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

An ecological analysis of socio-economic determinants associated with paediatric vaccination coverage in the Campania Region: A population-based study, years 2003-2017

Introduction

Vaccines are the most cost-effective and straightforward intervention against severe infectious diseases. However, in Europe and in Italy, paediatric vaccination coverage for certain vaccines remains suboptimal, with considerable regional differences in Italy. Vaccine coverage varies significantly due to socio-economic and organisational factors. Aim of this study was to assess the influence of the Deprivation Index, the density of General Practitioners and General Paediatricians per inhabitants on the coverage of both mandatory and non-mandatory paediatric vaccinations across local health authorities and health districts in the Campania Region for birth cohorts from 2001 to 2015.

Materials and methods

Population-based, ecological time series analysis focusing on the Campania Region, most populous region in the south of Italy. Vaccination coverage data were extracted from the regional immunization database, whilst information on the Deprivation Index and number of primary care doctors and primary care paediatricians per local health district were extracted from public health records. Univariate descriptive statistics were employed to describe study characteristics, as appropriate, whilst and mixed-effect linear regression models were employed to assess the associations between variables of interest and vaccination coverage.

Results

Overall vaccination coverage has generally increased, except for the MMR vaccine, which showed coverage fluctuations. An increase in the Deprivation Index, indicative of less favourable socio-economic conditions, was associated with decreased vaccination coverage in the 24-month age group for some mandatory vaccines (DTaP: Coef -0.97, 95% CI -1.77 | -0.17; Poliomyelitis: Coef -0.98, 95% CI -1.78 | -0.17; Hepatitis B: Coef -0.90, 95% CI -1.71 | -0.10). Moreover, areas with a greater density of General Paediatricians per inhabitants saw increased coverage for Haemophilus influenzae type b in the 6-year age group (Coef 9.78, 95% CI 1.00 | 18.56).

Conclusions

It is necessary to target public health policies to address vaccination inequalities. These efforts should include expanding vaccination campaigns, enhancing catch-up programs, and increase resource allocation in primary care settings to facilitate the role of General Practitioners and Paediatricians in fostering awareness and adherence.

Developing a novel screening tool to address pediatric COVID-19 vaccine hesitancy at point of care

Many children are still not vaccinated against COVID-19, often attributed to rising pediatric vaccine hesitancy. To address this complex public health issue, interventions that uncover parental thinking at point of care are needed to help facilitate discussions in the exam room. The cognitive science framework of Rule Developing Experimentation helps distinguish how people think about day-to-day topics by presenting respondents with a systematic combination of messages that determines the ideas primarily driving their decisions. We hypothesized that Rule Developing Experimentation can empirically assess and identify parental mind-sets in deciding to vaccinate their children to prevent COVID-19. Artificial intelligence was also incorporated to more efficiently help formulate messages. Through an iterative process, surveying a total of 600 participants, three mind-sets emerged regarding the types of messages which parents believe would convince them to vaccinate their children to prevent COVID-19. These three mind-sets are summarized by the following phrases - "Covid is Serious," "Science Says Vaccine Works," and "Vaccine Returns Kids to Normalcy". Using these mind-sets, a simple six-question instrument (i.e., Personal Viewpoint Identifier) was then created to quickly discern at point of care a parent's mind-set surrounding pediatric COVID-19 vaccination. By quickly identifying a parent's mindset at point of care, providers can then utilize the results of the assessment to deliver individualized messaging to parents about the benefits of COVID-19 vaccination. A future study is planned to evaluate the impact of incorporating the Personal Viewpoint Identifier into routine pediatric care settings on COVID-19 vaccination rates.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

BACKGROUND

Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.

METHODS

We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).

RESULTS

In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.

CONCLUSION

The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

Organisational and Structural Drivers of Childhood Immunisation in the European Region: A Systematic Review

Despite the implementation of widespread vaccination programs, the European Health Systems continue to experience care challenges attributable to organizational and structural issues. This study aimed to review the available data on aspects within the organizational and structural domains that might impact vaccination coverage. We searched a comprehensive range of databases from 1 January 2007 to 6 July 2021 for studies that reported quantitative or qualitative research on interventions to raise childhood vaccine coverage. Outcome assessments comprised organizational and structural factors that contribute to vaccine concern among pediatric parents, as well as data reported influencing the willingness to vaccinate. To analyze the risk of bias, the Ottawa, JBI’s (Joanna Briggs Institute) critical appraisal tool, and Amstar quality assessment were used accordingly. The inclusion criteria were met by 205 studies across 21 articles. The majority of the studies were conducted in the United Kingdom (6), the European Union (3), and Italy (3). A range of interventions studied in primary healthcare settings has been revealed to improve vaccination coverage rates including parental engagement and personalization, mandatory vaccination policies, program redesign, supply chain design, administering multiple/combination vaccines, improved vaccination timing and intervals, parental education and reminders, surveillance tools and Supplemental Immunisation Activity (SIA), and information model.

Immunization status of children at kindergarten entry in Alberta, Canada

OBJECTIVES

Little is known about immunization coverage among kindergarten-aged children in jurisdictions that do not require children's immunization records to be provided at school entry. Thus, we assessed immunization coverage and associated characteristics of a 2008 birth cohort of Alberta children at kindergarten entry as compared with at the end of grade one.

METHODS

This retrospective cohort study used population-based administrative health data for childhood vaccines in Alberta, Canada. We categorized and compared immunization status of children as follows: (a) complete at kindergarten entry; (b) incomplete at kindergarten entry but complete at the end of grade one; and (c) still incomplete at the end of grade one. To assess factors associated with immunization status, we used multinomial logistic regression.

RESULTS

Immunization coverage for the complete vaccine series for children (N = 41,515) at kindergarten entry was suboptimal (44.5%, 95% CI 44.0-45.0) and substantially lower than for children at the end of grade one (74.8%, 95% CI 74.3-75.2). Young maternal age, not living with a partner, and having > 1 child in a household were associated with incomplete immunization status at kindergarten entry. Midwife-assisted hospital and home delivery was strongly associated with incomplete immunization status at the end of grade one.

CONCLUSION

Immunization coverage at kindergarten entry was strikingly low. Risk factors for incomplete immunization status were identified that require particular attention when addressing immunization coverage. The school-based catch-up immunization program in grade one seems to have substantially improved coverage among children, suggesting a potential benefit of shifting the catch-up program from grade one to kindergarten entry.

Delay in childhood vaccinations during the COVID-19 pandemic

OBJECTIVES

In many jurisdictions, routine medical care was reduced in response to the COVID-19 pandemic. The objective of this study was to determine whether the frequency of on-time routine childhood vaccinations among children age 0-2 years was lower following the COVID-19 declaration of emergency in Ontario, Canada, on March 17, 2020, compared to prior to the pandemic.

METHODS

We conducted a longitudinal cohort study of healthy children aged 0-2 years participating in the TARGet Kids! primary care research network in Toronto, Canada. A logistic mixed effects regression model was used to determine odds ratios (ORs) for delayed vaccination (> 30 days vs. ≤ 30 days from the recommended date) before and after the COVID-19 declaration of emergency, adjusted for confounding variables. A Cox proportional hazards model was used to explore the relationship between the declaration of emergency and time to vaccination.

RESULTS

Among 1277 children, the proportion of on-time vaccinations was 81.8% prior to the COVID-19 declaration of emergency and 62.1% after (p < 0.001). The odds of delayed vaccination increased (odds ratio = 3.77, 95% CI: 2.86-4.96), and the hazard of administration of recommended vaccinations decreased after the declaration of emergency (hazard ratio = 0.75, 95% CI: 0.60-0.92). The median vaccination delay time was 5 days (95% CI: 4-5 days) prior to the declaration of emergency and 17 days (95% CI: 12-22 days) after.

CONCLUSION

The frequency of on-time routine childhood vaccinations was lower during the first wave of the COVID-19 pandemic. Sustained delays in routine vaccinations may lead to an increase in rates of vaccine-preventable diseases.

Reminder system for health screening in early childhood - an analysis regarding different social circumstances

Background

Children with a low socio-economic position (SEP) participate in prevention and health examinations less often. In order to increase participation, reminder systems have been implemented in Germany since 2009. The aim of the study is to investigate whether this implementation is associated with an increased participation in health examination in early childhood for children in disadvantaged social circumstances.

Methods

We used data from the school enrolment examination from 2002 to 2017 from the city of Duesseldorf (n = 64,883 children). With a trend analysis we observed health examination over time and we compared rates of children after implementation of the reminder system (2010 or later) to those who were not exposed to the programme (earlier than 2010). Health examination was measured by participation in the last examination before school entry (“U9”) documented by paediatricians. Social circumstances included neighbourhood deprivation (very high to very low), migration background (foreign first language vs. German) and family status (one-parent vs. two-parent families). Poisson regression estimated adjusted Prevalence Ratios (PR) with a 95% confidence interval (CI) of U9 participation by reminder system exposure, both for the total population and within groups of social circumstances. Based on that, we calculated adjusted participation rates (predictive margins) by reminder system exposure for the different social circumstances.

Results

Participation rates increased slightly, but gradually over time. The probability of U9 participation for children exposed to the reminder system is 1.04-fold (1.03–1.04 CI) compared to children who were not exposed to it. The association of the reminder system and U9 participation differs according to social circumstances. Adjusted prevalences increased the most in the group of children from very deprived neighbourhoods, ranging from 84.3 to 91.4% (PR = 1.07; 1.03–1.10 CI); in all language groups; more in children from one-parent families ranging from 82.4 to 88.9% (PR = 1.07; 1.05–1.09 CI).

Conclusion

Our results suggest that reminder systems have a moderate impact on the participation in health examinations in early childhood in the general population. In vulnerable groups, however, they could make a difference. Reminder systems should be combined with further activities of tailored prevention.

Measles, mumps, rubella prevention: how can we do better?

INTRODUCTION

Measles, mumps, and rubella incidence decreased drastically following vaccination programs' implementation. However, measles and mumps' resurgence was recently reported, outbreaks still occur, and challenges remain to control these diseases.

AREAS COVERED

This qualitative narrative review provides an objective appraisal of the literature regarding current challenges in controlling measles, mumps, rubella infections, and interventions to address them.

EXPERT OPINION

While vaccines against measles, mumps, and rubella (including trivalent vaccines) are widely used and effective, challenges to control these diseases are mainly related to insufficient immunization coverage and changing vaccination needs owing to new global environment (e.g. traveling, migration, population density). By understanding disease transmission peculiarities by setting, initiatives are needed to optimize vaccination policies and increase vaccination coverage, which was further negatively impacted by COVID-19 pandemic. Also, awareness of the potential severity of infections and the role of vaccines should increase. Reminder systems, vaccination of disadvantaged, high-risk and difficult-to-reach populations, accessibility of vaccination, healthcare infrastructure, and vaccination services management should improve. Outbreak preparedness should be strengthened, including implementation of high-quality surveillance systems to monitor epidemiology. While the main focus should be on these public health initiatives to increase vaccination coverage, slightly more benefits could come from evolution of current vaccines.

Play and medical play in teaching pre-school children to cope with medical procedures involving needles: A systematic review

AIM

Most toddlers experience pain and distress during doctor or dental visits. Aim of this systematic review was to investigate the role of play-based interventions in pain and fear or distress management in pre-school children (aged from 2 to 6 years old) undergoing needle-related medical procedures adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number: CRD42020192161).

METHODS

The key database that was searched was PubMed/MEDLINE along with references of relevant review studies. Only randomised controlled trials (RCTs) that fulfilled inclusion and eligibility criteria were selected for analysis. Methodological quality was evaluated using the Cochrane Collaboration's Risk of Bias Tool for RCTs and Review Manager version 5.4 was utilised in order to calculate standardised mean differences (SMDs) and create a forest plot for included studies that presented data on self-reported pain ratings. Primary outcomes refer to pain, anxiety and fear assessments, while secondary outcomes refer to physiological measures and cortisol levels.

RESULTS

All included RCTs suffered from high risk of bias that relied on selection and blinding methodology, while other sources of bias were also present in some cases. Despite low-quality of evidence, play-based interventions seem to favour less self-reported pain (SMD -0.39; 95% CI: -0.67 to -0.12; I² = 84%).

CONCLUSION

Limitations of evidence, except from high risk of bias, include inconsistency in reporting primary outcome assessments and study designs that preclude reproducibility. Play-based techniques seem to contribute to pre-schoolers' coping towards needle-related medical procedures and further research is warranted in order to explore clinical benefits.

Parents' and guardians' views and experiences of accessing routine childhood vaccinations during the coronavirus (COVID-19) pandemic: A mixed methods study in England

Objective

To explore parents’ and guardians’ views and experiences of accessing National Health Service (NHS) general practices for routine childhood vaccinations during the coronavirus (COVID-19) pandemic in England.

Design

Mixed methods approach involving an online cross-sectional survey (conducted between 19^th April and 11^th May 2020) and semi-structured telephone interviews (conducted between 27^th April and 27^th May 2020).

Participants

1252 parents and guardians (aged 16+ years) who reported living in England with a child aged 18 months or under completed the survey. Nineteen survey respondents took part in follow-up interviews.

Results

The majority of survey respondents (85.7%) considered it important for their children to receive routine vaccinations on schedule during the COVID-19 pandemic; however, several barriers to vaccination were identified. These included a lack of clarity around whether vaccination services were operating as usual, particularly amongst respondents from lower income households and those self-reporting as Black, Asian, Chinese, Mixed or Other ethnicity; difficulties in organising vaccination appointments; and fears around contracting COVID-19 while attending general practice.

Concerns about catching COVID-19 while accessing general practice were weighed against concerns about children acquiring a vaccine-preventable disease if they did not receive scheduled routine childhood vaccinations. Many parents and guardians felt their child’s risk of acquiring a vaccine-preventable disease was low as the implementation of stringent physical distancing measures (from March 23^rd 2020) meant they were not mixing with others.

Conclusion

To promote routine childhood vaccination uptake during the current COVID-19 outbreak, further waves of COVID-19 infection, and future pandemics, prompt and sustained national and general practice level communication is needed to raise awareness of vaccination service continuation and the importance of timely vaccination, and invitation-reminder systems for vaccination need to be maintained. To allay concerns about the safety of accessing general practice, practices should communicate the measures being implemented to prevent COVID-19 transmission.

The ‘new normal’: delivering childhood immunisations during the COVID-19 pandemic

Maintaining good coverage of childhood immunisations is vital. Dr Catherine Heffernan explains how practices in the London region are delivering a safe service to families

Exploring Strategies to Improve Adherence to Immunization Schedule: A Study among Children Attending Maternal and Child Health Clinic at Kenyatta National Hospital, Nairobi, Kenya

Background

Globally, immunization is among the major contributors to public health, preventing 20% of childhood mortality annually. The highest fatality rates from vaccine preventable diseases are usually among children under five. Despite immunization guidelines put in place by the World Health Organization, globally, 1.5 million children die annually related to inadequate vaccination coverage. Existing literature indicate that there is an increase in nonadherence to immunization schedule in developing countries, and therefore, there is an increased demand to improve adherence to immunization schedule.

Objective

To explore strategies that will improve adherence to immunization schedule among children under 24 months attending the Maternal and Child Health clinic at Kenyatta National Hospital.

Methods

A cross-sectional mixed method study involving caregivers (n = 214) of well babies attending the Maternal and Child Health clinic. Data was collected using semistructured questionnaires, focus group discussions, and key informant interviews and analyzed using SPSS V.20.

Results

There was a significant relationship between the level of education and marital status of the caregivers and adherence to immunization schedule. Barriers found that is related to adherence to immunization schedule included far distance from health facility, baby's sickness, and vaccine stock-outs while employment of a caregiver was a constrainer factor.

Conclusion

The enabling factors to current strategies of improving adherence to immunization schedule were having more health facilities near residential areas, using text messages reminders a day before the clinic date to remind caregivers of the due date for the clinic, and constant availability of vaccines. The health system strategies that would improve adherence to immunization schedules were more flexible clinic hours, availability of vaccines on daily basis, phone call reminders by health care providers, and increasing awareness on the importance of both vaccinations and adherence to immunization schedule.

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.

Improving vaccination uptake among adolescents

BACKGROUND

Adolescent vaccination has received increased attention since the Global Vaccine Action Plan's call to extend the benefits of immunisation more equitably beyond childhood. In recent years, many programmes have been launched to increase the uptake of different vaccines in adolescent populations; however, vaccination coverage among adolescents remains suboptimal. Therefore, understanding and evaluating the various interventions that can be used to improve adolescent vaccination is crucial.

OBJECTIVES

To evaluate the effects of interventions to improve vaccine uptake among adolescents.

SEARCH METHODS

In October 2018, we searched the following databases: CENTRAL, MEDLINE Ovid, Embase Ovid, and eight other databases. In addition, we searched two clinical trials platforms, electronic databases of grey literature, and reference lists of relevant articles. For related systematic reviews, we searched four databases. Furthermore, in May 2019, we performed a citation search of five other websites.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies of adolescents (girls or boys aged 10 to 19 years) eligible for World Health Organization-recommended vaccines and their parents or healthcare providers.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records, reviewed full-text articles to identify potentially eligible studies, extracted data, and assessed risk of bias, resolving discrepancies by consensus. For each included study, we calculated risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) where appropriate. We pooled study results using random-effects meta-analyses and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 16 studies (eight individually randomised trials, four cluster randomised trials, three non-randomised trials, and one controlled before-after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. We categorised interventions as recipient-oriented, provider-oriented, or health systems-oriented. The interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus-diphtheria-acellular-pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents. Health education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high-certainty evidence). In addition, one large study provided evidence that a complex multi-component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate-certainty evidence). Financial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low-certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence). Mandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate-certainty evidence). Provider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate-certainty evidence). Provider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non-participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low-certainty evidence). A class-based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age-based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate-certainty evidence). A multi-component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate-certainty evidence). A multi-component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class-based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low- and middle-income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage.

The quality of preventive care for pre-school aged children in Australian general practice

BACKGROUND

Variable and poor care quality are important causes of preventable patient harm. Many patients receive less than recommended care, but the extent of the problem remains largely unknown. The CareTrack Kids (CTK) research programme sought to address this evidence gap by developing a set of indicators to measure the quality of care for common paediatric conditions. In this study, we focus on one clinical area, 'preventive care' for pre-school aged children. Our objectives were two-fold: (i) develop and validate preventive care quality indicators and (ii) apply them in general medical practice to measure adherence.

METHODS

Clinical experts (n = 6) developed indicator questions (IQs) from clinical practice guideline (CPG) recommendations using a multi-stage modified Delphi process, which were pilot tested in general practice. The medical records of Australian children (n = 976) from general practices (n = 80) in Queensland, New South Wales and South Australia identified as having a consultation for one of 17 CTK conditions of interest were retrospectively reviewed by trained paediatric nurses. Statistical analyses were performed to estimate percentage compliance and its 95% confidence intervals.

RESULTS

IQs (n = 43) and eight care 'bundles' were developed and validated. Care was delivered in line with the IQs in 43.3% of eligible healthcare encounters (95% CI 30.5-56.7). The bundles of care with the highest compliance were 'immunisation' (80.1%, 95% CI 65.7-90.4), 'anthropometric measurements' (52.7%, 95% CI 35.6-69.4) and 'nutrition assessments' (38.5%, 95% CI 24.3-54.3), and lowest for 'visual assessment' (17.9%, 95% CI 8.2-31.9), 'musculoskeletal examinations' (24.4%, 95% CI 13.1-39.1) and 'cardiovascular examinations' (30.9%, 95% CI 12.3-55.5).

CONCLUSIONS

This study is the first known attempt to develop specific preventive care quality indicators and measure their delivery to Australian children in general practice. Our findings that preventive care is not reliably delivered to all Australian children and that there is substantial variation in adherence with the IQs provide a starting point for clinicians, researchers and policy makers when considering how the gap between recommended and actual care may be narrowed. The findings may also help inform the development of specific improvement interventions, incentives and national standards.

Assessing the methodological quality of systematic reviews of interventions aimed at improving vaccination coverage using AMSTAR and ROBIS checklists

Introduction: Systematic reviews (SRs) are the backbone of evidence-based health care, but no gold standard exists to assess their methodological quality. Although the AMSTAR tool is accepted for analyzing the quality of SRs, the ROBIS instrument was recently developed. This study compared the capacity of both instruments to capture the quality of SRs of interventions for improving vaccination coverage.Methods: We conducted a comprehensive literature search in the Cochrane Library and PubMed. Two reviewers independently screened the search output, assessed study eligibility, and extracted data from eligible SRs; resolving differences through consensus. We conducted Principal Component Analysis (PCA) in Stata 14 to determine similarities and differences between AMSTAR and ROBIS.Results: A total of 2322 records were identified through the search and 75 full-text publications were assessed for eligibility, of which 57 met inclusion criteria. Using AMSTAR, we found 32%, 60% and 9% of SRs to have high, moderate and low quality, respectively. With ROBIS, we judged 74%, 14% and 12% of SRs to have low, unclear and high risk of bias. PCA showed that SRs with low risk of bias in ROBIS clustered together with SRs having high-quality in AMSTAR, and SRs with high risk of bias in ROBIS clustered with low-quality SRs in AMSTAR.Conclusions: Our findings suggest that there is an association between methodological quality and risk of bias in SRs of interventions focused on improving vaccination coverage. Therefore, either AMSTAR or ROBIS checklists can be used to evaluate methodological quality of SRs in vaccinology.

Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines

Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.

Vaccination in England: a review of why business as usual is not enough to maintain coverage

BACKGROUND

The vaccine system in England underwent radical changes in 2013 following the implementation of the Health and Social Care Act. There have since been multi-year decreases in coverage of many vaccines. Healthcare professionals have reported finding the new system fragmented and challenging. This study aims to produce a logic model of the new system and evaluate the available evidence for interventions to improve coverage.

METHODS

We undertook qualitative document analysis to develop the logic model using process evaluation methods. We performed a systematic review by searching 12 databases with a broad search strategy to identify interventions studied in England conducted between 2006 and 2016 and evaluated their effectiveness. We then compared the evidence base to the logic model.

RESULTS

We analysed 83 documents and developed a logic model describing the core inputs, processes, activities, outputs, outcomes and impacts of the new vaccination system alongside the programmatic assumptions for each stage. Of 9,615 unique articles, we screened 624 abstracts, 45 full-text articles, and included 16 studies: 8 randomised controlled trials and 8 quasi-experimental studies. Four studies suggest that modifications to the contracting and incentive systems can increase coverage, but changes to other programme inputs (e.g. human or capital resources) were not evaluated. Four multi-component intervention studies modified activities and outputs from within a GP practice to increase coverage, but were part of campaigns or projects. Thus, many potentially modifiable factors relating to routine programme implementation remain unexplored. Reminder/recall systems are under-studied in England; incentive payments to adolescents may be effective; and only two studies evaluated carer information.

CONCLUSIONS

The evidence base for interventions to increase immunisation coverage in the new system in England are limited by a small number of studies and by significant risk of bias. Several areas important to primary care remain unexplored as targets for interventions, especially modification to organisational management.

A systematic review and meta-analysis of the effects of educating parents on the benefits and schedules of childhood vaccinations in low and middle-income countries

Public health benefits of childhood vaccinations risk being derailed by low vaccination coverage in low and middle-income countries. One reason for the low coverage is poor parental knowledge of the importance of completing vaccination schedules. We therefore assessed the effects on childhood vaccination coverage, of educating parents and other persons assuming the parental role. We prospectively registered the systematic review, published the protocol, and used standard Cochrane methods to collect and synthesise the evidence. We found six eligible randomised trials with 4248 participants. Three trials assessed health-facility based education of mothers on the importance of completing vaccination schedules; immediately after birth and three months later (one study) or during the first vaccination visit (two studies). The other trials assessed community-based education, including information campaigns on the importance of vaccines using audiotaped presentations and leaflet distributions (one study); structured group discussions on benefits and costs of childhood vaccination and local action plans for improving vaccine uptake (one study); and home-based information sessions using graphic cards showing benefits and costs of childhood vaccinations and location of vaccination centres (one study). Combining the data shows that these interventions lead to substantial improvements in childhood vaccination coverage (relative increase 36%, 95% confidence interval 14% to 62%). There was no difference between the effects of community-based and facility-based education. Therefore, education in communities and health facilities on the importance of childhood vaccinations should be integrated into all vaccination programmes in low and middle-income countries; accompanied by robust monitoring of impacts and use of data for action.

Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and 2015: findings from the Global Burden of Disease 2015 study

OBJECTIVES

We used data from the Global Burden of Disease 2015 study (GBD) to calculate the burden of lower respiratory infections (LRIs) in the 22 countries of the Eastern Mediterranean Region (EMR) from 1990 to 2015.

METHODS

We conducted a systematic analysis of mortality and morbidity data for LRI and its specific etiologic factors, including pneumococcus, Haemophilus influenzae type b, Respiratory syncytial virus, and influenza virus. We used modeling methods to estimate incidence, deaths, and disability-adjusted life-years (DALYs). We calculated burden attributable to known risk factors for LRI.

RESULTS

In 2015, LRIs were the fourth-leading cause of DALYs, causing 11,098,243 (95% UI 9,857,095-12,396,566) DALYs and 191,114 (95% UI 170,934-210,705) deaths. The LRI DALY rates were higher than global estimates in 2015. The highest and lowest age-standardized rates of DALYs were observed in Somalia and Lebanon, respectively. Undernutrition in childhood and ambient particulate matter air pollution in the elderly were the main risk factors.

CONCLUSIONS

Our findings call for public health strategies to reduce the level of risk factors in each age group, especially vulnerable child and elderly populations.

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effect of stepwise perinatal immunization education: A cluster-randomized controlled trial

BACKGROUND

Perinatal immunization education is important for improving the immunization outcomes of infants; however, the content of educational materials used at each perinatal period has not been carefully evaluated. We hypothesized that stepwise education offered at different perinatal periods would improve infant immunization status and enhance maternal immunization knowledge.

METHODS

In this cluster-randomized controlled trial, pregnant women were recruited from nine obstetric sites in Niigata, Japan. The intervention group received a stepwise, interactive education intervention (prenatally, postnatally, and 1month after birth). The control group received a leaflet containing general information on immunization. Infant immunization status was evaluated at 6months of age, and maternal immunization knowledge was evaluated by a written survey after each intervention.

RESULTS

Among 188 study participants, 151 (80.3%) replied to the final post-intervention survey. At 6months of age, the percentage of children who completed three doses of inactivated polio, diphtheria, tetanus toxoid, and acellular pertussis (DTaP-IPV) vaccine was higher in the intervention group than in the control (p=0.04); however, no differences between groups were observed for the Haemophilus influenzae type b (Hib) (p=0.67) or 13-valent pneumococcal conjugate (PCV13) vaccines (p=0.20). The duration to the completion of the third dose of the DTaP-IPV, Hib, and PCV13 vaccines was shorter in the intervention group than in the control (p=0.03, p<0.01, and p<0.01, respectively). Furthermore, maternal knowledge scores exhibited significantly greater improvement in the intervention group over time compared with those of the control group (p=0.02).

CONCLUSIONS

Stepwise perinatal immunization education improved immunization schedule adherence for required vaccines and improved maternal immunization knowledge.

Interventions to reduce inequalities in vaccine uptake in children and adolescents aged <19 years: a systematic review

BACKGROUND

In high-income countries, substantial differences exist in vaccine uptake relating to socioeconomic status, gender, ethnic group, geographic location and religious belief. This paper updates a 2009 systematic review on effective interventions to decrease vaccine uptake inequalities in light of new technologies applied to vaccination and new vaccine programmes (eg, human papillomavirus in adolescents).

METHODS

We searched MEDLINE, Embase, ASSIA, The Campbell Collaboration, CINAHL, The Cochrane Database of Systematic Reviews, Eppi Centre, Eric and PsychINFO for intervention, cohort or ecological studies conducted at primary/community care level in children and young people from birth to 19 years in OECD countries, with vaccine uptake or coverage as outcomes, published between 2008 and 2015.

RESULTS

The 41 included studies evaluated complex multicomponent interventions (n=16), reminder/recall systems (n=18), outreach programmes (n=3) or computer-based interventions (n=2). Complex, locally designed interventions demonstrated the best evidence for effectiveness in reducing inequalities in deprived, urban, ethnically diverse communities. There is some evidence that postal and telephone reminders are effective, however, evidence remains mixed for text-message reminders, although these may be more effective in adolescents. Interventions that escalated in intensity appeared particularly effective. Computer-based interventions were not effective. Few studies targeted an inequality specifically, although several reported differential effects by the ethnic group.

CONCLUSIONS

Locally designed, multicomponent interventions should be used in urban, ethnically diverse, deprived populations. Some evidence is emerging for text-message reminders, particularly in adolescents. Further research should be conducted in the UK and Europe with a focus on reducing specific inequalities.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Electronic supplementary material

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

Vaccination coverage of adolescents: Results of a Defense and Citizenship Day-based survey

INTRODUCTION

Vaccination coverage among French young adults is not routinely measured. Every French adolescent aged between 16 and 18years must take part in the Defense and Citizenship Day (French acronym JDC). We aimed to assess vaccination coverage among young adults for hepatitis B, group C meningococcus meningitis, human papillomavirus (HPV), and measles. We also aimed to assess the proportion of adolescents who received the pertussis booster between the age of 11 and 13years.

METHODS

The survey took place from January 19th to 26th, 2015 at the JDC center of Rennes, France. Vaccination coverage data was collected on site from the adolescents' health records. We collected the number of doses received and the dates of administration for each type of vaccine. A properly vaccinated adolescent was defined as having received the right number of doses according to the vaccination schedule.

RESULTS

A total of 467 adolescents attended the JDC Day: 408 (87.4%) had brought their health record or an equivalent document. Vaccination coverage was 92.6% [90.1-95.1] for measles, 34.6% [30-39.2] for group C meningococcus meningitis, 40.7% [35.9-45.5] for hepatitis B, and 30.1% [23.9-36.3] of girls had been vaccinated against HPV. Of all adolescents, 60.1% [55.7-64.9] received a dose of the pertussis vaccine between 11 and 13years of age.

CONCLUSION

Our results are similar to those of other data sources. With regard to the difficulty of assessing vaccination coverage in that age group, we believe recruitment bias was minimized due to our study location.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

REVIEW REGISTRATION NUMBER

PROSPERO registration number CRD42014012888.

Protocol for a systematic review of the effects of interventions to inform or educate caregivers about childhood vaccination in low and middle-income countries

INTRODUCTION

Despite their proven effectiveness in reducing childhood infectious diseases, the uptake of vaccines remains suboptimal in low and middle-income countries. Identifying strategies for transmitting accurate vaccine information to caregivers would boost childhood vaccination coverage in these countries. The purpose of this review is to assess the effects on childhood vaccination coverage of interventions for informing or educating caregivers about the importance of vaccines in low and middle-income countries, as defined by the World Bank.

METHODS AND ANALYSIS

Eligible study designs include randomised controlled trials (RCTs) as well as non-randomised controlled trials (non-RCTs). We will conduct a comprehensive search of both peer-reviewed and grey literature available up to 31 May 2015. We will search PubMed, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, Cumulative Index of Nursing and Allied Health, prospective trial registries and reference lists of relevant publications. Two authors will independently screen the search output, retrieve full texts of potentially eligible studies and assess the latter against predefined inclusion criteria. Disagreements between the two authors will be resolved through consensus and arbitration by a third author. We will pool data from studies with homogenous interventions and outcomes, using random-effects meta-analysis. We will assess statistical heterogeneity using the χ(2) test of homogeneity (with significance defined at the 10% α-level) and quantify it using Higgins' inconsistency index. We will explore the cause of any observed statistical heterogeneity using subgroup analysis, with subgroups defined by study design (RCTs vs non-RCTs) and type of intervention (information vs educational interventions).

ETHICS AND DISSEMINATION

The proposed systematic review will collect and analyse secondary data that are not associated with individuals. The review will make a significant contribution to the knowledge base of interventions for improving childhood vaccination coverage in low and middle-income countries.

PROTOCOL REGISTRATION NUMBER

PROSPERO, CRD42014010141.

Strategies intended to address vaccine hesitancy: Review of published reviews

When faced with vaccine hesitancy, public health authorities are looking for effective strategies to address this issue. In this paper, the findings of 15 published literature reviews or meta-analysis that have examined the effectiveness of different interventions to reduce vaccine hesitancy and/or to enhance vaccine acceptance are presented and discussed. From the literature, there is no strong evidence to recommend any specific intervention to address vaccine hesitancy/refusal. The reviewed studies included interventions with diverse content and approaches that were implemented in different settings and targeted various populations. Few interventions were directly targeted to vaccine hesitant individuals. Given the paucity of information on effective strategies to address vaccine hesitancy, when interventions are implemented, planning a rigorous evaluation of their impact on vaccine hesitancy/vaccine acceptance will be essential.

The influence of performance-based payment on childhood immunisation coverage

BACKGROUND

Pay-for-performance, also called the quality system (QS) in Estonia, was implemented in 2006 and one indicator for achievement is the childhood immunisation coverage rate. The WHO vaccination coverage in Europe for diphtheria, tetanus and pertussis, and measles in children aged around one year old should meet or exceed 90 per cent.

METHODS

The study was conducted using a database from the Estonian Health Insurance Fund. The study compared childhood immunisation coverage rates of all Estonian family physicians in two groups, joined and not joined to the quality system during the observation period 2006-2012. Immunisation coverage was calculated as the percentage of persons in the target age group who received a vaccine dose by a given age. The target level of immunisations in Estonia is set at 90 per cent and higher.

RESULTS

Immunisation coverage rates of family doctors (FD) in Estonia showed significant differences between two groups of doctors: joined to the quality system and not joined. Doctors joined to the quality system met the 90 per cent vaccination criterion more frequently compared to doctors not joined to the quality system. Doctors not joined to the quality system were below the 90 per cent vaccination criterion in all vaccinations listed in the Estonian State Immunisation Schedule.

CONCLUSION

Pay-for-performance as a financial incentive encourages higher levels of childhood immunisations.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Parental concern about vaccine safety in Canadian children partially immunized at age 2: a multivariable model including system level factors

Children who begin but do not fully complete the recommended series of childhood vaccines by 2 y of age are a much larger group than those who receive no vaccines. While parents who refuse all vaccines typically express concern about vaccine safety, it is critical to determine what influences parents of ‘partially’ immunized children. This case-control study examined whether parental concern about vaccine safety was responsible for partial immunization, and whether other personal or system-level factors played an important role. A random sample of parents of partially and completely immunized 2 y old children were selected from a Canadian regional immunization registry and completed a postal survey assessing various personal and system-level factors. Unadjusted odds ratios (OR) and adjusted ORs (aOR) were calculated with logistic regression. While vaccine safety concern was associated with partial immunization (OR 7.338, 95% CI 4.138– 13.012), other variables were more strongly associated and reduced the strength of the relationship between concern and partial immunization in multivariable analysis (aOR 2.829, 95% CI 1.151 – 6.957). Other important factors included perceived disease susceptibility and severity (aOR 4.629, 95% CI 2.017 – 10.625), residential mobility (aOR 3.908, 95% CI 2.075 – 7.358), daycare use (aOR 0.310, 95% CI 0.144 - 0.671), number of needles administered at each visit (aOR 7.734, 95% CI 2.598 – 23.025) and access to a regular physician (aOR 0.219, 95% CI 0.057 – 0.846). While concern about vaccine safety may be addressed through educational strategies, this study suggests that additional program and policy-level strategies may positively impact immunization uptake.

Improving immunization rates in a hospital-based primary care practice

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improving vaccine uptake: an overview

A task group was formed with the aim to improve the quality of the service offered by ensuring that all children waiting for an appointment for vaccination would be offered one at the earliest opportunity. Children aged between 12 mo-5 y that were not completely immunized for their age were identified and included in a pilot catch-up session. Following evaluation of the pilot session, four further immunization sessions were delivered. A total of 398 children attended the four sessions, representing an improved attendance rate of 39%. Most parents brought their children between 11 am-3 pm and 728 vaccines were administered: 339 MMR; 255 Pre-school boosters; 53 Hib/MenC and 81 PCV. Uptake of MMR vaccine in the PCT at age 24 mo increased by 9% by Q3 2008. For children aged five years, uptake of the first dose of MMR vaccine increased from 91.9% to 94% for the first dose and from 82.3 to 82.5% for the second dose by Q3 2008. This project demonstrates that new ways of delivering immunization sessions can be successfully implemented which can enhance access through the use of alternative venues and subsequently lead to increased vaccine uptake.

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.

"Communicate to vaccinate": the development of a taxonomy of communication interventions to improve routine childhood vaccination

Background

Vaccination is a cost-effective public health measure and is central to the Millennium Development Goal of reducing child mortality. However, childhood vaccination coverage remains sub-optimal in many settings. While communication is a key feature of vaccination programmes, we are not aware of any comprehensive approach to organising the broad range of communication interventions that can be delivered to parents and communities to improve vaccination coverage. Developing a classification system (taxonomy) organised into conceptually similar categories will aid in: understanding the relationships between different types of communication interventions; facilitating conceptual mapping of these interventions; clarifying the key purposes and features of interventions to aid implementation and evaluation; and identifying areas where evidence is strong and where there are gaps. This paper reports on the development of the ‘Communicate to vaccinate’ taxonomy.

Methods

The taxonomy was developed in two stages. Stage 1 included: 1) forming an advisory group; 2) searching for descriptions of interventions in trials (CENTRAL database) and general health literature (Medline); 3) developing a sampling strategy; 4) screening the search results; 5) developing a data extraction form; and 6) extracting intervention data. Stage 2 included: 1) grouping the interventions according to purpose; 2) holding deliberative forums in English and French with key vaccination stakeholders to gather feedback; 3) conducting a targeted search of grey literature to supplement the taxonomy; 4) finalising the taxonomy based on the input provided.

Results

The taxonomy includes seven main categories of communication interventions: inform or educate, remind or recall, teach skills, provide support, facilitate decision making, enable communication and enhance community ownership. These categories are broken down into 43 intervention types across three target groups: parents or soon-to-be-parents; communities, community members or volunteers; and health care providers.

Conclusions

Our taxonomy illuminates and organises this field and identifies the range of available communication interventions to increase routine childhood vaccination uptake. We have utilised a variety of data sources, capturing information from rigorous evaluations such as randomised trials as well as experiences and knowledge of practitioners and vaccination stakeholders. The taxonomy reflects current public health practice and can guide the future development of vaccination programmes.