recalls in an urban, low-income population.

METHODS

In 1 study, text message immunization reminders were sent to a random sample of parents (n = 195) whose children aged 11 to 18 years needed either or both meningococcal (MCV4) and tetanus-diphtheria-acellular pertussis (Tdap) immunizations. We compared receipt of MCV4 or Tdap at 4, 12, and 24 weeks with age- and gender-matched controls. In the other study, we compared attendance at a postshortage Haemophilus influenzae B (Hib) immunization recall session between parents who received text message and paper-mailed reminders (n = 87) and those who only received paper-mailed reminders (n = 87).

RESULTS

Significantly more adolescents with intervention parents received either or both MCV4 and Tdap at weeks 4 (15.4% vs 4.2%; P < .001), 12 (26.7% vs 13.9%; P < .005), and 24 (36.4% vs 18.1%; P < .001). Significantly more parents who received both Hib reminders attended a recall session compared with parents who only received a mailed reminder (21.8% vs 9.2%; P < .05). After controlling for age, gender, race/ethnicity, insurance status, and language, text messaging was still significantly associated with both studies' outcomes.

CONCLUSIONS

Text messaging for reminder-recalls improved immunization coverage in a low-income, urban population.

'Communicate to vaccinate' (COMMVAC). building evidence for improving communication about childhood vaccinations in low- and middle-income countries: protocol for a programme of research

BACKGROUND

Effective provider-parent communication can improve childhood vaccination uptake and strengthen immunisation services in low- and middle-income countries (LMICs). Building capacity to improve communication strategies has been neglected. Rigorous research exists but is not readily found or applicable to LMICs, making it difficult for policy makers to use it to inform vaccination policies and practice.The aim of this project is to build research knowledge and capacity to use evidence-based strategies for improving communication about childhood vaccinations with parents and communities in LMICs.

METHODS AND DESIGN

This project is a mixed methods study with six sub-studies. In sub-study one, we will develop a systematic map of provider-parent communication interventions for childhood vaccinations by screening and extracting data from relevant literature. This map will inform sub-study two, in which we will develop a taxonomy of interventions to improve provider-parent communication around childhood vaccination. In sub-study three, the taxonomy will be populated with trial citations to create an evidence map, which will also identify how evidence is linked to communication barriers regarding vaccination. In the project's fourth sub-study, we will present the interventions map, taxonomy, and evidence map to international stakeholders to identify high-priority topics for systematic reviews of interventions to improve parent-provider communication for childhood vaccination. We will produce systematic reviews of the effects of high-priority interventions in the fifth sub-study. In the sixth and final sub-study of the project, evidence from the systematic reviews will be translated into accessible formats and messages for dissemination to LMICs.

DISCUSSION

This project combines evidence mapping, conceptual and taxonomy development, priority setting, systematic reviews, and knowledge transfer. It will build and share concepts, terms, evidence, and resources to aid the development of communication strategies for effective vaccination programmes in LMICs.

Development of a taxonomy of interventions to organise the evidence on consumers' medicines use

OBJECTIVE

Safe, effective (quality) medicines use remains problematic worldwide, yet consumers' medicines use research is not well organised. This creates difficulties for decision makers in identifying evidence or research gaps and in understanding how or why interventions work. Developing a conceptual framework for this evidence helps to organise the evidence for application and raise awareness of the range of possible interventions.

METHODS

To scope the aims of interventions to improve consumers' medicines use we searched for and iteratively analysed policy documents, systematic reviews, and an existing consumer-oriented communication intervention taxonomy.

RESULTS

We identified eight recurrent themes associated with the purpose of the interventions: to inform and educate; to support behaviour change; to teach skills; to facilitate communication and/or decision making; to support; to minimise risk and harms; to involve consumers at the system level; and to improve health care quality.

CONCLUSION

The taxonomy accommodates the complexity and diversity of interventions in this field, by focussing on the purposes of interventions, rather than the intervention type.

PRACTICE IMPLICATIONS

Currently used to organise the evidence on consumers' medicines use, the taxonomy provides a conceptual and practical map of the evidence which will aid decision making and future research investment in the area.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Attitudes and practices of obstetrician-gynecologists regarding influenza vaccination in pregnancy

OBJECTIVE

To assess knowledge, attitudes, and practices of obstetrician-gynecologists (ob-gyns) regarding vaccination of pregnant women during the 2009 H1N1 pandemic.

METHODS

From February to July 2010, a self-administered mail survey was conducted among a random sample of American College of Obstetricians and Gynecologists (the College) members involved in obstetric care. To assess predictors of routinely offering influenza vaccination, adjusted prevalence ratios and 95% confidence intervals (CIs) were calculated from survey data.

RESULTS

Among 3,096 survey recipients, 1,310 (42.3%) responded to the survey, of whom 873 were eligible for participation. The majority of ob-gyns reported routinely offering both seasonal and 2009 H1N1 influenza vaccination to their pregnant patients (77.6% and 85.6%, respectively) during the 2009-2010 season; 21.1% and 13.3% referred patients to other specialists. Reported reasons for not offering vaccination included inadequate reimbursement, storage limitations, or belief that vaccine should be administered by another provider. Seasonal and 2009 H1N1 influenza vaccination during the first trimester was not recommended by 10.6% and 9.6% of ob-gyns, respectively. Predictors of routinely offering 2009 H1N1 influenza vaccine included: considering primary care and preventive medicine a very important part of practice (adjusted prevalence ratio 1.2, CI 1.01-1.4); observing serious conditions attributed to influenza-like illness (adjusted prevalence ratio 1.1, CI 1.02-1.1); personally receiving 2009 H1N1 influenza vaccination (adjusted prevalence ratio 1.2, CI 1.1-1.4); and practicing in multispecialty group (adjusted prevalence ratio 1.1, CI 1.1-1.2). Physicians in solo practice were less likely to routinely offer influenza vaccine (adjusted prevalence ratio 0.8, CI 0.7-0.9).

CONCLUSION

Although most ob-gyns routinely offered influenza vaccination to pregnant patients, vaccination coverage rates may be improved by addressing logistic and financial challenges of vaccine providers.

Strategies to overcome barriers to pneumococcal vaccination in older adults: an integrative review

Health care systems and policy changes have been critical in increasing pneumococcal vaccination rates to current levels. Still, numerous barriers to immunization persist. To assist clinicians caring for older adults, an integrative review of the literature was performed to examine interventions demonstrating efficacy in office settings. Within the 11 studies reviewed, immunization rates increased consistently when health care systems supported organizational changes in clinical procedures and staffing. Data supporting the use of provider reminders were inconsistent, but the availability of information technology to generate reminders and access clinical guidelines modestly increased vaccination rates. Patient reminders (telephone or mail) demonstrated efficacy in multiple studies. Not surprisingly, the literature also supported the nurse's role in enhancing vaccination rates. Findings of this review support the need for sustained organizational change; implications for clinical practice are apparent. Advanced practice nurses can assume leadership roles within change processes as the nation transitions to electronic medical records.

The relationship between office system tools and evidence-based care in primary care physician practice

A number of office system tools have been developed to improve the rates of preventive services and enhance the quality of medical care in practice settings. New approaches to measuring physician adherence to evidence-based standards of treatment, offer a unique opportunity to examine the link between the use of office system tools and evidence-based practices in primary care. Using episode-based profiling measures of adherence as the criterion, results from this investigation suggest that the application of simple physician reminders can be an effective technique for promoting evidence-based treatment. The data also reveal that the influence of health information technology (HIT) resources on adherence was not exclusively positive. Specifically, adherence to evidence-based standards was higher for primary care practices that employed HIT resources judiciously. In contrast, extensive use of personal digital assistants was negatively associated with adherence. Despite concerns directed towards the new generation of episode-based profiling measures, results from this research indicate that the measures behave similarly to traditional measures of quality.

Computerized clinical decision support systems for primary preventive care: a decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

BACKGROUND

Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs.

METHODS

We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.

RESULTS

We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects.

CONCLUSIONS

Evidence supports the effectiveness of CCDSSs for screening and treatment of dyslipidaemia in primary care with less consistent evidence for CCDSSs used in screening for cancer and mental health-related conditions, vaccinations, and other preventive care. CCDSS effects on patient outcomes, safety, costs of care, and provider satisfaction remain poorly supported.

Parents' acceptance of adolescent immunizations outside of the traditional medical home

PURPOSE

Numerous barriers to vaccination exist for adolescents. Using the medical home as the sole source of adolescent vaccination has potential limitations. The objectives of the present study were to examine parents' acceptance of adolescent vaccination outside of the medical home and parents' preferred setting for adolescent vaccination.

METHODS

A standardized, pilot-tested telephone survey was administered to a stratified random sample (n = 1,998) of Colorado households between August 2007 and February 2008. Households with English-speaking parents and adolescent(s) aged 11-17 years were eligible.

RESULTS

Survey response rate was 43%; there were no significant differences between respondents and nonrespondents for three known demographic variables. Although most parents (78%) preferred a doctor's office for adolescent vaccination, a majority were also definitively or probably accepting of vaccination in public health clinics (74%), school health clinics (70%), obstetrics and gynecology clinics (69%; asked for females only), and emergency departments (67%). Parents were less accepting of vaccination in family planning clinics (41%) and retail-based clinics (36%). Perceived convenience and adolescents' comfort in the setting were positively associated with vaccination acceptance in most settings; concern with keeping track of vaccines given outside of the medical home was negatively associated with acceptance. Parents in rural areas were more likely than parents in urban areas to identify a setting outside of the medical home as the preferred "best" setting for vaccination.

CONCLUSIONS

Most parents assessed a doctors' office as the best setting for adolescent vaccination. However, vaccination in certain settings outside of the medical home seems to be acceptable to many parents.