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Postnatal home visits in teenage mothers: a randomised controlled trial
Background In the UK public concern about the safety of the combined measles , mumps and rubella [ MMR ] vaccine continues to impact on MMR coverage . Whilst the sharp decline in uptake has begun to level out , first and second dose uptake rates remain short of that required for population immunity . Furthermore , international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children . Together , this work suggests that effective interventions are required to support parents to make informed decisions about MMR.This trial assessed the impact of a parent-centred , multi-component intervention ( balanced information , group discussion , coaching exercise ) on informed parental decision-making for MMR . Methods This was a two arm , cluster r and omised trial . One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations . The intervention arm received an MMR information leaflet and participated in the intervention ( parent meeting ) . The control arm received the leaflet only . The primary outcome was decisional conflict . Secondary outcomes were actual and intended MMR choice , knowledge , attitude , concern and necessity beliefs about MMR and anxiety . Results Decisional conflict decreased for both arms to a level where an ' effective ' MMR decision could be made one-week ( effect estimate = -0.54 , p < 0.001 ) and three-months ( effect estimate = -0.60 , p < 0.001 ) post-intervention . There was no significant difference between arms ( effect estimate = 0.07 , p = 0.215 ) . Heightened decisional conflict was evident for parents making the MMR decision for their first child ( effect estimate = -0.25 , p = 0.003 ) , who were concerned ( effect estimate = 0.07 , p < 0.001 ) , had less positive attitudes ( effect estimate = -0.20 , p < 0.001 ) yet stronger intentions ( effect estimate = 0.09 , p = 0.006 ) . Significantly more parents in the intervention arm reported vaccinating their child ( 93 % versus 73 % , p = 0.04 ) . Conclusions Whilst both the leaflet and the parent meeting reduced parents ' decisional conflict , the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake OBJECTIVE To improve health outcomes of children  , the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practice s and more coordination between practice s and community-based agencies . However , applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them . To improve the way that preventive health care services are organized and delivered in 1 community , we design ed , implemented , and assessed the impact of a health care system-level approach , which involved addressing multiple care delivery processes , at multiple levels in the community , the practice , and the family . Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community , with particular attention to health outcomes for low-income mothers and infants . DESIGN Observational intervention study in 1 North Carolina county ( population 182 000 ) involving low- income pregnant mothers and their infants , primary care practice s , and departments of health and mental health . An interrupted time-series design was used to assess rates of preventive services in office practice s before and after the intervention , and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program 's initiation . Outcomes were assessed when the infants reached 12 months of age . INTERVENTIONS Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families . We selected interventions that were directed toward major risk factors ( eg , poverty , ineffective care systems for preventive care in office practice s ) and for which there was existing evidence of efficacy . The interventions involved community- , practice - , and family-level strategies to improve processes of care delivery  to families and children . The objectives of the community-level intervention were : 1 ) to achieve policy level changes that would result in changes in re sources available at the level of clinical care , 2 ) to engage multiple practice organizations in the intervention to achieve an effect on most , if not all , families in the community , and 3 ) to enhance communication between , among , and within public and private practice organizations to improve coordination and avoid duplication of services . The objective of the practice -level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered . To assist the health department in implementing the family-level intervention , we provided assistance in hiring and training staff and ongoing consultation on staff supervision , including the use of structured protocol s for care delivery , and regular feedback data about implementation of the program . Interventions with primary care practice s focused on the design of the delivery system within the office and the use of teamwork and data in an " office systems " approach to improving clinical preventive care . All practice s ( N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems ( eg , preventive services flow sheets ) for preventive services delivery . Family-level interventions addressed the process of care delivery to high-risk pregnant women ( < 100 % poverty ) and their infants . Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center , the county 's largest provider of prenatal care to underserved women . The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant 's first year of life to provide parental education on fetal and infant health and development , enhance parents ' informal support systems , and link parents with needed health and human services . We included training in injury prevention and discipline , and home visitors assisted mothers in obtaining care from one of the primary care offices . RESULTS There were high levels of participation , changes in the organization of the delivery system , and improvements in preventive health outcomes . Agencies cooperated in joint contracting , staff training , and defining program eligibility . All 8 eligible practice s agreed to participate and 7/8 implemented at least 1 new office system element . Of eligible women , 89 % agreed to participate , and outcome data were available on 80 % ( 180/225 ) . After adjusting for differences in baseline characteristics , intervention group women were significantly more likely than comparison group women to use contraceptives ( 69 % vs 47 % ) , not smoke tobacco ( 27 % vs 54 % ) and have a safe and stimulating home environment for their children . Intervention group children were more likely to have had an appropriate number of well-child care visits ( 57 % vs 37 % ) and less likely to be injured ( 2 % vs 7 % ) . Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child ( 7.7 months vs 11.3 months ) . CONCLUSIONS We observed a number of positive effects at all 3 levels of intervention . Policy-level changes at the state and community led to lasting changes in the organization and financing of care , which enabled changes in clinical services to take place . These changes have now been exp and ed beyond this community to other communities in the state . We were also able to engage multiple practice organizations , reduce duplication , and improve the coordination of care . Changes in the process of preventive services delivery were noted in participating practice s. Finally , the outcomes of the family-level intervention  were comparable in direction and magnitude to the outcomes of previous r and omized trials of the intervention . All the changes were achieved over a relatively brief 3-year study period , and many have been sustained since the project was completed . Tiered , interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children We sought to determine if a simple educational intervention initiated at the first wellchild care visit , with reinforcement at subsequent visits , can improve inner-city infant immunization rates . We conducted a controlled trial involving 315 newborn infants and their primary caregivers in 3 inner-city primary care centers . Child health care providers gave caregivers in the intervention group an interactive graphic card with verbal reinforcement . At later visits , stickers were applied to the card when immunizations were given . Routine information was given to controls . After the trial , age-appropriate immunization rates at 7 months were 58 % in each group . Intervention infants had 50 % fewer missed opportunities to immunize ( p=0.01 ) but cancelled 77 % more appointments ( p=0.04 ) than controls . We conclude that a brief educational intervention at the first well-child care visit did not boost 7-month immunization rates , although it was associated with fewer missed opportunities to immunize Background In Pakistan , only 59 - 73 % of children 12 - 23 months of age are fully immunized . This r and omized , controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates . Methods Three hundred and sixty-six mother-infant pairs , with infants aged ≤ 6 weeks , were enrolled and r and omized into either the intervention or control arm between August - November 2008 . The intervention , administered by trained community health workers , consisted of three targeted pictorial messages regarding vaccines . The control group received general health promotion messages based on Pakistan 's Lady Health Worker program curriculum . Assessment of DPT/Hepatitis B vaccine completion ( 3 doses ) was conducted 4-months after enrollment . A Poisson regression model was used to estimate effect of the intervention . The multivariable Poisson regression model included maternal education , paternal occupation , ownership of home , cooking fuel used at home , place of residence , the child 's immunization status at enrollment , and mother 's perception about the impact of immunization on child 's health . Results Baseline characteristics among the two groups were similar . At 4 month assessment , among 179 mother-infant pairs in the intervention group , 129 ( 72.1 % ) had received all 3 doses of DPT/Hepatitis B vaccine  , whereas in the control group 92/178 ( 51.7 % ) had received all 3 doses . Multivariable analysis revealed a significant improvement of 39 % ( adjusted RR = 1.39 ; 95 % CI : 1.06 - 1.81 ) in DPT-3/Hepatitis B completion rates in the intervention group . Conclusion A simple educational intervention design ed for low-literate population s , improved DPT-3/Hepatitis B vaccine completion rates by 39 % . These findings have important implication s for improving routine immunization rates in Pakistan 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 setting s. 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 : underst and ing the relationships between different types of communication interventions ; facilitating conceptual mapping of these interventions ; clarifying the key purpose s 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 ) search ing for descriptions of interventions in trials ( CENTRAL data base ) 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 r and omised 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 CONTEXT An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations . Disparities in US childhood immunization rates persist , with inner-city , black , and Hispanic children having lower rates . Although practice or clinic-based interventions , such as patient reminder/recall systems , have been found to improve immunization rates in specific setting s , there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level . OBJECTIVE To assess the effect of a community-wide reminder , recall , and outreach ( RRO ) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban population s and among white , black , and Hispanic children within an entire county . SETTING Monroe County , New York ( birth cohort : 10 000 , total population : 750 000 ) , which includes the city of Rochester . Three geographic regions within the county were compared : the inner city of Rochester , which contains the greatest concentration of poverty ( among 2-year-old children , 64 % have Medicaid ) ; the rest of the city of Rochester ( 38 % have Medicaid ) ; and the suburbs of the county ( 8 % have Medicaid ) . INTERVENTIONS An RRO system was implemented in 8 city practice s in 1995 ( covering 64 % of inner-city children ) and was exp and ed to 10 city practice s by 1999 ( covering 74 % of inner-city children , 61 % of rest-of-city children , and 9 % of suburban children ) . The RRO intervention involved lay community-based outreach workers who were assigned to city practice s to track immunization rates of all 0- to 2-year-olds , and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations ( tracking for all children , mail , or telephone reminders for most children , assistance with transportation or scheduling for some children , and home visits for 5 % of children who were most behind in immunizations and who faced complex barriers ) . STUDY PARTICIPANTS Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993 , 1996 , and 1999 . STUDY DESIGN Immunization rates were measured for each geographic region in Monroe County at 3 time periods : before the implementation of a systematic RRO system ( 1993 ) , during early phases of implementation of the RRO system ( 1996 ) , and after implementation of the RRO system in 10 city practice s ( 1999 ) . Immunization rates were compared for children living in the 3 geographic regions , and for white , black , and Hispanic children . Immunization rates were measured by the same methodology in each of the 3 time periods . A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practice s in the county ( covering 85 % to 89 % of county children ) . A r and om sample of children ( > 500 from the suburbs and > 1200 from the city for each sampling period ) was then selected for medical chart review at practice s to determine demographic characteristics ( including race and ethnicity ) and immunization rates . City children were over sample d to allow detection of effects by geographic region and race . Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling . MAIN OUTCOME MEASURES Immunization rates at 12 and 24 months for recommended vaccines ( 4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella : > or = 1 Haemophilus influenzae type b on or after 12 months of age ) . RESULTS DISPARITIES BY GEOGRAPHIC REGION : Baseline immunization rates ( 1993 ) for 24-month-olds were as follows : inner city ( 55 % ) , rest of city ( 64 % ) , and suburbs ( 73 % ) , with an 18 % difference in rates between the inner city and suburbs . By 1996 , immunization rates rose faster in the inner city ( + 21 % points ) than in the suburbs ( + 14 % points ) so that the difference in rates between the inner city and suburbs had narrowed to 11 % . In 1999 , rates were similar across geographic regions : inner city ( 84 % ) , rest of city ( 81 % ) , and suburbs ( 88 % ) , with a 4 % difference between the inner city and suburbs . DISPARITIES BY RACE AND ETHNICITY : Immunization rates were available in 1996 and 1999 by race and ethnicity . Twenty-four-month immunization rates in 1996 showed disparities : white ( 89 % ) , black ( 76 % ) , and Hispanic ( 74 % ) , with a 13 % difference between rates for white and black children and a 15 % difference between white and Hispanic children . In 1999 , rates were similar across the groups : white ( 88 % ) , black ( 81 % ) , and Hispanic ( 87 % ) , with a 7 % difference between rates for white and black children , and a 1 % difference between white and Hispanic children . CONCLUSIONS A community-wide intervention of patient RRO  raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority population s. By targeting a relatively manageable number of primary care practice s that serve city children and using an effective strategy to increase immunization rates in each practice , it is possible to eliminate disparities in immunizations for vulnerable children STUDY OBJECTIVE : To see whether the community mothers ' programme , using lay volunteer mothers to deliver a childhood development programme , could be extended successfully to the travelling community in Irel and . DESIGN : This was a prospect i ve study of the travelling community ; comparisons were made with results of a previous r and omised trial of settled mothers . SETTING : A regional health authority in Irel and . PARTICIPANTS : These comprised 39 traveller and 127 settled intervention mother/ infant pairs ( r and omised controlled trial ( RCT ) intervention ) ; settled community mothers ; 105 settled control pairs ( RCT control ) . All mothers received st and ard support ; traveller and RCT intervention groups also received the services of a community mother . MAIN RESULTS : The travellers ' sociodemographic profile differed significantly from the other groups . At the end of the study , traveller and intervention children were exposed to more  cognitive games and nursery rhymes .  There were significant differences in the proportions who received all three shots of their primary immunisation schedule before 12 months of age and who received " three in one " vaccination , with traveller children doing least well . The diet of traveller children surpassed that of RCT controls in all food groups except fruit ; they were less likely to begin cows ' milk before 26 weeks of age . Traveller mothers ' diet was superior to that of RCT control and similar to RCT intervention mothers . Traveller and RCT intervention mothers were less likely to feel tired , feel miserable , and want to stay indoors than RCT control mothers . CONCLUSIONS : The results of the community mothers ' programme in the travelling community are encouraging ; poor immunisation uptake remains a challenge Background Household decision-makers decide about service use based largely on the costs and perceived benefits of health interventions . Very often this leads to different decisions than those imagined by health planners , result ing in under-utilisation of public services like immunisation . In the case of Lasbela district in the south of Pakistan , only one in every ten children is immunised despite free immunisation offers by government health services . Methods / design In 32 communities representative of Lasbela district , 3344 households participated in a baseline survey on early child health . In the 18 r and omly selected intervention communities , we will stimulate discussion s on the household cost-benefit equation , as measured in the baseline . The reference ( control ) communities will also participate in the three annual follow-up surveys , feedback of the general survey results and the usual health promotion activities relating to immunisation , but without focussed discussion on the household cost-benefit equations . Discussion This project proposes knowledge translation as a two-way communication that can be augmented by local and international evidence . We will document cultural and context ual barriers to immunisation in the context of household cost-benefit equations . The project makes this information accessible to health managers , and reciprocally , makes information on immunisation effects and side effects available to communities . We will measure the impact of this two-way knowledge translation on immunisation uptake OBJECTIVES : To test the effectiveness of messages design ed to reduce vaccine misperceptions and increase vaccination rates for measles-mumps-rubella ( MMR ) . METHODS : A Web-based nationally representative 2-wave survey experiment was conducted with 1759 parents age 18 years and older residing in the United States who have children in their household age 17 years or younger ( conducted June – July 2011 ) . Parents were r and omly assigned to receive 1 of 4 interventions : ( 1 ) information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention ; ( 2 ) textual information about the dangers of the diseases prevented by MMR from the Vaccine Information Statement ; ( 3 ) images of children who have diseases prevented by the MMR vaccine ; ( 4 ) a dramatic narrative about an infant who almost died of measles from a Centers for Disease Control and Prevention fact sheet ; or to a control group . RESULTS : None of the interventions increased parental intent to vaccinate a future child . Refuting cl aims of an MMR/autism link successfully reduced misperceptions that vaccines cause autism but nonetheless decreased intent to vaccinate among parents who had the least favorable vaccine attitudes . In addition , images of sick children increased expressed belief in a vaccine/autism link and a dramatic narrative about an infant in danger increased self-reported belief in serious vaccine side effects . CONCLUSIONS : Current public health communications about vaccines may not be effective . For some parents , they may actually increase misperceptions or reduce vaccination intention . Attempts to increase concerns about communicable diseases or correct false cl aims about vaccines may be especially likely to be counterproductive . More study of pro-vaccine messaging is needed OBJECTIVE To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income , minority mothers in Washington , DC . DESIGN The experimental design was a r and omized , controlled study in which 286 mother-infant dyads were assigned to either the st and ard social services ( control ) group or to the intervention group .  Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington , DC , hospital sites from April 1995 to April 1997 . The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the st and ard social services available at the hospital sites . A total of 286 postpartum women with inadequate prenatal care were assigned r and omly to the control or the intervention group . Women and their infants were followed for 1 full year . Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant 's life . RESULTS Infants in the intervention group initiated well care at an earlier age than controls ( by 6 weeks , 62.5 % vs 50 % had received their first well infant visit ) . Infants in the intervention group had more frequent well visits ( by 12 months of age , 3.5 vs 2.7 visits ) . Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations ( by 9 months , odds ratio = 2.2 , 95 % confidence interval : 1.09 - 4.53 ) . Those in the intervention group with more frequent contacts ( 30 + visits ) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls ( at 9 months odds ratio = 3.63 , 95 % confidence interval : 1.58 - 8.33 ) . CONCLUSIONS It is possible to influence health care usage patterns of high-risk minority population s through public health interventions that are global in their perspective . Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care re sources A r and omized controlled trial was conducted comparing home visits with office visits by physicians to families with newborns within the first two weeks of life . Results showed that physicians were significantly more satisfied and rated their relationship with the family significantly higher after home visits than after office visits . Fathers were present at 50 percent of the home visits compared with 26 percent of office visits ( P less than .05 ) . Mothers in the home visit group rated caring for their baby as significantly easier than the office visit group . There was no difference in infant immunization rate or number of well-child visits , although infants in the home visit group had significantly more visits to their own physician . The mean length of visit was 33 minutes ( not including travel time ) for home visits and 23 minutes for office visits . Physicians were better able to note home environment and family interactions during home visits . This study supports the view that home visits by physicians enhance the physician-family relationship CONTEXT Immunization rates in the inner city remain lower than in the general US population , but efforts to raise immunization levels in inner-city areas have been largely untested . OBJECTIVE To assess the effectiveness of case management in raising immunization levels among infants of inner-city , African American families . DESIGN R and omized controlled trial with follow-up through 1 year of life . SETTING Low-income areas of inner-city Los Angeles , Calif. PATIENTS A representative sample of 419 African American infants and their families . INTERVENTIONS In-depth assessment by case managers before infants were 6 weeks of age , with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed . MAIN OUTCOME MEASURES Percentage of children with up-to- date immunizations at age 1 year , characteristics associated with improved immunization rates , and cost-effectiveness of case management intervention .  RESULTS A total of 365 newborns were followed up to age 1 year . Overall , the immunization completion for the case management group was 13.2 percentage points higher than the control group ( 63.8 % vs 50.6 % ; P=.01 ) . In a logistic model , the case management effect was limited to the 25 % of the sample who reported 3 or fewer well-child visits ( odds ratio , 3.43 ; 95 % confidence interval , 1.26 - 9.35 ) ; for them , immunization levels increased by 28 percentage points . Although for the case management group intervention was not cost-effective ( $ 12022 per additional child immunized ) , it was better ( $ 4546 ) for the 25 % of the sample identified retrospectively to have inadequate utilization of preventive health visits . CONCLUSIONS A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city , African American infants . The intervention was demonstrated to be particularly effective for sub population s that do not access well-child care ; however , currently there are no means to identify these groups prospect ively . For case management to be a useful tool to raise immunizations levels among high-risk population s , better methods of tracking and targeting , such as immunization registries , need to be developed OBJECTIVE To measure the effect of a multimodal intervention on well-child care visit ( WCV ) and immunization rates in an inner-city population . DESIGN Cluster r and omized controlled trial . SETTING AND PARTICIPANTS One-year cohort of 2843 infants born at a hospital in an integrated inner-city health care system . INTERVENTIONS Eleven clinics were r and omly allocated to 1 of 3 study arms : WCV intervention ( n = 3 ) , immunization intervention ( n = 4 ) , and controls ( n = 4 ) . Interventions to improve immunization and WCV rates included both patient-based and clinic-based activities . MAIN OUTCOME MEASURES Up-to- date status with childhood immunizations and WCVs by age 12 months ( primary ) and health care utilization and charges ( secondary ) . RESULTS Compared with the control arm , the WCV and immunization arms had 5 % to 6 % higher immunization rates and 7 % to 8 % higher WCV rates . In multivariate analyses that accounted for the clustered nature of the data , the number of immunizations received was greater in the WCV arm than in controls . However , neither the WCV nor the immunization intervention increased WCV or immunization up-to- date rates . The WCV arm had slightly higher health care charges . Neither intervention affected emergency , urgent care or inpatient utilization . CONCLUSIONS This multimodal intervention produced a small increase in the number of childhood immunizations delivered . However , patient- and clinic-based methods did not lead to significant increases in WCV or immunization up-to- date rates after controlling for other factors . Methods found in some setting s to increase immunization up-to- date rates may not be as effective in a population of inner-city socioeconomically disadvantaged children Objective To assess the efficacy of modest non-financial incentives on immunisation rates in children aged 1 - 3 and to compare it with the effect of only improving the reliability of the supply of services . Design Clustered r and omised controlled study . Setting Rural Rajasthan , India . Participants 1640 children aged 1 - 3 at end point . Interventions 134 villages were r and omised to one of three groups : a once monthly reliable immunisation camp  ( intervention A ; 379 children from 30 villages ) ; a once monthly reliable immunisation camp with small incentives ( raw lentils and metal plates for completed immunisation ;  intervention B ; 382 children from 30 villages ) , or  control ( no intervention , 860 children in 74 villages ) . Surveys were undertaken in r and omly selected households at baseline and about 18 months after the interventions started ( end point ) . Main outcome measures Proportion of children aged 1 - 3 at the end point who were partially or fully immunised . Results Among children aged 1 - 3 in the end point survey , rates of full immunisation were 39 % ( 148/382 , 95 % confidence interval 30 % to 47 % ) for intervention B villages ( reliable immunisation with incentives ) , 18 % ( 68/379 , 11 % to 23 % ) for intervention A villages ( reliable immunisation without incentives ) , and 6 % ( 50/860 , 3 % to 9 % ) for control villages . The relative risk of complete immunisation for intervention B versus control was 6.7 ( 4.5 to 8.8 ) and for intervention B versus intervention A was 2.2 ( 1.5 to 2.8 ) . Children in areas neighbouring intervention B villages were also more likely to be fully immunised than those from areas neighbouring intervention A villages ( 1.9 , 1.1 to 2.8 ) . The average cost per immunisation was $ 28 ( 1102 rupees , about £ 16 or € 19 ) in intervention A and $ 56 ( 2202 rupees ) in intervention B. Conclusions Improving reliability of services improves immunisation rates , but the effect remains modest . Small incentives have large positive impacts on the uptake of immunisation services in re source poor areas and are more cost effective than purely improving supply . Trial registration IRSCTN87759937 BACKGROUND Tuberculosis is re-emerging as an important health problem in industrialised countries . Uncertainty surrounds the effect of public-health control options . We therefore aim ed to assess a programme to promote screening for tuberculosis in a UK primary health care district . METHODS In a cluster r and omised controlled trial , we r and omised 50 of 52 ( 96 % ) eligible general practice s in Hackney , London , UK , to receive an  outreach programme that promoted screening for tuberculosis in people registering in primary care , or to continue with usual care . Screening was verbal , and proceeded to tuberculin skin testing , if appropriate . The primary outcome was the proportion of new cases of active tuberculosis identified in primary care . Analyses were done on an intention-to-treat basis . This study was registered at clinical trials.gov , number NCT00214708 . FINDINGS Between June 1 , 2002 , and Oct 1 , 2004 , 44,986 and 48,984 patients registered with intervention and control practice s , respectively . In intervention practice s 57 % ( 13,478 of 23,573 ) of people attending a registration health check were screened for tuberculosis compared with 0.4 % ( 84 of 23 051 ) in control practice s. Intervention practice s showed increases in the diagnosis of active tuberculosis cases in primary care compared with control practice s ( 66/141 [ 47 % ] vs 54/157 [ 34 % ] , odds ratio ( OR ) 1.68 , 95 % CI 1.05 - 2.68 , p=0.03 ) . Intervention practice s also had increases in diagnosis of latent tuberculosis ( 11/59 [ 19 % ] vs 5/68 [ 9 % ] , OR 3.00 , 0.98 - 9.20 , p=0.055 ) and BCG coverage ( mean BCG rate 26.8/1000 vs 3.8/1000 , intervention rate ratio 9.52 , 4.0 - 22.7 , p<0.001 ) . INTERPRETATION Our educational intervention for promotion of screening for tuberculosis in primary care improved identification of active and latent tuberculosis , and increased BCG coverage . Yield from screening was low , but was augmented by improved case-finding . Screening programmes in primary care should be considered as part of tuberculosis control initiatives in industrialised countries The widespread decline in uptake of the measles , mumps and rubella ( MMR ) vaccine started when an association between vaccination and Crohn ’s disease was suggested by research ers at the Royal Free Hospital and elsewhere in a series of papers published between 1993 and 1996 . It accelerated after February 1998 when the same workers hypothesized an association with autism through a putative mechanism of enterocolitis and toxin absorption . The widespread media coverage that the papers received result ed in a substantial minority of parents being misled into believing that there was a large body of medical opinion suspicious of MMR .  Uptake of MMR vaccine  began to decline rapidly and the incidence of measles and mumps infections increased . Novel methods of improving uptake of MMR vaccine  have been explored , but the authors ’ approach – to issue teddy bears wearing T-shirts displaying a website address and telephone number that provided information about MMR – has not been described previously . A pragmatic r and omized controlled trial was design ed with prospect i ve selection of subjects . Children eligible for their first dose of MMR vaccine ( MMR1 ) in Flintshire , being seen by their health visitor ( HV ) for the routine 8-month assessment , were recruited to the study . At the time of planning the study , Flintshire had the lowest uptake rate of all childhood immunizations inWales and the lowest uptake of MMR1 ( 69 % ) in North Wales . Children were r and omized to receive normal management plus a teddy bear ( intervention arm of the study ) or normal management alone ( nonintervention arm of the study ) . The bear ’s T-shirt contained three items of information We conducted a r and omized , controlled trial to determine the effectiveness of an immunization tracking system design ed to increase the number of infants of lower socioeconomic status who receive their primary series of vaccinations at age-appropriate times . By 7 months of age , 91 % ( 274/301 ) of the infants in the intervention group were up-to- date on their primary series of vaccinations versus 72 % ( 214/296 ) of the infants in the control group ( p < 0.0001 ) . The estimated cost of follow-up for each infant in the intervention group was $ 18.05 . ( J PEDIATR 1995 ; 126:583 - 6 BACKGROUND At child health visits , immunizations that are due are frequently not given . Increased parent underst and ing of and dem and for immunizations may influence providers to not miss these opportunities . OBJECTIVE To assess , as part of a larger study of effectiveness of parent education and case management ( CM ) in raising immunization rates , the intervention 's effectiveness at reducing missed opportunities to vaccinate during child health visits . METHODS A representative sample of African American newborns and their families from south central Los Angeles , Calif , were r and omly assigned to a control or a CM group and observed during the first year of life . Case managers visited and telephoned parents , educating them on the benefits and safety of immunizations , and encouraging them to request immunizations from providers . When the children were at least 1 year of age , parents were interviewed and provider records were abstract ed . RESULTS Complete records were abstract ed for 126 controls and 129 CM group children . For these children , 1092 visits were documented where immunizations were due . Missed opportunities to vaccinate occurred at more than 50 % of visits . Case management was associated with a modest reduction in the percentage of visits with missed opportunities in the bivariate analysis but not after adjustment for other covariates . In a logistic regression model , missed opportunities were more frequent at visits with private than public physicians and at acute illness than well-child visits . Missed opportunities were less frequent among children with a history of at least 1 cancelled appointment , and for visits of children with mothers who smoked . CONCLUSIONS Missed opportunities were minimally influenced by a home visitation and parent education program . They are primarily determined by issues under the control of the provider . Family- and child-related characteristics , however , do influence the likelihood of a missed opportunity occurring independent of provider factors Objectives To conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries . Design Systematic review . Setting Developed countries Participants Preschool children who were due , or overdue , one or more of their routine primary immunisations . Main outcome measures Increase in the proportion of the target population up to date with st and ard recommended universal vaccinations . Results Forty-six studies were included for analysis , published between 1980 and 2009 . Twenty-six studies were r and omized controlled trials , 11 were before and after trials , and nine were controlled intervention trials . Parental reminders showed a statistically significant increase in immunisation rates in 34 % of included intervention arms . These effects were reported with both generic and specific reminders and with all methods of reminders and recall . Strategies aim ed at immunisation providers were also shown to improve immunisation rates with a median change in immunisation rates of 7 % when reminders were used , 8 % when educational programmes were used and 19 % when feedback programmes were used . Conclusion General practitioners are uniquely positioned to influence parental decisions on childhood immunisation . A variety of strategies studied in primary care setting s have been shown to improve immunisation rates , including parental and healthcare provider reminders In Pakistan during 2000 - 2004 , about 11 - 13 % of children who received the first dose of diphtheria-pertussis-tetanus ( DPT1 )  failed to complete its third dose ( DPT3 ) . We assessed the effect of a re design ed immunization card and center-based education to mothers on DPT3 completion . We enrolled 1500 mother-child units at DPT1 , r and omized them to three intervention and one st and ard care groups , and recorded their DPT3 visits during a 90-day follow-up . In multivariable analysis , a significant increase of 31 % ( adjusted RR=1.31 , 95 % CI=1.18 - 1.46 ) in DPT3 completion was estimated in the group that received both re design ed card and center-based education compared with the st and ard care group Aims : The present study was carried out to impart correct health education regarding polio eradication programme and to assess the impact of social mobilization of a Muslim community carried out by medical interns . Methods : One round of a polio immunization campaign was selected r and omly . Five highly resistant areas were included in the study . During house to house A-Team activity , teams of health workers visited the houses and resistant families were identified . These families refused to give polio drops to their children . On the second day of A-Team activity , medical interns visited those identified resistant families . They imparted correct health education and tried to convince them to give polio drops . However , after prolonged persuasion , some of the families were not ready to give polio drops . These more resistant families were again visited by more motivated and enthusiastic teams during B-Team activity , started two to three days after the completion of A-Team activity . Data were collected , tabulated and analysed . Results : Total number of resistant families identified during house to house A-Team activity was 1025 in five high risk areas of Aligarh , India . Out of 1025 resistant houses , 510 ( 49.76 % ) houses were converted to P houses where polio drops were given to the children . Five hundred and fifteen ( 50.24 % ) houses remained resistant even after social mobilization by A-Team members . These most resistant houses were again visited by B-team members . Out of these 515 houses , polio drops were administered in 303 ( 58.83 % ) . The overall number of converted houses was 813 ( 79.32 % ) after A and B-team activities . 20.68 % of families remained resistant and their children could not be given polio drops . Conclusions : In all high risk areas , maximum numbers of resistant houses were converted to P houses . These families were persuaded and convinced by the teams of interns , social workers and influential persons that polio drops did not have any side effects . They were more receptive to the advice given by medical interns compared to other staff members of the Government District Hospital because of quality of health services provided to the community . There is a need to impart correct health education regarding importance of polio drops and routine immunization more vigorously through information , education and communication ( IEC ) activities The results of a four year demonstration project of preventive services for Medicare managed care enrollees suggest that health promotion programs can impact health behaviors and outcomes . The study provided selected preventive services to 1,800 Medicare enrollees in a managed care environment . Participants were r and omly assigned to control and experimental groups with the experimental group receiving an intervention service package and the control group usual care . The results included enhanced health behavior practice s , lower depression , and higher immunization rates among those individuals in the experimental group . This study suggests that selected preventive services can be provided in a managed care environment to Medicare enrollees with likely positive health status and utilization outcomes CONTEXT A lack of awareness about entitled health and social services may contribute to poor delivery of such services in developing countries , especially among individuals of low socioeconomic status . OBJECTIVE To determine the impact of informing re source -poor rural population s about entitled services . DESIGN , SETTING , AND PARTICIPANTS Community-based , cluster r and omized controlled trial conducted from May 2004 to May 2005 in 105 r and omly selected village clusters in Uttar Pradesh state in India . Households ( 548 intervention and 497 control ) were selected by a systematic sampling design , including both low-caste and mid- to high-caste households . INTERVENTION Four to 6 public meetings were held in each intervention village cluster to disseminate information on entitled health services , entitled education services , and village governance requirements . No intervention took place in control village clusters . MAIN OUTCOME MEASURES Visits by nurse midwife ; prenatal examinations , tetanus vaccinations , and prenatal supplements received by pregnant women ; vaccinations received by infants ; excess school fees charged ; occurrence of village council meetings ; and development work in villages . RESULTS At baseline , there were no significant differences in self-reported delivery of health and social services . After 1 year , intervention villagers reported better delivery of several services compared with control villagers : in a multivariate analysis , 30 % more prenatal examinations ( 95 % confidence interval [ CI ] , 17%-43 % ; P < .001 ) , 27 % more tetanus vaccinations ( 95 % CI , 12%-41 % ; P < .001 ) , 24 % more prenatal supplements ( 95 % CI , 8%-39 % ; P = .003 ) , 25 % more infant vaccinations ( 95 % CI , 8%-42 % ; P = .004 ) , and decreased excess school fees of 8 rupees ( 95 % CI , 4 - 13 rupees ; P < .001 ) . In a difference-in-differences analysis , 21 % more village council meetings were reported ( 95 % CI , 5%-36 % ; P = .01 ) . There were no improvements in visits by a nurse midwife or in development work in the villages . Both low-caste and mid- to high-caste intervention households reported significant improvements in service delivery . CONCLUSIONS Informing re source -poor rural population s in India about entitled services enhanced the delivery of health and social services among both low- and mid- to high-caste households . Interventions that emphasize educating re source -poor population s about entitled services may improve the delivery of such services . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00421291 Eighty-two Asian women ( mostly Muslims ) living in East London were prospect ively studied through their pregnancy and delivery . Their infants were assessed during the second year of life for growth , nutrition , morbidity , development and vaccination history . There was no increase in perinatal or infant mortality over the general population in the same borough , though there was increased infant morbidity , most commonly iron deficiency ( in 25 % ) , and one child with sub clinical rickets . One child had a genetic neurodegenerative disorder . The incidence of low birth weight babies was only slightly greater than that of the district as a whole , but after 1 year of age they were less well grown than the population studied by Tanner & Whitehouse . Sixty-four per cent of the women started to breast feed , but many also gave artificial milk and they usually ceased to breast feed earlier than most women in the same district . When half of the women were r and omly allocated to receive specialized education , with the others acting as controls , very few attended and little benefit was detected . Though the significance is doubtful , the infants of those educated did tend to be better grown ( especially in length ) , be less likely to have development well below average , have reduced morbidity and have more complete immunization schedules than those of the women not receiving education . This study shows no benefit due to antenatal education , but suggests that the children have advantages when their mothers have the drive to attend the education sessions OBJECTIVE To determine if health care utilization and health status among high-risk children is modified by the use of group well child care ( GWCC ) as compared with traditional one-to-one individual well child care ( IWCC ) . STUDY DESIGN R and omized controlled trial . PARTICIPANTS Children less than 4 months old from families with at least one of the following maternal risk factors : poverty , single marital status , age < 20 years at delivery , less than a high school education , previous substance abuse , or history of abuse as a child . SETTING Two urban , university pediatric clinics in Seattle , Washington . INTERVENTIONS Children were r and omized to receive GWCC or IWCC at the time of enrollment .  Health supervision visits with two study nurse practitioners were scheduled at 4 , 5 , 6 , 8 , 10 , 12 , and 15 months of age . GWCC study visits consisted of a group discussion of age-appropriate child-rearing issues , along with a physical examination , health screening , and immunizations . Health care utilization among children receiving GWCC and those r and omized to IWCC was assessed using the following measures : compliance with study visits , compliance with any age-appropriate health supervision visit , emergency department utilization , and immunization rates ( defined as the proportion of children in each group who had received all recommended vaccines by 1 year of age ) . Provider time for GWCC and IWCC study visits was also recorded . Health status was measured using Stein 's Functional Status IIR , completed by the mothers of study patients when their children completed the study at 15 months of age . RESULTS A total of 106 children received GWCC , whereas 104 were r and omized to IWCC . Compliance with scheduled study visits was 47 % for GWCC patients and 54 % for IWCC recipients ; overall compliance with any age-appropriate health supervision visit was 68 % and 66 % , respectively . Provider time was similar for GWCC and IWCC visits . By the age of 1 year , 67 % of GWCC recipients and 73 % of those receiving IWCC had received three DTP/DT , three OPV/IPV , three Hib , and three hepatitis B immunizations . A total of 242 emergency department visits were made by study patients during their enrollment in the project ; there was no difference in the average number of visits between GWCC or IWCC children . However , children receiving IWCC were more likely to have at least one emergency department visit than GWCC recipients . At the conclusion of the project , health status , as measured by the Functional Status IIR , was similar in GWCC and IWCC patients ( mean scores 92.4 + /- 1.4 and 92.5 + /- 1.1 , respectively ) . CONCLUSIONS Health care utilization and health status was similar in high-risk children whether they received GWCC or IWCC . GWCC is a viable format for health supervision visits in this population OBJECTIVE To assess the impact of a tiered patient immunization navigator intervention ( immunization tracking , reminder/recall , and outreach ) on improving immunization and preventive care visit rates in urban adolescents . DESIGN R and omized clinical trial allocating adolescents ( aged 11 - 15 years ) to intervention vs st and ard of care control . SETTING Eight primary care practice s. PARTICIPANTS Population -based sample of adolescents ( N = 7546 ) .  INTERVENTION Immunization navigators at each practice implemented a tiered protocol : immunization tracking , telephone or mail reminder/recall , and home visits if participants remained unimmunized or behind on preventive care visits . MAIN OUTCOME MEASURES Immunization rates at study end . Secondary outcomes were preventive care visit rates during the previous 12 months and costs . RESULTS The intervention and control groups were similar at baseline for demographics ( mean age , 13.5 years ; 63 % black , 14 % white , and 23 % Hispanic adolescents ; and 74 % receiving Medicaid ) , immunization rates , and preventive care visit rates . Immunization rates at the end of the study were 44.7 % for the intervention group and 32.4 % for the control group ( adjusted risk ratio , 1.4 ; 95 % confidence interval , 1.3 - 1.5 ) ; preventive care visit rates were 68.0 % for the intervention group and 55.2 % for the control group ( 1.2 ; 1.2 - 1.3 ) . Findings were similar across practice s , sexes , ages , and insurance providers . The number needed to treat for immunizations and preventive care visits was 9 . The intervention cost was $ 3.81 per adolescent per month ; the cost per additional adolescent fully vaccinated was $ 465 , and the cost per additional adolescent receiving a preventive care visit was $ 417 . CONCLUSION A tiered tracking , reminder/recall , and outreach intervention improved immunization and preventive care visit rates in urban adolescents . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00581347 Abstract Objectives : To evaluate impact of postnatal health education for mothers  on infant care and postnatal family planning practice s in Nepal . Design : R and omised controlled trial with community follow up at 3 and 6 months post partum by interview . Initial household survey of study areas to identify all pregnant women to facilitate follow up . Setting : Main maternity hospital in Kathm and u , Nepal . Follow up in urban Kathm and u and a periurban area southwest of the city . Subjects : 540 mothers r and omly allocated to one of four groups : health education immediately after birth and three months later ( group A ) , at birth only ( group B ) , at three months only ( group C ) , or none ( group D ) . Interventions : Structured baseline household question naire ; 20 minute , one to one health education at birth and three months later . Main outcome measures : Duration of exclusive breast feeding , appropriate immunisation of infant , knowledge of oral rehydration solution and need to continue breast feeding in diarrhoea , knowledge of infant signs suggesting pneumonia , uptake of postnatal family planning . Results : Mothers in groups A and B ( received health education at birth ) were slightly more likely to use contraception at six months after birth compared with mothers in groups C and D ( no health education at birth ) ( odds ratio 1.62 , 95 % confidence interval 1.06 to 2.5 ) . There were no other significant differences between groups with regards to infant feeding , infant care , or immunisation . Conclusions : Our findings suggest that the recommended practice of individual health education for postnatal mothers in poor communities has no impact on infant feeding , care , or immunisation , although uptake of family planning may be slightly enhanced . Key messages Health education is widely promoted in primary care , but there have been few rigorous evaluations of its impact , especially in developing countries A r and omised controlled trial of postnatal individual health education for mothers given by trained female health workers showed no significant impact on maternal knowledge and practice s of child care or on infant health outcomes , but there was a small improvement in uptake of family planning at six months after birth The efficacy of health education interventions that rely solely on giving people information to bring about a change in health behaviour is unproved ; interventions should be evaluated before being implemented on a large scale Alternative strategies for health promotion in developing countries such as interactions within families , peer groups , or communities may be more effective but are costly and difficult to implement on a large This publication reports the findings of a 1987 study design ed to measure the reliability of Indian mothers as informants of immunization coverage . The study took place in the Kilvazhithunayan Kuppam Block in the North Arcot District of Tamil Nadu , a region with a population of approximately 104,000 inhabitants . Whenever immunization is carried out , proper procedure calls for the paramedical worker involved to register the information on a health card . To carry out the study , trained field workers r and omly selected the names of children between the aged of 6 - 12 months . The field workers then interviewed the mothers of these children with regard to immunization coverage . The mother 's response was checked according to the health card . The study revealed a concordance rate of 85 % between the mother 's verbal response and the recorded response . All the mothers who had visited the immunization clinic correctly identified the doses , but only 12 % of the mothers with unimmunized children ( 21/178 ) correctly identified their children 's immunization status . The study also found that mothers tended to overestimate the immunization coverage by about 8 % . But considering the high degree of concordance between the verbal and recorded responses , the study suggests that mothers do form a reliable source of information concerning immunization coverage , encouraging information for areas where immunization records are absent or inadequate PURPOSE To compare effects of an early intervention program ( EIP ) of intense home visitation by public health nurses ( PHNs ) with effects of traditional public health nursing care ( TPHN ) on infant health and selected maternal outcomes of adolescent mothers . METHODS EIP adolescents ( N = 102 ) received preparation-for-motherhood classes and individual home visits  ( from pregnancy through 1 year postpartum ) from PHNs employed in a county health department . Participants were predominantly Latina ( 64 % ) and African-American ( 11 % ) and from impoverished background s. Infant health outcomes were determined based on medical record data ; interviews and st and ardized question naires evaluated other program effects ( e.g. , maternal educational achievement and psychological status ) . Data were analyzed using Chi-square and repeated measures ANOVA . RESULTS Infants of EIP mothers experienced significantly fewer total days ( n = 74 ) and actual episodes ( n = 14 ) of hospitalization during the first year of life than those receiving TPHN ( n = 154 , n = 24 , respectively ) . Similarly , positive program effects were found for immunization rates . There were no group differences in emergency room visits or repeat pregnancy rates . Alcohol , tobacco , and marijuana use significantly increased from pregnancy through 1 year postpartum in both groups but remained markedly lower than rates prior to pregnancy ( lifetime rates ) . CONCLUSIONS These findings demonstrate the positive effects of a PHN home visitation program on health outcomes for children of adolescent mothers . Days of infant hospitalization were substantially reduced and immunization rates increased during the first year of life for children of EIP mothers . Greater efforts need to be directed toward preventing repeat pregnancy and return to substance use following childbirth in at-risk adolescent mothers Background The UN Millennium Development Goals call for substantial reductions in maternal and child mortality , to be achieved through reductions in morbidity and mortality during pregnancy , delivery , postpartum and early childhood . The M aiM wana Project aims to test community-based interventions that tackle maternal and child health problems through increasing awareness and local action . Methods / Design This study uses a two-by-two factorial cluster-r and omised controlled trial design to test the impact of two interventions . The impact of a community mobilisation intervention run through women 's groups , on home care , health care-seeking behaviours and maternal and infant mortality , will be tested . The impact of a volunteer-led infant feeding and care support intervention , on rates of exclusive breastfeeding , uptake of HIV-prevention services and infant mortality , will also be tested . The women 's group intervention will employ local female facilitators to guide women 's groups through a four-phase cycle of problem identification and prioritisation , strategy identification , implementation and evaluation . Meetings will be held monthly at village level . The infant feeding intervention will select local volunteers to provide advice and support for breastfeeding , birth preparedness , newborn care and immunisation . They will visit pregnant and new mothers in their homes five times during and after pregnancy . The unit of intervention allocation will be clusters of rural villages of 2500 - 4000 population . 48 clusters have been defined and r and omly allocated to either women 's groups only , infant feeding support only , both interventions  , or no intervention . Study villages are surrounded by ' buffer areas ' of non- study villages to reduce contamination between intervention and control areas . Outcome indicators will be measured through a demographic surveillance system . Primary outcomes will be maternal , infant , neonatal and perinatal mortality for the women 's group intervention , and exclusive breastfeeding rates and infant mortality for the infant feeding intervention . Structured interviews will be conducted with mothers one-month and six-months after birth to collect detailed quantitative data on care practice s and health-care-seeking . Further qualitative , quantitative and economic data will be collected for process and economic evaluations . Trial registration IS RCT OBJECTIVE --To see whether non-professional volunteer community mothers  could deliver a child development programme to disadvantaged first time mothers for children aged up to 1 year . DESIGN --R and omised controlled trial . SETTING --A regional health authority in Dublin . SUBJECTS--262 first time mothers who were delivered during six months in 1989 and who lived in a deprived area of Dublin ; 30 experienced mothers from the same community recruited as community mothers . INTERVENTIONS --All the first time mothers received st and ard support from the public health nurse . In addition , those in the intervention group received the services of a community mother , who was scheduled to visit monthly during the first year of the child 's life . RESULTS --232 ( 89 % ) first time mothers completed the study --127 in the intervention group , 105 controls . At the end of the study children in the intervention group were more likely to have received all of their primary immunisations , to be read to , and to be read to daily , played more cognitive games ; and were exposed to more nursery rhymes . They were less likely to begin cows ' milk before 26 weeks and to receive an inappropriate energy intake and inappropriate amounts of animal protein , non-animal protein , wholefoods , vegetables , fruit , and milk . Mothers in the intervention group also had a better diet than controls . At the end of the study they were less likely to be tired , feel miserable , and want to stay indoors ; had more positive feelings ; and were less likely to display negative feelings . CONCLUSION --Non-professionals can deliver a health promotion programme on child development effectively . Whether they can do so as effectively as professionals requires further study Objective To determine the safety and logistic feasibility of a mass immunization strategy outside the local immunization program in the pediatric population of urban squatter settlements in Karachi , Pakistan . Methods A cluster-r and omized double blind preventive trial was launched in August 2003 in 60 geographic clusters covering 21,059 children ages 2 to 16 years . After consent was obtained from parents or guardians , eligible children were immunized parenterally at vaccination posts in each cluster with Vi polysaccharide or hepatitis A vaccine . Safety , logistics , and st and ards were monitored and documented . Results The vaccine coverage of the population was 74 % and was higher in those under age 10 years . No life-threatening serious adverse events were reported . Adverse events occurred in less than 1 % of all vaccine recipients and the main reactions reported were fever and local pain . The proportion of adverse events in Vi polysaccharide and hepatitis A recipients will not be known until the end of the trial when the code is broken . Throughout the vaccination campaign safe injection practice s were maintained and the cold chain was not interrupted . Mass vaccination in slums had good acceptance . Because population s in such areas are highly mobile , settlement conditions could affect coverage . Systemic reactions were uncommon and local reactions were mild and transient . Close community involvement was pivotal for information dissemination and immunization coverage . Conclusion This vaccine strategy described together with other information that will soon be available in the area ( cost/effectiveness , vaccine delivery costs , etc ) will make typhoid fever control become a reality in the near future Abstract Background The trial addresses the general question of whether community re source centers run by a non-government organization improve the health of women and children in slums . The re source centers will be run by the Society for Nutrition , Education and Health Action , and the trial will evaluate their effects on a series of public health indicators . Each re source center will be located in a vulnerable Mumbai slum area and will serve as a base for salaried community workers , supervised by officers and coordinators , to organize the collection and dissemination of health information , provision of services , home visits to identify and counsel families at risk , referral of individuals and families to appropriate services and support for their access , meetings of community members and providers , and events and campaigns on health issues . Methods / design A cluster r and omized controlled trial in which 20 urban slum areas with re source centers are compared with 20 control areas . Each cluster will contain approximately 600 households and r and omized allocation will be in three blocked phases , of 12 , 12 and 16 clusters . Any resident of an intervention cluster will be able to participate in the intervention , but the re source centers will target women and children , particularly women of reproductive age and children under 5.The outcomes will be assessed through a household census after 2 years of re source center operations . The primary outcomes are unmet need for family planning in women aged 15 to 49 years , proportion of children under 5 years of age not fully immunized for their ages , and proportion of children under 5 years of age with weight for height less than 2 st and ard deviations below the median for age and sex . Secondary outcomes describe adolescent pregnancies , home deliveries , receipt of conditional cash transfers for institutional delivery , other childhood anthropometric indices , use of public sector health and nutrition services , indices of infant and young child feeding , and consultation for violence against women and children . Trial registration IS RCT N Register : IS RCT N56183183 Clinical Trials Registry of India : Lars Åke Persson and colleagues conduct a  cluster r and omised control in northern Vietnam to analyze the effect of the activity of local community-based maternal- and -newborn stakeholder groups  on neonatal mortality . Please see later in the article for the Editors ' Background Maternal , neonatal and child health outcomes are worse in families from black and ethnic minority groups and disadvantaged background s. There is little evidence on whether lay support improves maternal and infant outcomes among women with complex social needs within a disadvantaged multi-ethnic population in the United Kingdom ( UK ) . Method / Design The aim of this study is to evaluate a lay Pregnancy Outreach Worker ( POW ) service for nulliparous women identified as having social risk within a maternity service that is systematic ally assessing social risks alongside the usual obstetric and medical risks . The study design is a r and omised controlled trial ( RCT ) in nulliparous women assessed as having social risk comparing st and ard maternity care  with the addition of referral to the POW support service .  The POWs work alongside community midwifery teams and offer individualised support to women to encourage engagement with services ( health and social care ) from r and omisation ( before 28 weeks gestation ) until 6 weeks after birth . The primary outcomes have been chosen on the basis that they are linked to maternal and infant health . The two primary outcomes are engagement with antenatal care , assessed by the number of antenatal visits ; and maternal depression , assessed using the Edinburgh Postnatal Depression Scale at 8 - 12 weeks after birth . Secondary outcomes include maternal and neonatal morbidity and mortality , routine child health assessment s , including immunisation uptake and breastfeeding at 6 weeks . Other psychological outcomes ( self efficacy ) and mother-to-infant bonding will also be collected using vali date d tools . A sample size of 1316 will provide 90 % power ( at the 5 % significance level ) to detect increased engagement with antenatal services of 1.5 visits and a reduction of 1.5 in the average EPDS score for women with two or more social risk factors , with power in excess of this for women with any social risk factor . Analysis will be by intention to treat . Qualitative research will explore the POWs ' daily work in context . This will complement the findings of the RCT through a triangulation of quantitative and qualitative data on the process of the intervention , and identify other context ual factors that affect the implementation of the intervention . Discussion The trial will provide high quality evidence as to whether or not lay support ( POW ) offered to women identified with social risk factors improves engagement with maternity services and reduces numbers of women with depression . MREC number10/H1207/23Trial registration numberIS RCT N : IS RCT Aims : To assess outcomes in families who received the First Parent Health Visitor Scheme ( FPHVS )  , in comparison with families who received  conventional ( “ generic ” ) health visiting .  Methods : Retrospective data on 2113 families were collected during 1986–92 as part of National Health Service ( NHS ) service provision . Prospect i ve data were collected during 1993–98 on 459 mothers and their children , with outcomes assessed at one year ( 93 % follow up ) and two years ( 80 % follow up ) . Results : There were no differences between the groups of mothers in self esteem , locus of control , or depression rates . The women who received the  FPHVS were more likely to have changed partners , but they also had a wider support network than comparison women , and consulted their general practitioner ( GP ) less often . Breast feeding rates were higher in the FPHVS mothers , who also gave their infants more fruit juice drinks than the comparison group . No differences were apparent in developmental outcome using the Bayley Scales at 1 and 2 years of age . Both height and weight Z scores at 2 years of age were lower in the FPHVS children than the comparison children . Receipt of the FPHVS was associated with increased use of electric socket covers and lower accident rates in the second year of life . No differences were seen in immunisation rates , uptake of child health surveillance , or use of hospital services . A higher proportion of families who received the FPHVS were registered on the local child protection register compared with comparison families . Conclusion : Clustering effects dominated the analysis , but overall this evaluation could not show a clear advantage for the FPHVS over conventional health visiting Background Childhood vaccination rates are low in Lasbela , one of the poorest districts in Pakistan 's Balochistan province . This r and omised cluster controlled trial tested the effect on uptake of informed discussion of vaccination costs and benefits , without relying on improved health services . Methods Following a baseline survey of r and omly selected representative census enumeration areas , a computer generated r and om number sequence assigned 18 intervention and 14 control clusters . The intervention comprised three structured discussion s separately with male and female groups in each cluster . The first discussion shared findings about vaccine uptake from the baseline study ; the second focussed on the costs and benefits of childhood vaccination ; the third focussed on local action plans . Field teams encouraged the group participants to spread the dialogue to households in their communities . Both intervention and control clusters received a district-wide health promotion programme emphasizing household hygiene . Interviewers in the household surveys were blind of intervention status of different clusters . A follow-up survey after one year measured impact of the intervention on uptake of measles and full DPT vaccinations of children aged 12 - 23 months , as reported by the mother or caregiver . Results In the follow-up survey , measles and DPT vaccination uptake among children aged 12 - 23 months ( 536 in intervention clusters , 422 in control clusters ) was significantly higher in intervention than in control clusters , where uptake fell over the intervention period . Adjusting for baseline differences between intervention and control clusters with generalized estimating equations , the intervention doubled the odds of measles vaccination in the intervention communities ( OR 2.20 , 95 % CI 1.24 - 3.88 ) . It trebled the odds of full DPT vaccination ( OR 3.36 , 95 % CI 2.03 - 5.56 ) . Conclusion The relatively low cost knowledge translation intervention significantly increased vaccine uptake , without relying on improved services , in a poor district with limited access to services . This could have wide relevance in increasing coverage in developing countries . Trial registration IS RCT N12421731 OBJECTIVE To determine if group well child care ( GWCC ) for high-risk children affects maternal-child interaction and development as compared to these outcomes in children receiving traditional individual well child care ( IWCC ) .  STUDY DESIGN R and omized controlled trial . PARTICIPANTS Infants less than 4 months old at the initiation of the study who came from high-risk families . Families were classified as high risk , and eligible for study participation , if the mother had one or more of the following characteristics : poverty , single marital status , less than a high school education , age less than 20 years at delivery , previous substance abuse , or a history of abuse as a child . SETTING Two urban , university pediatric clinics in Seattle , Washington . INTERVENTIONS Study children were r and omized to receive GWCC or IWCC prior to the first study visit at the age of 4 months . Study health supervision visits were scheduled at 4 , 5 , 6 , 8 , 10 , 12 , and 15 months of age . For children r and omized to receive GWCC , study visits consisted of an age-matched group discussion of child rearing issues , either preceding or following a brief physical examination . After the 15-month visit , development of study patients was assessed by the use of Bayley Scales of Infant Development ( Bayley ) . Maternal-child interaction and the home environment were evaluated by the use of the Nursing Child Assessment Teaching Scale ( NCATS ) and the Home Observation for Measurement of the Environment ( HOME ) , respectively . RESULTS At least one outcome measure was obtained on 114 children ; 86 patients completed all three outcome measures . Bayley psychomotor mean scores were 103.6 + /- 11.5 for GWCC patients versus 100.0 + /- 12.4 for those receiving IWCC ( P = .14 ) ; mean scores for the mental section were 99.3 + /- 14.8 and 100.4 + /- 14.3 , respectively ( P = .71 ) . The prevalence of high-risk maternal-child interactions was 10 % in both the GWCC and IWCC groups . A high-risk home environment was found in 16 % of IWCC patients versus 4 % of those r and omized to GWCC ( odds ratio comparing IWCC to GWCC 4.6 , 95 % confidence interval 0.78 , 26.0 , after controlling for confounding variables ) . Provider time was similar among groups ( mean number of minutes/patient/ study visit : 19.8 + /- 5.6 and 20.4 + /- 6.7 for GWCC and IWCC , respectively , P = .66 ) . CONCLUSION GWCC is a viable alternative to IWCC for high-risk children . Developmental outcomes and maternal-child interaction are at least as good for children who received GWCC as compared to traditional IWCC , without any increase in provider time required OBJECTIVE To evaluate the impact of interventions by a community-based organization on immunization rates . DESIGN Controlled community intervention trial . SETTING AND PARTICIPANTS Children aged 3 to 59 months in Fulton County , Georgia , who were patients of 1 of 4 public clinics ( clinic based ) , or residents of 1 of 9 inner-city communities ( residence based ) . INTERVENTIONS ( 1 ) Clinic-based intervention included monthly review of clinic vaccination records to identify undervaccinated children followed by contact with family ( reminder-recall strategy ) ; ( 2 ) residence-based intervention included door-to-door assessment and education campaigns followed by mobile van vaccinations , temporary on-site vaccination stations , free child care and transportation to providers , incentives of food and baby products , focus groups , and coalitions with local organizations ( community saturation with vaccination messages and opportunities ) . OUTCOME MEASURES Change in vaccination rates after 1 year based on clinic record review s and population surveys . RESULTS For clinic-based intervention , series completion rates improved from 43 % ( 87/204 ) to 58 % ( 99/170 ) in intervention clinics ( P=.003 ) , while rates in control clinics did not change from the baseline of 52 % ( 81/157 to 78/150 ) , for a net difference between intervention and control arms of + 15 percentage points ( P=.046 ) . For residence-based intervention , age-appropriate vaccination rates improved from 44 % ( 154/347 ) to 61 % ( 260/429 ) in intervention communities ( + 17 percentage points ; P<.001 ) compared with improvement of 44 % ( 78/178 ) to 58 % ( 129/221 ) for control communities ( + 14 percentage points ; P=.004 ) , but the difference between arms was not significant ( + 3 percentage points , P=.78 ) . CONCLUSIONS Reminder-recall activities by the community-based organization improved vaccination rates in intervention clinics compared with control clinics . A statistically significant impact on vaccination rates could not be detected for residence-based interventions by the community-based organization OBJECTIVE A cluster r and omized trial was performed to evaluate an educational intervention to improve parental attitudes and vaccine uptake in vaccine-hesitant parents . METHODS Two primary care sites were r and omized to provide families with either usual care or an intervention ( video and written information ) for vaccine-hesitant parents . Eligible parents included those presenting for their child 's 2-week well-child visit with performance on the Parent Attitudes about Childhood Vaccines ( PACV ) survey suggesting vaccine hesitancy ( score ≥25 ) . Enrollees completed PACV surveys at the 2-month well-child visit and vaccination status at 12 weeks of age was assessed . The primary outcome was the difference in PACV scores obtained at enrollment and 2 months between the 2 groups . The proportion of on-time vaccination was also compared at 12 weeks . RESULTS A total of 454 parents were approached , and 369 ( 81.3 % ) participated ; 132 had PACV scores of ≥25 and were enrolled , 67 in the control group ( mean PACV score 37 ) and 55 in the intervention group ( mean PACV score 40 ) . Two-month PACV surveys were completed by 108 ( ∼90 % ) of enrollees . Parents in the intervention group had a significant decrease in PACV score at 2 months compared to control ( median difference 6.7 , P = .049 ) ; this remained significant after adjustment for baseline PACV score , race/ethnicity , and income ( P = .044 ) . There was no difference in the on-time receipt of vaccines between groups at 12 weeks . CONCLUSIONS A brief educational intervention for vaccine-hesitant parents was associated with a modest but significant increase in measured parental attitudes toward vaccines Public policy initiatives have begun to recommend that interventions have strong evidence of effectiveness before there is expenditure of restrained public funds . The Nurse Family Partnership ( NFP ) , a home visiting program for low-income parents expecting their first child , has been identified as a preventive intervention program that meets high evidentiary st and ards based on results from three r and omized trials . Strategies used to promote successful translation of the research intervention into clinical practice , findings from the evaluation of the replication of the NFP in 22 states , and challenges experienced in moving a research program to practice are discussed . Editors ’ Strategic Implication s : Policymakers , community public health officials , and research ers planning to disseminate their prevention programs will find many lessons in this example of bringing a model program ( i.e. , a prevention strategy that works ) up to scale . Although results at replication sites are somewhat weaker than at model sites , the consistent positive outcomes are a testimony to the strength of the NFP model  and the fidelity of its implementation across sites OBJECTIVES To describe how parents actually use federally m and ated vaccine information pamphlets and to evaluate the pamphlets ' effects on  parents ' opinions about vaccination . DESIGN A controlled trial of vaccine information pamphlets based on a survey mailed to parents who either received ( n = 140 ) or did not receive ( n = 167 ) the pamphlets .  STUDY POPULATION Parents of infants aged 2 to 8 months in a suburban , mainly upper-middle class private group practice in northern California . RESULTS More than 90 % of parents believed that they had enough information to decide whether their child should be vaccinated , even among those who did not receive the pamphlets . Among parents who received the pamphlets , fewer than half ( 38 % ) read them thoroughly , and most ( 63 % ) said that they should be distributed only on the first visit for vaccinations . Parents who received the pamphlets  did not differ from those who did not in terms of the proportions who would have liked more time to be spent discussing vaccines ( 34 % vs 34 % ) or who were anxious about how the diphtheria and tetanus toxoids and pertussis vaccine would affect their child ( 60 % vs 52 % ) . CONCLUSIONS Vaccine information pamphlets , when used as an adjunct to discussion s with physicians and nurses , have little effect on the opinions of well-educated parents . Future research and policy changes might focus on how to make the contents of the pamphlets less frightening and on allowing greater flexibility in how they are distributed A prospect i ve community-based intervention study was conducted in a slum area of Karachi , Pakistan , with the objective of evaluating the impact of health education on the knowledge of mothers . One hundred and fifty households were studied in the intervention and the same in the non-intervention group . The post intervention knowledge scores of the mothers showed a significant difference of P < 0.05 . Nearly 50.7 % mothers in the intervention group knew of at least four diseases against which vaccination is given as compared to the non-intervention group ( P < 0.05 ) . Similarly , mothers in the intervention group were more aware about the advantages of breast feeding , signs of dehydration , measures for prevention of measles and tuberculosis as compared to the non-intervention group ( P < 0.05 ) . Finally , a comparison was made between the pre- and post-intervention scores between the two groups . The score in the non-intervention group changed from 11.5 to 16.1 ( P > 0.05 ) as compared to the intervention group in which it changed from 10.2 to 32.2 ( P < 0.05 ) This article describes approaches for planning , dealing , and analyzing heterogeneity in a systematic review of complex interventions . Approaches aim to generate a priori hypotheses of the mechanism of action of a complex intervention to identify the key variables that might contribute to variation among studies and guide statistical analysis . In addition to characteristics related to the population , intervention , and outcomes , we describe study -related variables , such as the way the interventions have been implemented and the context and conduct of studies . These approaches will guide review ers planning a meta- analysis and provide a rationale for not meta-analyzing data if there is too much variability . Potential difficulties in applying meta-analytical techniques to examine statistical association among study results and sources of potential heterogeneity are described ; these include the selection of a fixed or r and om-effects model , the risk of multiple testing and confounding when studies include different aspects of a complex intervention or different sub sample s of the intended participant pool In this paper we focus on the first wave of outcomes in a pilot phase r and omized control trial of a home-based intervention for infants and their families , Minding the Baby ® ( MTB ) , an interdisciplinary , mentalization-based intervention in which home visiting services are provided by a team that includes a nurse practitioner and a clinical social worker . Families are recruited during mother 's pregnancy and continue through the child 's second birthday . Analyses revealed that intervention families were more likely to be on track with immunization schedules at 12 months , had lower rates of rapid subsequent childbearing , and were less likely to be referred to child protective services . In addition , mother-infant interactions were less likely to be disrupted at 4 months when mothers were teenagers , and all intervention infants were more likely to be securely attached , and less likely to be disorganized in relation to attachment at one year . Finally , mothers ' capacity to reflect on their own and their child 's experience improved over the course of the intervention in the most high-risk mothers We evaluated the relative impact of four procedures design ed to encourage parents to obtain immunizations for their children . In a public health setting , the families of 1,133 immunization-deficient preschool children were r and omly assigned to six conditions : ( a ) a general prompt ; ( b ) a more client-specific prompt ; ( c ) a specific prompt and increased public health clinic access ; ( d ) a specific prompt and monetary incentives ; ( e ) contact control ; and ( f ) no contact control . All interventions , except the general prompt , produced some evidence of improvement when compared with the control groups . The monetary incentive group revealed the largest effect , followed by the increased access group , specific prompt group , and general prompt group , respectively . The data suggest that relatively powerful and immediate effects on preschoolers ' clinic attendance for immunization may be produced by monetary incentives in conjunction with client-specific prompts . However , client-specific prompts alone appear to be the most cost-effective of the interventions This was a prospect i ve r and omized cohort study to assess the effectiveness of an educational immunization intervention with pregnant Latinas on timely initiation of infant immunization . Study participants were recruited from two community clinics in north San Diego County . A total of three hundred and fifty-two Latinas in the third trimester of pregnancy were recruited and r and omly assigned to intervention or control groups . Participants received either a culturally and linguistically appropriate session on infant immunization ( intervention ) or a session on prevention of Sudden Infant Death Syndrome ( control ) . The main outcome measures were pre-post immunization knowledge change and infant immunization status at 92 days . Immunization knowledge increased significantly in the intervention group [ p < .0001 , 95%CI ( 1.76 , 2.47 ) ] . No difference was found between groups in immunization series initiation : 95 percent of the children in the intervention group were up-to- date by 92 days from birth , and 93 percent of the control group was up-to- date at 92 days . The lack of significant association between receiving immunization education and infant immunization series initiation suggests that parent education may be necessary but not sufficient for timely immunization , particularly in clinics with effective well-child programs . Given the significant increase in immunization knowledge , the broader and perhaps more important implication is that language - and culturally specific infant health education messages in the prenatal period may have a positive long-term impact on the child 's health and promote well-child care overall . Future studies should assess the role of prenatal well-child education in the context of clinics with low immunization Objective . To compare and measure the effects and cost-effectiveness of two interventions design ed to raise immunization rates . Setting s. Nine primary care sites serving impoverished and middle-class children . Subjects . Complete birth cohorts ( ages 0 to 12 months ; n = 3015 ) from these sites . Interventions . 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 ) . Design . R and omized , controlled trial , r and omizing 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 abstract ion . Measures . Immunization status for age ; number of days of delay in immunization ; primary care utilization ; and rates of screening for occult disease . Results . 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 result ed 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 . Conclusions . 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 . immunization , primary care , r and omized , controlled trial , missed immunization opportunities , outreach PURPOSE To increase  childhood influenza vaccination rates using a toolkit and early vaccine delivery in a r and omized cluster trial . METHODS Twenty primary care practice s treating children ( range for n=536 - 8183 ) were r and omly assigned to Intervention and Control arms to test the effectiveness of an evidence -based practice improvement toolkit ( 4 Pillars Toolkit ) and early vaccine supplies for use among disadvantaged children on influenza vaccination rates among children 6 months-18 years . Follow-up staff meetings and surveys were used to assess use and acceptability of the intervention strategies in the Intervention arm . Rates for the 2010 - 2011 and 2011 - 2012 influenza seasons were compared . Two-level generalized linear mixed modeling was used to evaluate outcomes . RESULTS Overall increases in influenza vaccination rates were significantly greater in the Intervention arm ( 7.9 percentage points ) compared with the Control arm ( 4.4 percentage points ; P<0.034 ) . These rate changes represent 4522 additional doses in the Intervention arm vs. 1390 additional doses in the Control arm . This effect of the intervention was observed despite the fact that rates increased significantly in both arms - 8/10 Intervention ( all P<0.001 ) and 7/10 Control sites ( P-values=0.04 to < 0.001 ) . Rates in two Intervention sites with pre-intervention vaccination rates > 58 % did not significantly increase . In regression analyses , a child 's likelihood of being vaccinated was significantly higher with : younger age , white race ( Odds ratio [OR]=1.29 ; 95 % confidence interval [CI]=1.23 - 1.34 ) , having commercial insurance ( OR=1.30 ; 95%CI=1.25 - 1.35 ) , higher pre-intervention practice vaccination rate ( OR=1.25 ; 95%CI=1.16 - 1.34 ) , and being in the Intervention arm ( OR=1.23 ; 95%CI=1.01 - 1.50 ) . Early delivery of influenza vaccine was rated by Intervention practice s as an effective strategy for raising rates . CONCLUSIONS Implementation of a multi- strategy toolkit and early vaccine supplies can significantly improve influenza vaccination rates  among children in primary care practice s but the effect may be less pronounced in practice s with moderate to high existing vaccination rates . Clinical trial registry name/number : From Innovation to Solutions : Childhood Influenza/NCT01664793 PURPOSE To assess the impact of integral support on the health of children of adolescent mothers and their children . METHODS A prospect i ve study involving 50 adolescent mothers , who had frequent meetings with a multi-professional group throughout pregnancy . After birth , medical followup was provided to mother and child . RESULTS Mean schooling proved higher than the national average . After follow-up , the rate of return to education was 24 % . These adolescents had good social network support from both family and father of the child . They considered themselves good mothers and felt happier after maternity experience . Adolescents demonstrated a responsible sex life involving family planning and correct use of contraception , yielding extremely low levels of repeat pregnancy . Of the mothers , 48 % were employed , working , earning a mean monthly salary of 150 % minimum wage . The children of mothers followed by were breastfed longer and had greater vaccination cover than the average for São Paulo State . CONCLUSIONS The results suggest that our program promotes education of adolescents and their children ; demonstrates the importance of a social support network through the family of the young mother and father of the child ; fosters positive maternal social model addressing self-esteem and responsibility ; informs mothers on contraception and encourages a responsible sex life , baby care , vaccination , and maternal breastfeeding BACKGROUND Timely  vaccination  is important to protect children from common infectious diseases . We assessed vaccination timeliness and vaccination coverage as well as coverage of  vitamin A supplementation  in a Ug and an setting . METHODS AND FINDINGS This study used vaccination information gathered during a cluster-r and omized trial promoting exclusive breastfeeding in Eastern Ug and a between 2006 and 2008 ( Clinical Trials.gov no. NCT00397150 ) . Five visits were carried out from birth up to 2 years of age ( median follow-up time 1.5 years ) , and 765 children were included in the analysis . We used Kaplan-Meier time-to-event analysis to describe vaccination coverage and timeliness . Vaccination coverage at the end of follow-up was above 90 % for all vaccines assessed individually that were part of the Exp and ed Program on Immunization ( EPI ) , except for the measles vaccine which had 80 % coverage ( 95%CI 76 - 83 ) . In total , 75 % ( 95%CI 71 - 79 ) had received all the recommended vaccines at the end of follow-up . Timely vaccination according to the recommendations of the Ug and an EPI was less common , ranging from 56 % for the measles vaccine ( 95%CI 54 - 57 ) to 89 % for the Bacillus Calmette-Guérin ( BCG ) vaccine ( 95%CI 86 - 91 ) . Only 18 % of the children received all vaccines within the recommended time ranges ( 95%CI 15 - 22 ) . The children of mothers with higher education had more timely vaccination . The coverage for vitamin A supplementation  at end of follow-up was 84 % ( 95%CI 81 - 87 ) . CONCLUSIONS Vaccination coverage was reasonably high , but often not timely . Many children were unprotected for several months despite being vaccinated at the end of follow-up . There is a need for continued efforts to optimise vaccination timeliness This article describes a pilot study that ( 1 ) assessed the self-report of highest grade completed in school and the actual reading and comprehension skills of low-income mothers whose children receive immunizations in urban public clinics and ( 2 ) tested the effectiveness of a nursing intervention on immunization knowledge using revised easy-to-read written education material s.  Thirty-seven mothers were r and omized either to a control group ( asked to read the st and ard vaccine information sheets ) or to an experimental group ( asked to read the revised immunization pamphlets ) . Although there was a modest increase in immunization knowledge for both groups , it was not significant . Thus , simplifying information alone may not increase parental knowledge BACKGROUND 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 design ed to evaluate the effect of a brief patient education encounter with new mothers on pediatric immunization rates . METHODS 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 h and out . 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 . RESULTS 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 . CONCLUSIONS 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 Objective : To determine the safety , efficacy , and cost savings of early hospital discharge of women delivered by unplanned cesarean delivery . Methods : Using r and omized assignment , 61 postpartum women were discharged from the hospital at the usual time , and 61 were discharged early and had nurse specialist home follow-up care .  The latter group received comprehensive discharge planning , instruction , counseling , home visits , and daily on-call availability from the nurse specialists . Both groups were followed from delivery to 8 weeks postpartum . Results : Women who were discharged early and received transitional home care services by clinical nurse specialists were sent home a mean of 30.3 hours earlier than the control group ( P<.001 ) . They had significantly greater satisfaction with care , more of their infants had timely immunizations at the end of follow-up , and they had a 29 % reduction in health care charges compared to the control group receiving routine care . Although there were no statistically significant differences in maternal and infant rehospitalizations and acutecare visits , there were more maternal rehospitalizations in the control group than in the nurse specialist-followed group ( three versus zero ) . No statistically significant differences were found between the groups in the outcomes of maternal affect and overall functional status . Conclusion : Early hospital discharge of women after unplanned cesarean birth , using the model of nurse specialist transitional home care , is safe , feasible , and cost-effective BACKGROUND The use of immunization assessment and referral ( A/R ) in the Special Supplemental Nutrition Program for Women , Infants , and Children ( WIC ) has been shown to produce dramatic improvements in vaccination coverage when coupled with parental incentive ; however , data are lacking to support the use of A/R alone . OBJECTIVE To determine the effectiveness of A/R in increasing immunization coverage among WIC participants . DESIGN Participating WIC centers were assigned to1 of 3 interventions that delivered A/R of varying frequency or a control group . SETTING Twenty of the largest Public Health Foundation Enterprises-WIC centers in Los Angeles County . PARTICIPANTS Children continuously enrolled in participating WIC centers from 6 to 24 months of age . INTERVENTION Assessment of child 's vaccination status followed by referral to a health care provider for those lacking indicated vaccinations . MAIN OUTCOME MEASURE Up-to- date ( UTD ) status at 24 months of age for all recommended vaccines . RESULTS Baseline coverage rates were similar among all study sites ( overall , 77 % UTD ) . After the study period , compared with the controls ( 88 % UTD ) , we found no differences in immunization coverage among WIC centers that administered A/R at every visit ( every 2 months ) to all children ( 90 % UTD ; adjusted odds ratio [ OR ] , 1.02 ; 95 % confidence interval [ CI ] , 0.54 - 1.94 ) , every 6 months to all children ( 89 % UTD ; OR , 0.98 ; 95 % CI , 0.62 - 1.56 ) , or every visit to children found to be behind at 8 months of age ( 89 % UTD ; OR , 0.89 ; 95 % CI , 0.48 - 1.68 ) . CONCLUSION In this urban population of WIC children with high baseline immunization coverage , A/R was not effective in increasing immunization coverage OBJECTIVE Chronic infection with the hepatitis B virus is endemic in Southeast Asian population s , including Vietnamese . Previous research has documented low rates of hepatitis B vaccine coverage among Vietnamese-American children and adolescents ages 3 to 18 . To address this problem , we design ed and tested in a controlled trial 2 public health outreach " catch-up " campaigns for this population . DESIGN In the Houston , Texas metropolitan area , we mounted a media-led information and education campaign , and in the Dallas metropolitan area , we organized a community mobilization strategy . We evaluated the success of these interventions in a controlled trial , using the Washington , DC metropolitan area as a control site . To do so , we conducted computer-assisted telephone interviews with r and om sample s of approximately 500 Vietnamese-American households in each of the 3 study sites both before and after the interventions . We assessed respondents ' awareness and knowledge of hepatitis B and asked for hepatitis B vaccination date s for a r and omly selected child in each household . When possible , we vali date d vaccination date s through direct contact with each child 's providers . RESULTS Awareness of hepatitis B increased significantly between the pre- and postintervention surveys in all 3 areas , and the increase in the media education area ( + 21.5 percentage points ) was significantly larger than in the control area ( + 9.0 percentage points ) . At postintervention , significantly more parents knew that free vaccines were available for children in the media education ( + 31.9 percentage points ) and community mobilization ( + 16.7 percentage points ) areas than in the control area ( + 4.7 percentage points ) . An increase in knowledge of sexual transmission of hepatitis B virus was significant in the media education area ( + 14.0 percentage points ) and community mobilization ( + 13.6 percentage points ) areas compared with the control area ( + 5.2 percentage points ) . Parent- or provider-reported data ( n = 783 for pre- and n = 784 for postintervention surveys ) suggest that receipt of 3 hepatitis B vaccinations increased significantly in the community mobilization area ( from 26.6 % at pre- to 38.8 % at postintervention ) and in the media intervention area ( 28.5 % at pre- and 39.4 % at postintervention ) , but declined slightly in the control community ( 37.8 % at pre- and 33.5 % at postintervention ) . Multiple logistic regression analyses estimated that the odds of receiving 3 hepatitis B vaccine doses were significantly greater for both community mobilization ( odds ratio 2.15 , 95 % confidence interval 1.16 - 3.97 ) and media campaign ( odds ratio 3.02 , 95 % confidence interval 1.62 - 5.64 ) interventions compared with the control area . The odds of being vaccinated were significantly greater for children who had had at least 1 diphtheria-tetanus-pertussis shot , and whose parents were married , knew someone with liver disease , had heard of hepatitis B , and had greater knowledge about hepatitis B. The odds of being vaccinated were significantly lower for older children . CONCLUSIONS Both community mobilization and media campaigns significantly increased the knowledge of Vietnamese-American parents about hepatitis B vaccination , and the receipt of " catch-up " vaccinations among their children This article describes the outcomes at 1 year for a r and omized clinical trial of Re sources , Education and Care in the Home-Futures : a program to reduce infant mortality through home visits by a team of trained community residents led by a nurse . Low-income , inner-city pregnant women who self-identified as African American or Mexican American were recruited in two university prenatal clinics in Chicago . Because African Americans and Mexican Americans differed greatly at intake , we compared their outcomes at 12 months and then examined the effects of the intervention separately for these two groups . Participants were r and omly assigned to the intervention or control group and were interviewed during the last trimester of pregnancy and at 2 , 6 , and 12 months after birth . The effects of the program varied by race/ethnicity . For African Americans , the program was associated with better maternal documentation of infant immunizations , more developmentally appropriate parenting expectations , and higher 12-month infant mental development scores . For Mexican Americans , the program had positive effects on maternal daily living skills and on the play material s subscale of the Home Observation for the Measurement of the Environment assessment . This study , along with previous research , suggests that home visits by a nurse-health advocate team can improve maternal and infant outcomes even for inner-city , low-income , minority families . Effective programs must be culturally sensitive , intensive , and adequately staffed and financed OBJECTIVE A substantial dropout from the first dose of diphtheria-tetanus-pertussis ( DTP1 ) to the 3rd dose of DTP ( DTP3 ) immunization has been recorded in Pakistan . We conducted a r and omized controlled trial to assess the effects of providing a substantially re design ed immunization card , centre-based education , or both interventions together on DTP3 completion at six rural exp and ed programme on immunization ( EPI ) centres in Pakistan . METHODS Mother-child pairs were enrolled at DTP1 and r and omized to four study groups : re design ed card , centre-based education , combined intervention and st and ard care . Each child was followed up for 90 days to record the date s of DTP2 and DTP3 visits . The study outcome was DTP3 completion by the end of follow-up period in each study group . RESULTS We enrolled 378 mother-child pairs in re design ed card group , 376 in centre-based education group , 374 in combined intervention group and 378 in st and ard care group . By the end of follow-up , 39 % of children in st and ard care group completed DTP3 . Compared to this , a significantly higher proportion of children completed DTP3 in re design ed card group ( 66 % ) ( crude risk ratio [ RR ] = 1.7 ; 95 % CI = 1.5 , 2.0 ) , centre-based education group ( 61 % ) ( RR = 1.5 ; 95 % CI = 1.3 , 1.8 ) and combined intervention group ( 67 % ) ( RR = 1.7 ; 95 % CI = 1.4 , 2.0 ) . CONCLUSIONS Improved immunization card alone , education to mothers alone , or both together were all effective in increasing follow-up immunization visits . The study underscores the potential of study interventions ' public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system 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 result ed 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 OBJECTIVE To evaluate the efficacy of an early home-based intervention on the quality of maternal-infant attachment , maternal mood and child health parameters in a cohort of vulnerable families . METHODOLOGY A total of 181 families were recruited to the study in the immediate postnatal period on the basis of a self report question naire relating to known family vulnerability factors . Families were assigned r and omly to intervention ( 90 ) , or control ( 91 ) groups . The intervention group received a series of home visits from a child health nurse ( weekly to 6 weeks , fortnightly to 3 months ) , with a subgroup receiving home based short-term dynamic therapy from a social worker .  Parent/family function was assessed at inception and at 4 months by the Parenting Stress Index and the Edinburgh Post Natal Depression Scale . At 4 months the quality of the home environment was assessed , utilizing the Home Observation for Measurement of the Environment Inventory , as were child and family health parameters and satisfaction with the community child health service . RESULTS At 4 month follow-up , 160 families ( 80 intervention , 80 control ) were available for assessment . The intervention improved family functioning at 4 months . All aspects of the home environment , including the quality of maternal-infant attachment and mothers ' relationship with their child , were significantly enhanced . In particular , significant and positive differences were found in parenting with the intervention group feeling less restrictions imposed by the parenting role , greater sense of competence in parenting , greater acceptability of the child , and the child being more likely to provide positive reinforcement to the parent . Early differences in maternal mood were not maintained at 4 months . Various child health parameters were enhanced including immunization status , fewer parent-reported injuries and bruising , and research er confirmed lack of smoking in the house or around the infant . The families were consistently more satisfied with their community health service . CONCLUSIONS This form of early home based intervention targeted to vulnerable families promotes an environment conducive for infant mental and general health and hence long-term psychological and physical well-being , and is highly valued by the families who receive it atric visits more frequently bytelephoning themafter theybrought their children toour immunizationclinics . We conducted a r and omized , controlled study in whichattending families received either fourfollow-up telephone calls over 13weeksor no telephonecalls . Inthis article , we reporttheeffect ofthefollow-up  telephone calls  on thefrequency ofwell-child medical visits , and we alsobriefly discuss the literature on thecharacteristics ofsuccessfulimmunization programs OBJECTIVE To test the effects of the Healthy Steps for Young Children program ( HS ) ( which supports parents managing children 's developmental and behavioral issues)-with  and without a prenatal component-on child health and development , parenting practice s , and parental well-being . DESIGN A concurrent comparison with clinic-level assignment to intervention or usual care status . Nested in the intervention arm , a r and omized trial compared HS with and without a prenatal component . SETTING Five primary care clinics in an integrated delivery system in the Pacific Northwest . PARTICIPANTS A consecutive sample of 439 pregnant women ( 80 % of eligible ) were enrolled . Follow-up data were obtained for 78 % when the child was 30 months old . Intervention Families in intervention clinics received HS services , including developmental and behavioral advice and risk factor screening . In addition , those r and omized to prenatal services received 3 home visits during pregnancy . MAIN OUTCOME MEASURES Assessed by telephone interview in the 3 domains of child health and development , parenting practice s , and parental well-being . RESULTS Intervention was associated with positive outcomes in timely well-child care , immunization rates , breastfeeding , television viewing , injury prevention , and discipline strategies . Prenatal initiation of services was associated with larger expressive vocabularies at age 24 months . Mothers who received the intervention reported more depressive symptoms , but there was no increase in the proportion with clinical ly significant depression . CONCLUSIONS For members of an integrated delivery system , the HS intervention was associated with positive effects on children 's health and parenting practice s. There was little evidence of any additional benefit of HS services initiated during the prenatal period A prospect i ve , r and omized , clinical trial was conducted to investigate whether a postpartum visit between a mother and her neonate 's future primary care provider combined with telephone access would improve health care utilization , enhance identification of the provider as a source of advice , increase maternal knowledge of infant care , and decrease maternal anxiety and depression . Of 251 mother-neonate pairs , 122 were r and omized to the control group and 129 to the intervention group . Outcome variables included health care utilization and results of maternal interviews . More mothers in the intervention group made a scheduled clinic visit in the first 30 days ( P = .003 ) , were more likely to seek some form of care at the clinic ( P = .006 ) , and tried to reach their physician by phone more often than the control group ( P less than .001 ) . There were no differences between the groups ' emergency room utilization , the percent who received immunizations by 90 days of age , maternal knowledge of infant care , maternal anxiety , or postpartum depression . The intervention succeeded in improving some measures of health care utilization and results suggest that the relationship between the mother and clinician was strengthened BACKGROUND Part of the payoff of immunization registries may be to lower costs of immunization intervention . However , registry-based intervention costs have not been evaluated in a community setting . METHODS The purpose of this study was to prospect ively measure the cost of three equally effective registry-based interventions , evaluate how the size of the targeted population affects cost estimates , and compare these results with previously reported studies . A total of 3050 children aged < 12 months were r and omized to one of four study arms : ( 1 ) computer-generated telephone messages ( autodialer ) , ( 2 ) outreach worker , ( 3 ) autodialer with outreach worker backup , or ( 4 ) usual care . The cost data collected included capital equipment , supplies , travel , and personnel . RESULTS Monthly costs of the three registry-based intervention types were ( 1 ) autodialer , $ 1.34 per child ; ( 2 ) outreach worker , $ 1.87 per child , and ( 3 ) combination , $ 2.76 per child . Personnel costs represented the majority of incremental costs for all three interventions . Increasing the number of children targeted sharply decreased the cost per child for the autodialer but had only a modest effect on outreach costs . The monthly costs for outreach were substantially lower than previously reported for nonregistry-based interventions in part because of differences in the number of children who were followed up . Monthly costs for the autodialer intervention were slightly higher than previously reported , but several published studies excluded important costs . CONCLUSIONS By facilitating the management of a larger cohort of children , some registry-based immunization interventions appear to be less costly than nonregistry interventions . Further work is needed to establish whether registry maintenance costs may be recouped in part by these savings This prospect i ve , intervention-control study in hospitalized , underimmunized children assessed the effect of vaccination reminders to parents during hospitalization and provides postdischarge rates of catch-up immunizations . One month after hospital discharge , significantly more children in the intervention group ( 27 % ) than the controls ( 8 % ) had received catch-up immunizations ( P < .001 ) OBJECTIVES This study evaluated the effectiveness of registry-driven , community-based outreach directed toward children with immunization delays . METHODS A sample of 1,856 children aged 6 to 10 months was r and omly assigned to receive either outreach or no intervention . RESULTS Children in the outreach group were more likely to receive an immunization during the observation period than children in the control group ( 61 % vs 43 % ) . Outreach was most effective for children with multiple risks , as measured by their immunization record ; it was not effective for children whose mothers had received inadequate prenatal care . CONCLUSIONS Registry-driven outreach can effectively identify high-risk children and bring them to care BACKGROUND National immunization st and ards call for all primary care providers to implement immunization tracking systems that include contacting families when children are overdue for vaccines . The restructuring of Medicaid systems toward managed care models with a greater emphasis on having defined medical homes for children presents opportunities to exp and the use of immunization recall systems among low-income children . OBJECTIVE To assess the impact of telephone , mail , and a combined approach to reaching underimmunized children enrolled in a hospital-based Medicaid managed care practice . DESIGN AND METHODS All underimmunized children younger than 6 years who had been continuously enrolled in the hospital-based Medicaid managed care practice for 3 months were r and omly assigned to 1 of 4 groups : ( 1 ) control group with no intervention , ( 2 ) telephone reminder group , ( 3 ) mail reminder group , or ( 4 ) sequential mail/telephone reminder group . After a 10-week follow-up , medical records and the hospital 's computerized appointment scheduling system were review ed to determine the effect of the outreach effort on appointments made , visits attended , immunizations received , and immunization status . RESULTS Outreach efforts had a positive impact on the proportion of children immunized and on the result ing immunization coverage rates . The percentage of children receiving immunizations during the 10-week follow-up was 4.2 % ( 3/71 ) for the control group , 16.7 % ( 10/60 ) for the telephone reminder group , 19.0 % ( 12/63 ) for the mail reminder group , and 25.7 % ( 18/70 ) for the sequential mail/telephone reminder group . The percentage of children up-to- date for all immunizations at the end of the 10-week follow-up was 2.8 % ( 2/71 ) for the control group , 13.3 % ( 8/60 ) for the telephone reminder group , 14.3 % ( 9/63 ) for the mail reminder group , and 17.1 % ( 12/70 ) for the sequential mail/telephone reminder group . Forty-eight children were seen during follow-up without receiving all indicated vaccines . CONCLUSIONS Outreach efforts were modestly successful in reaching underimmunized children in a Medicaid managed care practice , although the lack of accurate information on telephone numbers and addresses limited the effectiveness . Missed opportunities for immunization also reduced the impact of outreach on immunization coverage . Arch Pediatr Adolesc Med . 2000;154:1243 - 1247 CONTEXT There is growing concern regarding the quality of health care available in the United States for young children , and specific limitations have been noted in developmental and behavioral services provided for children in the first 3 years of life . OBJECTIVE To determine the impact of the Healthy Steps for Young Children Program on quality of early childhood health care and parenting practice s. DESIGN , SETTING , AND PARTICIPANTS Prospect i ve controlled clinical trial enrolling participants between September 1996 and November 1998 at 6 r and omization and 9 quasi-experimental sites across the United States . Participants were 5565 children enrolled at birth and followed up through age 3 years . INTERVENTION Incorporation of developmental specialists and enhanced developmental services into pediatric care in participants ' first 3 years of life . MAIN OUTCOME MEASURES Quality of care was operationalized across 4 domains : effectiveness ( eg , families received > or = 4 Healthy Steps-related services or discussed > 6 anticipatory guidance topics ) , patient-centeredness ( eg , families were satisfied with care provided ) , timeliness ( eg , children received timely well-child visits and vaccinations ) , and efficiency ( eg , families remained at the practice for > or = 20 months ) . Parenting outcomes included response to child misbehavior ( eg , use of severe discipline ) and practice s to promote child development and safety ( eg , mothers at risk for depression discussed their sadness with someone at the practice ) . RESULTS Of the 5565 enrolled families , 3737 ( 67.2 % ) responded to an interview at 30 to 33 months ( usual care , 1716 families ; Healthy Steps , 2021 families ) . Families who participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps-related services ( for r and omization and quasi-experimental sites , respectively : odds ratio [ OR ] , 16.90 [ 95 % confidence interval [ CI ] , 12.78 to 22.34 ] and OR , 23.05 [ 95 % CI , 17.38 to 30.58 ] ) , of discussing more than 6 anticipatory guidance topics ( OR , 8.56 [ 95 % CI , 6.47 to 11.32 ] and OR , 12.31 [ 95 % CI , 9.35 to 16.19 ] ) , of being highly satisfied with care provided ( eg , someone in the practice went out of the way for them ) ( OR , 2.06 [ 95 % CI , 1.64 to 2.58 ] and OR , 2.11 [ 95 % CI , 1.72 to 2.59 ] ) , of receiving timely well-child visits and vaccinations ( eg , age-appropriate 1-month visit ) ( OR , 1.98 [ 95 % CI , 1.08 to 3.62 ] and OR , 2.11 [ 95 % CI , 1.16 to 3.85 ] ) , and of remaining at the practice for 20 months or longer ( OR , 2.02 [ 95 % CI , 1.61 to 2.55 ] and OR , 1.75 [ 95 % CI , 1.43 to 2.15 ] ) . They also had reduced odds of using severe discipline ( eg , slapping in face or spanking with object ) ( OR , 0.82 [ 95 % CI , 0.54 to 1.26 ] and OR , 0.67 [ 95 % CI , 0.46 to 0.97 ] ) . Among mothers considered at risk for depression , those who participated in the Healthy Steps Program had greater odds of discussing their sadness with someone at the practice ( OR , 0.95 [ 95 % CI , 0.56 to 1.63 ] and OR , 2.82 [ 95 % CI , 1.57 to 5.08 ] ) . CONCLUSION Universal , practice -based interventions can enhance quality of care for families of young children and can improve selected parenting practice Two hundred forty-six full-term , first-born well infants were r and omly assigned to receive well-baby care during their first year in one of four ways : six visits by a physician ; three visits by a physician ; six visits by a pediatric nurse practitioner ( PNP ) ; or three visits by a PNP .  One hundred sixteen of the study babies received care in a  clinic  setting and 130 in a  private- practice setting . The adequacy of care rendered was assessed by measurement of gain in maternal knowledge important for competence in child-rearing , level of maternal satisfaction , degree of maternal compliance , and attainment of the health supervision planned . These endpoints were subjected to two-way and three-way analyses of variance to determine if there were differences across the setting , provider , or schedule variables . Essentially no differences were observed in the endpoints measured within setting s between providers of care , between visit schedules , or between any of the provider and visit schedule combinations . These results indicate that well-baby care during the first year delivered by PNPs is as adequate as that delivered by physicians and the use of abbreviated visit schedules by either professional does not reduce the adequacy of care BACKGROUND The Community Mothers Programme aims at using experienced volunteer mothers in disadvantaged areas to give support to first-time parents in rearing their children up to 1 year of age . The programme was evaluated by r and omized controlled trial in 1990 . METHODS Seven years later , trial participants were interviewed about child health , nutrition , cognitive stimulation , parenting skills , and maternal self-esteem . The aim of this study was to see whether the demonstrated benefits at 1 year of age of this programme could be sustained at age 8 . RESULTS One-third of the original group ( 38 intervention , 38 control ) , were contacted and interviewed . The risk for having an accident requiring a hospital visit was lower in the intervention group : relative risk ( RR ) 0.59 , 95 per cent confidence interval ( CI ) 0.31 - 1.11 . Intervention children were more likely to visit the library weekly : RR 1.58 , 95 per cent CI 1.10 - 2.26 . Intervention mothers were more likely to  check homework every night : RR 1.23 , 95 per cent CI 1.05 - 1.43 ( p=0.006 ) ; and to disagree with the statement ' children should be smacked for persistently bad behaviour ' : RR 2.11 , 95 per cent CI 1.10 - 4.06 . They were more likely to disagree with the statement ' I do not have much to be proud of ' : RR 1.24 , 95 per cent CI 1.04 - 1.40 ; and to make a positive statement about motherhood than controls : RR 1.53 , 95 per cent CI 1.06 - 2.20 . Subsequent children of intervention mothers were more likely to have completed Haemophilus influenzae b : RR 1.26 , 95 per cent CI 1.06 - 1.51 ; and polio immunization : RR 1.19 , 95 per cent CI 1.02 - 1.40 . CONCLUSIONS The Community Mothers programme had sustained beneficial effects on parenting skills and maternal self-esteem 7 years later with benefit extending to subsequent children The purpose of this study was to characterize the effects of an educational program on knowledge , attitude , concern , and first-aid measures among parents with febrile convulsive children . All parents completed a pretest question naire 3 weeks before the meeting . The parents were assigned r and omly into experimental ( n = 65 ) and control ( n = 64 ) groups on the day they attended the program . The control group completed the identical question naire ( posttest ) before the program , whereas the experimental group completed the same posttest after the program . In pretest , most parents considered electroencephalogram or computed tomography necessary in evaluating their children , suggested that immunization be postponed , and rated the risk of subsequent epilepsy as high for their children . Most of them favored frequent body temperature measurement , were very anxious about further febrile convulsion episodes during the night , and were fever phobic . After education , although only a slight change in fever anxiety was found , the experimental group showed significant improvement in knowledge , attitude , concerns , and anticipatory practice of febrile convulsion compared with the control group . In conclusion the parents '  poor knowledge , negative attitudes , anxiety , and inadequate first-aid measures toward febrile convulsion can be effectively improved by an educational intervention program It is important to systematic ally assess the vaccine information needs of parents in order to maintain or improve childhood immunization coverage . Our objectives were to obtain suggestions for the optimal presentation of vaccine-related information and to determine if an educational intervention affected mothers ' vaccine safety attitudes . Focus groups were used to develop messages that then were tested through a r and omized , pre- and post-test mail survey of non-Hispanic White mothers who reported vaccine safety concerns ( n = 927 ) . Focus groups were analyzed using text analysis software . Increases in attitude scores between the pre- and post-test surveys were calculated , and logistic regression was used to compare intervention groups with a control group . Of survey participants who recalled the test messages , 50 % ( 85/171 ) who received a “ consequences of reduced coverage ” message reported an improved opinion of vaccines . A greater proportion of participants receiving one or more intervention messages reported an improved attitude score from pre-to post-test compared with the control group for four of the five variables measured ; however , differences were small and none were statistically significant . A mixed method approach was used to develop and test vaccine messages . The message describing potential consequences of reduced vaccination coverage had the greatest impact on improving concerned mothers ' opinions of childhood vaccines The st and ard WHO cluster sampling technique was applied to 30 r and omly selected villages covering a population of 89,470 and 2010 live births in Jasra Community Development Block with a population of 123,000 distributed in 123 villages and 27 subcenters . In each cluster , 67 mothers were interviewed who gave birth between March 1989 and April 1990 . Immunization history of tetanus toxoid given during the antenatal period and the delivery was recorded by 2 teams . There were 49 neonatal deaths : 30 ( 61.2 % ) were caused by tetanus neonatorum , 10 ( 30.4 % ) died of high fever of undetermined etiology , 5 ( 10.2 % ) of pneumonia , 3 ( 6.1 % ) of diarrhea , and there was 1 case of death of undetermined cause . The tetanus neonatorum rate was 18.7/1000 live births . 93 % of the births were assisted by family members and untrained dais , and 2.4 % by trained traditional birth attendants . In 69 deliveries ( 3.4 % ) , a doctor was called , while in 24 cases a multi purpose female worker assisted . 46.7 % of neonates with tetanus were brought to the district hospital for treatment , the rest were either taken to private practitioners or to traditional healers . 1336 ( 66.5 % ) of 2010 mothers interviewed had not received tetanus toxoid , 359 ( 17.8 % ) had received only 1 dose of toxoid , and 315 ( 15.7 % ) had been immunized with 2 doses . The mothers of 27 ( 90.0 % ) of those 30 neonates who died of tetanus had not received a dose of toxoid during the antenatal period , whereas 3 mothers obtained only 1 dose . None of the newborn of mothers immunized with 2 doses during pregnancy contracted tetanus . 61 % of the neonatal deaths were attributed to tetanus . The causes of neonatal tetanus include unhygienic cutting of the cord and lack of immunization of mothers with tetanus toxoid during pregnancy . The administration of 2 doses of antenatal tetanus toxoid and health education regarding the importance of conducting hygienic deliveries could eliminate this disease BACKGROUND Teenage pregnancies are associated with negative socioeconomic effects . Our aim was to ascertain whether a postnatal home-visiting service for teenage mothers younger than age 18 years could reduce the frequency of adverse neonatal outcomes and improve knowledge of contraception , breastfeeding , and infant vaccination schedules in this parent group . METHODS We enrolled 139 adolescents , attending a teenage pregnancy clinic , in a r and omised controlled trial . After completing an antenatal question naire design ed to assess their knowledge of contraception , infant vaccination , and breastfeeding , we assigned participants to either receive five structured postnatal home visits by nurse-midwives ( n=65 ) or not ( n=71 ) . Assessment interviews were done 6 months postpartum . Our primary endpoint was unadjusted difference in knowledge between groups , and incidence of predefined adverse neonatal outcomes . Analysis was by intention to treat . FINDINGS Three women withdrew before r and omisation because of late fetal loss , 11 mothers withdrew because of adverse neonatal outcomes  ( adverse neonatal outcome was a primary endpoint , but result ed in withdrawal from the study for knowledge outcomes ) , and one left voluntarily . Follow-up data were , therefore , available for 124 teenagers . Postnatal home visits were associated with a reduction in adverse neonatal outcomes ( intervention : 2 ; control : 9 ; relative risk 0.24 , 95 % CI 0.05 - 1.08 ) , and a significant increase in contraception knowledge ( mean difference 0.92 , 95 % CI 0.32 - 1.52 ) . However , there was no significant increase in knowledge with respect to breastfeeding or infant vaccination schedules associated with the home visits . INTERPRETATION Postnatal home-visiting services by nurse-midwives reduce adverse neonatal events and improve contraception outcomes , but do not affect breastfeeding or infant vaccination knowledge or compliance
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 underst and 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 underst and ing of vaccination .
Such interventions may describe or explain the practical and logistical factors associated with vaccination , and enable parents to underst and 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 .
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 .