Maximizing immunization coverage through home visits: a controlled trial in an urban area of Ghana. The impact of health education on frequency and cost of health care use by low income children with asthma. Evaluation of telephoned computer-generated reminders to improve immunization coverage at inner-city clinics. Improving the immunization coverage of children less than 7 years old in a family practice residency. Increasing the demand for childhood vaccination in developing countries: a systematic review. Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. The effect of patient education on pediatric immunization rates.
A strategy of home visits to maximize children's immunization coverage was implemented in three towns in Ghana. The strategy was tested in town 1 in a controlled trial where clusters of children were allocated to the intervention and control groups. A total of 200 mothers in the intervention group were visited at home by non-health workers and their children were referred to a routine under-fives' clinic. Subsequent home visits targeted at those who failed to complete immunization schedules were made by nurses. After 6 months, coverage had risen from 60% to 85%, which was 20% higher than in the town 1 control group of 219 age-matched children (P < 0.005). A similar home-visiting strategy in a neighbouring town resulted in a rise in coverage from 38% to 91% (n = 55), mainly through home immunizations. Children were more likely to complete the schedule if their fathers were interviewed and participated in the decision to send them to the clinic. Countries with national service programmes can use a home-visiting strategy to supplement and strengthen their routine immunization programmes. A wide range of other community-based primary health care interventions could also be tested and implemented using this methodology. A sample of 310 low income urban children with asthma from 290 families was randomized into a control group and an experimental group that received health education to improve asthma management at home. No significant decreases in subsequent health care use were observed when the experimental group was compared to the control group without regard to previous hospitalization. When the comparison was restricted to children who had been hospitalized during the preceding year, however, the experimental group was found to have decreased its use of the emergency room significantly more than the control group (p less than 0.05) and to have experienced a significantly greater reduction in the mean number of hospitalizations (p less than 0.05) during the year of follow-up. The program reduced health care costs for children with one or more hospitalizations, saving $11.22 for every $1.00 spent to deliver health education. The authors evaluated the effectiveness of computer-generated telephoned reminders used to raise the rates of on-time immunization among preschool-age children in two public clinics in Atlanta, GA. The overall effect of the intervention on immunization levels appeared to be minimal (crude relative risk = 1.07, 95 percent confidence interval = 0.78, 1.46), in part because only about 80 percent of children in both the randomly selected intervention group and in the control group were members of a household with a telephone number listed in clinic records. However, logistic regression analysis indicated that 36 of 68 children (52.9 percent) in the intervention group whose households were reached were vaccinated within 30 days of their due dates, compared to 31 of 75 children (41.3 percent) in the control group whose household telephone numbers were recorded but not called (adjusted odds ratio = 2.12, 95 percent confidence interval = 1.01, 4.46). This analysis indicates that telephoned reminders demonstrated a level of effectiveness in improving immunization levels at inner-city clinics that recommends further trial and study. This prospective cohort study was designed to evaluate the effectiveness of mail and telephone contact with parents as a means to improve the immunization coverage of children less than 7 years old in a family practice residency clinic.
                Immunization records for 519 children enrolled in an outpatient clinic were reviewed and updated. Children whose immunizations were current (55) were excluded, which left 464 children whose immunizations were more than 1 month behind for their age groups. A random sample of one-half of these children (231) were mailed a postcard listing the immunizations that they required to be up to date. The mailing was followed up with telephone contact, when necessary, to prompt compliance. The other one-half of the children were not contacted and served as the control group. Immunizations provided to the two groups were compared 6 months after the initial mailing.
                Before the initiation of the study, only 10.6 percent of the infants and children in the practice had their immunizations completed or were up to date. There were 124 immunizations given to 49 children in the intervention group compared with 84 immunizations to 33 children in the control (P < 0.047). Thirty-four children were brought up to date in the control group compared with 17 in the intervention cohort (P < 0.011).
                Direct mail reminders and telephone contact with parents of children who were behind in their immunizations were effective methods to encourage compliance. The increased number of immunizations received by the children in the intervention group was overshadowed by the poor coverage of the entire practice, a highly mobile and predominantly indigent group. Additional interventions are urgently needed to improve immunization levels in infants and children. Attempts to maintain or increase vaccination coverage almost all focus on supply side interventions: improving availability and delivery of vaccines. The effectiveness and cost-effectiveness of efforts to increase demand is uncertain.
                We performed a systematic review of studies that provided quantitative estimates of the impact of demand side interventions on uptake of routine childhood vaccination. We retrieved studies published up to Sept 2008.
                The initial search retrieved 468 potentially eligible studies, including four systematic reviews and eight original studies of the impact of interventions to increase demand for vaccination. We identified only two randomised controlled trials. Interventions with an impact on vaccination uptake included knowledge translation (KT) (mass media, village resource rooms and community discussions) and non-KT initiatives (incentives, economic empowerment, household visits by extension workers). Most claimed to increase vaccine coverage by 20 to 30%. Estimates of the cost per vaccinated child varied considerably with several in the range of $10-20 per vaccinated child.
                Most studies reviewed here represented a low level of evidence. Mass media campaigns may be effective, but the impact depends on access to media and may be costly if run at a local level. The persistence of positive effects has not been investigated. The economics of demand side interventions have not been adequately assessed, but available data suggest that some may be very cost-effective. Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams.
                70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation.
                The household-level intervention had a large impact (15-20 percentage points; p<0.01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15-21 percentage points; p<0.01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications.
                Conditional payments to households increase the use and coverage of preventive health care interventions. To assess the effectiveness of computer-generated telephone reminder and recall messages in increasing preschool immunization visits.
                Randomized, controlled trial.
                Fourteen counties in urban and rural Georgia.
                Children (N = 8002) who were younger than 2 years; had telephone numbers listed in preexisting computerized immunization databases; and were due or late for immunization(s) during the 4-month enrollment period.
                Households of children were randomized to receive or not receive a general or vaccine-specific computer-generated telephone reminder or recall message the day before the child was due, or immediately after randomization if the child was late.
                The rates of immunization visits during the 30-day follow-up period.
                Of the 4636 children whose households were randomized to receive a message, 1684 (36.3%) visited the health department within 30 days compared with 955 (28.4%) of the 3366 children whose households were not contacted (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.20 to 1.37; P < .01). Immunization visits were more frequent (41.1%) among the 3257 children whose households actually received the message (RR = 1.45; 95% CI = 1.36 to 1.56; P < .01). Improvement in immunization visits was similar for general and specific messages, greater for recall than reminder messages, and greatest for children who were late for the third dose of the diphtheria-tetanus-pertussis vaccine and the measles-mumps-rubella vaccine.
                These data suggest a simple and effective way to increase preschool immunization visits, particularly for vaccines associated with the lowest immunization rates. To compare and measure the effects and cost-effectiveness of two interventions designed to raise immunization rates.
                Nine primary care sites serving impoverished and middle-class children.
                Complete birth cohorts (ages 0 to 12 months; n = 3015) from these sites.
                Two 18-month duration interventions: 1) tracking with outreach [tracking/outreach] to bring underimmunized children to their primary care provider office, and 2) a primary care provider office policy change to identify and reduce missed immunization opportunities (prompting).
                Randomized, controlled trial, randomizing within sites using a two-by-two factorial design. Subjects were allocated to one of four study groups: control, prompting only, tracking/outreach only, and combined prompting with tracking/outreach. Outcomes were obtained by blinded chart abstraction.
                Immunization status for age; number of days of delay in immunization; primary care utilization; and rates of screening for occult disease.
                Out of 3015 subjects, 274 subjects (9%) transferred out of the participating sites or had incomplete charts and were excluded. The 2741 (91%) remaining subjects were assessed. At baseline, study groups did not differ in age, gender, insurance type, or immunization status. Of the remaining subjects, 63% received Medicaid. Final series-complete immunization coverage levels were: control, 74%; prompting-only, 76%; tracking/outreach-only 95%; and combined tracking/outreach with prompting, 95%. Analysis of variance showed that: 1) tracking/outreach increased immunization rates 20 percentage points; 2) tracking/outreach decreased mean immunization delay 63 days; 3) tracking/outreach increased mean health supervision visits 0.44 visits per child; 4) tracking/outreach increased mean anemia screening 0.17 screenings per child and mean lead screenings 0.12 screenings per child; 5) impact of tracking/outreach was greatest for uninsured and impoverished patients; and 6) the prompting intervention had no impact on the studied outcomes, and its failure was caused by inconsistent use of prompts and failure to vaccinate ill children when prompted. Using tracking/outreach, the cost per additional child fully immunized was $474. Each $1000 spent on the tracking/outreach intervention resulted in: 2.1 additional fully vaccinated children and 668 fewer child-days of delayed immunization; 4.6 additional health supervision visits and 5.9 additional other visits to the primary care provider; and 1.8 additional anemia screenings and 1.3 additional lead screenings.
                Outreach directed toward children not up-to-date on immunizations improves not only immunization status, but also health supervision visit attendance and screening rates. The cost per additional child immunized was high, but should be interpreted in view of the spillover benefits that accompanied improved immunization. Effective means to improve coverage by reducing missed immunization opportunities still need to be identified. Over the last decade, the immunization rate among preschool children has decreased, especially in the lower socioeconomic population. During this period, reports of outbreaks of immunizable diseases, especially pertussis and measles, have correspondingly increased. This study was designed to evaluate the effect of a brief patient education encounter with new mothers on pediatric immunization rates.
                Two hundred thirty-eight mothers and infants were assigned to an intervention or control group. On the first day postpartum, the mothers in the intervention group participated in a 10- to 15-minute discussion on the importance of immunizations and were given a patient education handout. A reminder letter was mailed to the intervention group at 2 months postpartum. The control group received no special intervention. Infants were followed for their 2- and 4-month immunizations for diphtheria, pertussis, and tetanus and oral polio vaccine (DPT/OPV). At 1 year of age, the infants' immunization records were assessed for the completion of their first three DPT/OPV immunizations.
                There was no statistically significant difference, by chi-square analysis, in the immunization rates of the control and intervention groups at 2, 4, or 12 months of age. At 1 year of age, 29 of 122 (24%) of the control group had received all three DPT/OPV immunizations, compared with 33 (28%) of 116 infants in the intervention group.
                Concordant with similar studies, the immunization rate among infants of parents of lower socioeconomic status (26%) is low. An educational intervention presented to mothers in the postpartum period did not improve the rate of immunization by the age of 12 months. There are undoubtedly several reasons for this failure. Other means to improve immunization rates of infants should be developed and tested.
Home visits and health education may improve immunization coverage but the quality of evidence is low.