Targeted mailing of information to improve uptake of measles, mumps, and rubella vaccine: a randomised controlled trial. A Simple Provider-Based Educational Intervention to Boost Infant Immunization Rates: A Controlled Trial Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Randomised controlled trial of the use of a modified postal reminder card on the uptake of measles vaccination Impact of a novel way to communicate information about MMR on uptake of MMR vaccine: a randomized controlled trial. Development of a vaccine tracking system to improve the rate of age-appropriate primary immunization in children of lower socioeconomic status. Evaluation of a home based health record booklet. Effectiveness and Cost-effectiveness of Letters, Automated Telephone Messages, or Both for Underimmunized Children in a Health Maintenance Organization The impact of reminder-recall interventions on low vaccination coverage in an inner-city population. Risk factors associated with failure to receive vaccinations. Immunization registry-based recall for a new vaccine. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study Increasing the immunization of preschool children; an evaluation of applied community interventions. A Randomized Study of Tracking With Outreach and Provider Prompting to Improve Immunization Coverage and Primary Care Cost-effectiveness analysis of a practice-based immunization education intervention. Impact of appointment reminders on vaccination coverage at an urban clinic. The effect of patient education on pediatric immunization rates. Challenges and successes of immunization registry reminders at inner-city practices. Effectiveness of a physician peer educator in improving the quality of immunization services for young children in primary care practices. Computer reminders improve on-time immunization rates. Improving The Immunization Coverage Of Children Less Than 7 Years Old In A Family Practice Residency Practice based education to improve delivery systems for prevention in primary care: randomised trial Early results from the Northland immunisation register. Evaluation of telephoned computer-generated reminders to improve immunization coverage at inner-city clinics. Initiatives to improve childhood immunisation uptake: a randomised controlled trial Reducing missed opportunities for immunizations. Easier said than done. Effectiveness of chart prompt about immunizations in an urban health center. Registry-driven, community-based immunization outreach: a randomized controlled trial. The impact of outreach efforts in reaching underimmunized children in a Medicaid managed care practice. The impact of computer-generated messages on childhood immunization coverage. Computer-generated recall letters for underimmunized children: how cost-effective? A Preschool Immunization Project to Enhance Immunization Levels, the Public-Private Relationship, and Continuity of Care Immunization recall: effectiveness and barriers to success in an urban teaching clinic. Effectiveness of a mailed reminder on the immunization levels of infants at high risk of failure to complete immunizations. The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates. Development of a vaccine tracking system to improve the rate of age-appropriate primary immunization in children of lower socioeconomic status. Variation in vaccination coverage among children of Hispanic ancestry.
Uptake of the measles , mumps , and rubella vaccine in the United Kingdom has declined to levels that will allow outbreaks of these preventable diseases to occur . A leaflet sent with a personalized reminder did not increase vaccine uptake in children who had not been immunised at 21 months of age 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 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 OBJECTIVE To determine whether rewording postal reminder cards according to the “ health belief model ” , a theory about preventive health behaviour , would help to improve measles vaccination rates . DESIGN A r and omised controlled trial , with blind assessment of outcome status . Parents of children due for their first measles vaccination were r and omised to one of two groups , one receiving the health belief model reminder card , the other receiving the usual , neutrally worded card . The proportion of children subsequently vaccinated in each group over a five week period was ascertained from clinical ( provider based ) records . SETTING A local government operated public vaccination clinic . PARTICIPANTS Parents of 259 children due for measles vaccination . MAIN RESULTS The proportion of children vaccinated in the health belief model card group was 79 % compared with 67 % of those sent the usual card ( 95 % CI , 2 % to 23 % ) , a modest but important improvement . CONCLUSION This study illustrates how the effectiveness of a minimal and widely practised intervention to promote vaccination compliance can be improved with negligible additional effort 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 Despite the widespread use of home based child health records of varying complexity in Engl and , there is a notable absence of their evaluation . Such a record booklet developed in the West Lambeth Health Authority has been used by parents , doctors , and community nurses to build up an independent chronological record of a child 's birth statistics , health , growth , immunisation , development checks , and contacts with health services . A r and omised controlled evaluation of the record , analyses of entries in it , and a survey of the views of mothers and health professionals using the record have been carried out . The need for such a record was confirmed by those question ed and analyses of entries in the booklet helped to modify and improve it . The evaluation was unable to show , however , any effect of the record on immunisation and developmental assessment service uptake . Its value in improving communication between the numerous health and other care agencies was dependent on its proper use Background . Immunization rates have improved in the United States , but are still far from the national 90 % goal for the year 2000 . There is scant evidence about the effectiveness and costs of automated telephone messages to improve immunization rates among privately insured children . Objective . To evaluate the effectiveness and cost-effectiveness of sending letters , automated telephone messages , or both to families of underimmunized 20-month-olds in a health maintenance organization ( HMO ) . Methods . In this r and omized trial , underimmunized 20-month-olds identified by the HMO 's computerized immunization tracking system were assigned to one of four interventions : 1 ) an automated telephone message alone ; 2 ) a letter alone ; 3 ) an automated telephone message followed by a letter 1 week later ; and 4 ) a letter followed by an automated telephone message 1 week later . The primary outcome was receipt of any needed immunization by 24 months of age . Decision analysis was used to evaluate the projected cost-effectiveness of the alternative strategies . Results . A total of 648 children were r and omized . A letter followed by a telephone message ( 58 % immunized ) was significantly better than either a letter alone ( 44 % immunized ) or a telephone message alone ( 44 % immunized ) . A telephone message followed by a letter ( 53 % immunized ) also was more effective than either alone , although the differences were not statistically significant . Among a similar comparison group that received no systematic intervention , 36 % were immunized . The estimated cost per child immunized was $ 7.00 using letters followed by automated telephone messages , $ 9.80 using automated telephone messages alone , and $ 10.50 using letters alone . Under alternative cost assumptions for automated telephone messages and mailed messages , the cost per child immunized ranged from $ 2.20 to $ 6.50 . Conclusions . For underimmunized 20-month-olds in this HMO setting , letters followed by automated telephone messages were more effective and cost-effective than either message alone . The cost-effectiveness of automated telephone messages and letters may vary widely depending on the setting , and choices among strategies should be tailored to the population s being served BACKGROUND Reminder-recall interventions have improved immunization rates in numerous studies . OBJECTIVE To evaluate the impact of large-scale , registry-based reminder-recall interventions on low immunization rates in an inner-city population . DESIGN R and omized , controlled , effectiveness trial . SETTING Fulton County , Georgia . PARTICIPANTS A total of 3050 children ( 76 % black , 14 % Hispanic , 7 % white , and 3 % other or unknown ; median age , 9 months ; range , 1 - 14 months ) identified in an immunization registry as receiving health care in the public sector . INTERVENTIONS Each child was r and omly assigned to 1 of 4 groups : control ( usual care ) , autodialer ( automated telephone or mail reminder recall ) , outreach ( in-person telephone , mail , or home visit recall ) , and combination ( autodialer with outreach backup ) . Interventions continued until the child reached 24 months of age . MAIN OUTCOME MEASURE Completion by the age of 24 months of the 4 - 3 - 1 - 3 vaccination series based on intention-to-treat analysis . RESULTS A total of 260 ( 34 % ) of the 763 patients in the control group , 306 ( 40 % ) of the 763 in the autodialer group , 284 ( 37 % ) of the 760 in the outreach group , and 293 ( 38 % ) of 764 in the combination group completed the vaccination series . CONCLUSION Large-scale , registry-based reminder-recall interventions produced only small improvements in low immunization rates of an inner-city population A major purpose of a state-wide survey to document the vaccination status of 1,003 2-year-old children was to identify factors associated with failure to receive the recommended vaccinations . With a basic series of immunization defined as three doses of diphtheria-tetanus-pertussis ( DTP ) , three oral polio vaccine ( OPV ) , one measles , and one rubella , 72.5 % of the children had completed the series . When the completed series was redefined to include a fourth DTP and mumps vaccine the rate of completion dropped to 40.8 % . However , 59.1 % of the children who had not completed this optimal series could be brought up-to- date with a single visit to their provider of medical care . Demographic variables independently associated with completion of the basic series were increased paternal education ( P less than .001 ) , increased maternal education ( P less than .02 ) , smaller family size ( P less than .01 ) and higher socioeconomic status , as determined by census tract or rural town of residence ( P less than .02 ) . Race was not found to be a factor associated with vaccination rates when socioeconomic status was controlled . Patients who received their vaccinations from private physicians had a better vaccination rate than those who attended health department clinics . This difference persisted even when socioeconomic status was controlled by residence ( P less than .02 ) . The simultaneous comparison of parental education and family size demonstrated that a child having one parent with less than 12 years education or having at least three siblings has a fourfold greater risk of failure to complete his immunization than children whose parents are both college graduates . By using paternal and maternal education level and family size as screening variables , children at high risk for failure to complete their immunizations could be identified prospect ively and made the target of intervention programs to improve compliance BACKGROUND Immunization recall for specific vaccines may be necessary to " catch up " children with newly available vaccines or recall children after vaccine shortages . The extent to which immunization registry-based recall can increase immunization rates for a new vaccine has not been prospect ively studied . OBJECTIVE To assess the efficacy of letter/telephone recall for immunization with pneumococcal conjugate vaccine ( PCV7 ) in an economically disadvantaged urban population . DESIGN / METHODS R and omized controlled trial at an inner-city teaching hospital . Using an immunization registry , we r and omly assigned children aged 6 weeks to 22 months unimmunized for PCV7  to an intervention group ( n = 610 ) or a control group ( n = 624 ) . The intervention consisted of letter and telephone recall for PCV7 vaccination . Two months after intervention , receipt of 1 or more doses of PCV7 was assessed . Intention-to-treat analysis was used . RESULTS We were unable to successfully contact 42.3 % of the intervention subjects by mail and telephone . In the intervention group , 23.0 % ( 140 children ) received PCV7 within 2 months compared with 20.2 % ( 126 children ) in the control group ( P = NS ) . No intervention effect was evident when children were stratified by age . A large proportion of the study population had Medicaid insurance ( 51.2 % ) or were uninsured ( 28.5 % ) , but response to PCV7 recall did not vary by insurance status . CONCLUSIONS Letter and telephone recall for PCV7 vaccine did not significantly increase the rate of PCV7 immunization in an inner-city teaching hospital serving a disadvantaged population . The effectiveness of recall appears to have been limited by the inability to reach many subjects by mail and telephone OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity Abstract Objective To compare demographic , social , maternal , and infant related factors associated with partial immunisation and no immunisation in the first year of life in the United Kingdom . Design Prospect i ve cohort study . Setting Sample of electoral wards in Engl and , Wales , Scotl and , and Northern Irel and , stratified by measures of ethnic composition and social disadvantage . Participants 18 488 infants born between September 2000 and January 2002 , resident in the UK and eligible to receive child benefit ( a universal benefit available to all families ) at age 9 months . Main outcome measure Immunisation status at 9 months of age , defined as fully immunised , partially immunised , or not immunised . Results Overall in the UK , 3.3 % of infants were partially immunised and 1.1 % were unimmunised ; these rates were highest in Engl and ( 3.6 % and 1.3 % , respectively ; P < 0.01 ) . Residence in ethnic or disadvantaged wards , larger family size , lone or teenaged parenthood , maternal smoking in pregnancy , and admission to hospital by 9 months of age were independently associated with partial immunisation status . In contrast , a higher proportion of mothers of unimmunised infants were educated to degree level or above ( 1.9 % ) , were older ( 3.1 % ) , or were of black Caribbean ethnicity ( 4.7 % ) . Conclusions Mothers of unimmunised infants differ in terms of age and education from those of partially immunised infants . Interventions to reduce incomplete immunisation in infancy need different approaches 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 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 OBJECTIVE To evaluate the cost-effectiveness of academic detailing programs to improve immunization coverage in communities through implementation and evaluation of the  Raising Immunizations Thru Education ( RITE ) program in the Greater Houston area . METHODS RITE was a preintervention and postintervention pilot study with r and omized intervention and control sites implemented in private practice s in pediatrics and family medicine . Changes in self-reported provider behaviors ( n = 186 ) and comparisons of immunization coverage levels between intervention ( n = 61 ) and control ( n = 62 ) practice s were evaluated . Intervention costs , computed from the perspective of an agency wanting to replicate the intervention , included direct expenses and time costs , based on time logs and compensation . Sensitivity analysis describes variations in costs . The cost-effectiveness ratio was computed as dollars per additional outcome unit . RESULTS The RITE intervention improved self-reported provider behavior . The immunization rates in the intervention group increased by 1 per cent , whereas immunization rates in the control group decreased by 2 per cent -3 per cent , but the 3 per cent - 4 per cent difference was not significant . A 1 per cent increase in practice immunization rates costs $ 424-$550 , depending on the up-to- date criteria used and the targeted age group . CONCLUSIONS The costs for 1 additional child with up-to- date immunization status are higher than potential societal savings , as reported in the literature . This intervention does not have a favorable cost-benefit ratio OBJECTIVE To test if appointment reminders blinded to immunization status improve kept-appointment and vaccination coverage rates . Design . Controlled trial . SETTING Pediatric clinic serving a low-income community in New York City . INTERVENTION Children ages 4 through 18 months ( n = 1273 ) scheduled sequentially for clinic appointments were systematic ally assigned to 1 of 4 study groups : control ( n = 346 ) ; postcard ( n = 314 ) ; telephone call ( n = 307 ) ; and postcard and telephone call ( n = 306 ) . OUTCOME MEASURES Kept-appointment and vaccination coverage rates . RESULTS Children assigned to the postcard and telephone group were 1.75 times more likely to keep their appointments than controls ( 95 % confidence interval [ CI ] = 1.2 , 2.5 ) . Children who actually received the postcard and telephone reminders were 2.3 times more likely to keep an appointment than controls ( 95 % CI = 1.4 , 3.7 ) . Children who kept appointments were 2.3 times more likely to be up-to- date with their immunizations ( 95 % CI = 1.7 , 3.2 ) . The reminders selectively increased vaccination coverage for the subgroup of children who were not up-to- date before the appointment ( chi(2 ) = 11.2 ) . The cost of the reminders was $ .67 for the postcard and $ 1.58 for the postcard and telephone . Assuming 5000 visits per year and $ 100 reimbursement per visit , the return on each dollar invested was $ 10 for the postcard and $ 7.28 for the postcard and telephone reminder . CONCLUSIONS Appointment reminders blind to immunization status are a practical and cost-effective strategy to increase kept-appointment rates for all children , and , through this mechanism , reach and vaccinate children who are not up-to- date .appointment  reminder , vaccination coverage 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 OBJECTIVES To assess the effectiveness of two serial registry reminder protocol s and the interactive effects of reminders with child characteristics on immunization rates . METHODS At an inner city practice network in New York City we r and omized 1662 children aged 6 weeks-15 months due or late for a diphtheria-tetanus-pertussis ( DTaP ) to 3 groups : continuous reminders ( as needed ) , limited reminders ( up to 3 ) and controls , for 6 months . Reminders were triggered by the hospital registry and immunizations were tracked with both the hospital and city registries . Analyses were based on intention to treat . RESULTS At r and omization , the study groups were comparable ( 9.2 months of age , 77 % Latino , 86 % Medicaid , 49.3 % up-to date ) . A quarter of the children were sent false reminders , 15 % had incorrect contact information , and 15 % had missed opportunities for vaccination . In the univariate analysis , reminders improved coverage rates , but only for the children sent continuous reminders ( 51.2 % vs. 44.9 % controls , p < .01 ) . Multivariate analysis showed reminders had no independent effect on immunization outcomes . Age , up-to- date and Medicaid status at r and omization were strong predictors of a child receiving any subsequent immunization . However , reminders interacted synergistically with Medicaid to increase the likelihood of receiving an immunization . CONCLUSION At an inner city practice network , registry reminders were not effective at improving immunization outcomes due to major system barriers . Immunization registries are powerful vehicles for identifying children in need of immunizations and generating reminders but system challenges must be addressed if this promise is to be achieved in inner city practice OBJECTIVE To determine if the addition of a physician peer educator would lead to improved immunization quality when compared to the traditional education provided as part of a  vaccines for children ( VFC ) site visit . METHODS A r and omized controlled trial was conducted . Study participants were private pediatric and family medicine practice s. Both the intervention and control groups received a VFC visit ; in intervention practice s this visit was augmented by a presentation by the physician peer educator . Data on immunization rates and quality of immunization services were collected prior to the VFC visits and approximately 1 year later . RESULTS A total of 73 practice s participated , including 37 in the intervention group and 36 in the control group . At follow-up there was no difference in practice immunization rates ( PIR ) between intervention and control practice s ( mean rates 71.4 % and 69.6 % , respectively , P=0.94 ) . There were also no significant differences between groups for any of the quality measures except that significantly more intervention practice s used the appropriate length needle for vaccine injections in 2-month-old infants at follow-up ( P=0.02 ) . When assessing the overall impact of VFC visits , no significant increase in PIR were noted from baseline to follow-up assessment s. However , statistically significant improvements in several quality measures were found . CONCLUSIONS The addition of a physician peer educator did not result in improved immunization quality when compared to VFC visits alone . The educational content of the VFC site visit was associated with improved quality of immunization services delivered by primary care practice OBJECTIVES This study examines the effectiveness of computer-generated telephone reminders in improving infants receiving on-time immunizations .  A computer called parents at home , reminded them of their child 's visit , and asked if they could keep the appointment . If parents either canceled or failed to honor the appointment , the computer called back a few days later and asked them to reschedule . METHODS A medical assistant recruited 124 consecutive mothers to receive automated computer reminders .  These mothers ' infants were younger than 6 months , were being seen at an outpatient clinic for a first visit , and were patients of three attending physicians and three nurse practitioners . These infants were compared to 89 infants from the same clinic , in the same age range , who were being seen for the first time during the same period by the same providers but not contacted by the medical assistant . Subjects were selected from mothers who brought their infants for their first visit in an outpatient urban clinic that serves predominantly minority clients . A research assistant review ed patients ' medical records and collected the infants ' birthday , mothers ' age , race , source of payments , and the immunization record of the infants . Immunization was considered to be late if , at the time of the first visit , it was more than 30 days past due for any of the recommended immunizations of the American Academy of Pediatrics , except for Hepatitis B vaccine which was not recommended at the time of the study . The dependent variable was on-time immunization . The independent variables were age of the mother at baseline , age of the child at baseline , and membership in either the comparison or the experimental group . Chi-square tests and logistic regression were used to analyze the data . RESULTS The participation rate for appointments for the experimental group was 82 % , as compared to a 69 % overall participation rate for the clinic providers . The on-time immunization rate for experimental subjects was 67.8 % , whereas the comparison group had an on-time immunization rate of 43.4 % ( differences were significant at alpha levels less than 0.01 ) . CONCLUSIONS Computerized reminders sent to the parents led to an increase in participation rate at the clinic and an increase in on-time immunization for their infants Background : This prospect i ve cohort study was design ed to evaluate the effectiveness of mail and telephone contact with parents  as a means to improve the immunization coverage of children less than 7 years old in a family practice residency clinic . Methods : Immunization records for 519 children enrolled in an outpatient clinic were review ed and up date d. Children whose immunizations were current ( 55 ) were excluded , which left 464 children whose immunizations were more than 1 month behind for their age groups . A r and om sample of one-half of these children ( 231 ) were mailed a postcard listing the immunizations that they required to be up to date . The mailing was followed up with telephone contact , when necessary , to prompt compliance . The other one-half of the children were not contacted and served as the control group . Immunizations provided to the two groups were compared 6 months after the initial mailing . Results : Before the initiation of the study , only 10.6 percent of the infants and children in the practice had their immunizations completed or were up to date . There were 124 immunizations given to 49 children in the intervention group compared with 84 immunizations to 33 children in the control ( P<0.047 ) . Thirty-four children were brought up to date in the control group compared with 17 in the intervention cohort ( P<0.011 ) . Conclusions : Direct mail reminders and telephone contact with parents of children who were behind in their immunizations were effective methods to encourage compliance . The increased number of immunizations received by the children in the intervention group was overshadowed by the poor coverage of the entire practice , a highly mobile and predominately indigent group . Additional interventions are urgently needed to improve immunization levels in infants and children Abstract Objective To examine the effectiveness of an intervention that combined continuing medical education with process improvement methods to implement “ office systems ” to improve the delivery of  preventive care to children . Design R and omised trial in primary care practice s. Setting Private paediatric and family practice s in two areas of North Carolina . Participants R and om sample of 44 practice s allocated to intervention and control groups . Intervention Practice based continuing medical education in which project staff coached practice staff in review ing performance and identifying , testing , and implementing new care processes ( such as chart screening ) to improve delivery of preventive care . Main outcome measure Change over time in the proportion of children aged 24 - 30 months who received age appropriate care for four preventive services ( immunisations , and screening for tuberculosis , anaemia , and lead ) . Results The proportion of children per practice with age appropriate delivery of all four preventive services changed , after a one year period of implementation , from 7 % to 34 % in intervention practice s and from 9 % to 10 % in control practice s. After adjustment for baseline differences in the groups , the change in the prevalence of all four services between the beginning and the end of the study was 4.6-fold greater ( 95 % confidence interval 1.6 to 13.2 ) in intervention practice s. Thirty months after baseline , the proportion of children who were up to date with preventive services was higher in intervention than in control practice s ; results for screening for tuberculosis ( 54 % v 32 % ) , lead ( 68 % v 30 % ) , and anaemia ( 79 % v 71 % ) were statistically significant ( P < 0.05 ) . Conclusion Continuing education combined with process improvement methods is effective in increasing rates of delivery of preventive care to children A controlled trial to determine the effects of introducing a central ised , computerised immunisation register  commenced in Northl and in May 1985 . All infants born since 1 January 1985 have been registered on the Health Department 's mainframe computer and assigned to either control or test groups . This birth information has been used to study two interventions aim ed at increasing immunisation levels in the experimental group . The first involves sending to general practitioners lists of infants due for immunisation , and the second sending immunisation reminder cards to parents . Results show significant differences in immunisation levels between test group infants and comparable controls : an 18.2 % increase for the six week immunisation , a 16.7 % increase for the three month immunisation , and a 4.7 % increase for the five month immunisation . A user survey has shown a high degree of acceptance by GPs and practice nurses . The pilot scheme will continue through 1986 , and will be used over this period to improve acceptability to users and assist in planning a possible national computerised immunisation information system The authors evaluated the effectiveness of computer-generated telephoned reminders used to raise the rates of on-time immunization  among preschool-age children in two public clinics in Atlanta , GA . The overall effect of the intervention on immunization levels appeared to be minimal ( crude relative risk = 1.07 , 95 percent confidence interval = 0.78 , 1.46 ) , in part because only about 80 percent of children in both the r and omly selected intervention group and in the control group were members of a household with a telephone number listed in clinic records . However , logistic regression analysis indicated that 36 of 68 children ( 52.9 percent ) in the intervention group whose households were reached were vaccinated within 30 days of their due date s , compared to 31 of 75 children ( 41.3 percent ) in the control group whose household telephone numbers were recorded but not called ( adjusted odds ratio = 2.12 , 95 percent confidence interval = 1.01 , 4.46 ) . This analysis indicates that telephoned reminders demonstrated a level of effectiveness in improving immunization levels at inner-city clinics that recommends further trial and study Levels of childhood immunisation are high in the United Kingdom but are proving difficult to maintain . Several initiatives to improve uptake have been described , including sending written information to parents,1 specialist immunisation clinics,2 and prompts to health visitors and general practitioners.3 However , none of these interventions has been the subject of a r and omised controlled trial . We tested the effectiveness of two such interventions . The child health system  , which maintains computerised data on immunisation status of all children , was used as the sampling frame . The study population comprised children resident in the former county of South Glamorgan who were ( a ) born between 1 April and 30 September 1995 and scheduled to complete the primary course of diphtheria , pertussis , tetanus , polio , and Haemophilus influenzae type b immunisation or ( b ) born between 1 April and 30 September 1994 and scheduled to receive measles , mumps , and rubella immunisation . Children were included in the trial if they had not completed their primary course by 9 BACKGROUND Missed opportunities for immunizations are associated with underimmunization of preschool-age children . Practice policies limiting immunizations to scheduled preventive visits and guidelines requiring legal guardians to sign consent forms for vaccinations are 2 factors contributing to missed opportunities . However , methods to change these policies have not been sufficiently evaluated . OBJECTIVE To measure the effectiveness of ( 1 ) changing practice policies to incorporate the new national st and ard to screen and vaccinate eligible children at all office visits and ( 2 ) eliminating legal guardian signature requirements . DESIGN A r and omized controlled trial of 2 interventions : ( 1 ) changing practice policy and routine to have office nurses screen for immunization status at all visits , attach immunization reminder cards to medical charts for eligible patients , and have providers vaccinate eligible children ( " no missed opportunities " intervention ) and ( 2 ) changing practice guidelines to allow vaccinations without a legal guardian 's signature . The first intervention was performed at both sites ; the second only at the neighborhood health center ( NHC ) . SETTING A Pediatric Continuity Clinic in a teaching hospital ( hereafter referred to as Clinic ) , and an NHC . PATIENTS Enrolled in the trial were 1005 Clinic patients and 983 NHC patients , 0 to 2 years of age . MAIN OUTCOME MEASURES Missed opportunity rates , immunization rates , and rates of preventive services . RESULTS Eliminating the requirement for a legal guardian 's signature had no effect on any of the outcome measures . The no missed opportunities intervention was partially effective .  Study patients had slightly fewer missed opportunities than control patients at each site : ( 0.60 vs 0.90 per patient per year at the Clinic , P = .01 ; 1.1 vs 1.3 per patient per year at the NHC , P = .02 ) . For study group patients , immunization reminder cards were attached to medical charts in only one third of vaccine-eligible visits ; when attached , they markedly increased vaccination by providers ( odds ratio for vaccinating at a visit was 6.9 comparing visits when immunization reminder cards were attached vs not attached ) . However , at the end of the study , immunization rates were similar for study and control groups at each site . The number of undervaccinated days was slightly lower for the no missed opportunities study group at the Clinic than for the control group ( 56 days vs 77 days , P < .001 ) , but they were similar for both groups at the NHC . There were no differences in rates of preventive visits or screening tests between study and control groups . CONCLUSIONS The interventions evaluated to reduce missed opportunities did not increase immunization rates . The key problem was failure to screen for immunization status at all visits . More effective interventions will be needed to overcome barriers within busy primary care practice s to substantially reduce missed opportunities OBJECTIVE To determine whether a nurse-initiated chart review and prompt to physicians is an effective method to increase immunization rates . STUDY DESIGN This study was a controlled trial with systematic assignment of children to intervention or control groups based on chart number . Each day , a nurse review ed the charts of children to be seen that day who were in the intervention group . The nurse prepared a 1-page form about the child 's immunization status that requested permission from the physician to administer needed vaccines and attached the form to the chart . The duration of the study period was 1 year . POPULATION Nine hundred ninety-seven pediatric patients attending 2 inner-city primary care health centers . OUTCOME MEASURED On-time immunization rates in both groups . RESULTS Among children eligible to receive vaccines during the study period , a higher percentage in the intervention group received  on-time vaccines for diphtheria/tetanus/pertussis-4 ( DTP4 ; 51 % vs 36 % ; P=.03 ) ,  oral polio vaccine-3 ( OPV3 ; 70 % vs 56 % , P=.04 ) , and  measles/mumps/rubella-1  ( 42 % vs 26 % ; P=.01 ) than did children in the control group . No statistically significant differences were noted for DTP3 , DTP5 , hepatitis B3 , or OPV4 . No statistically significant difference was noted for the combined series ( ie , all age-appropriate immunizations as recommended by the 1995 Childhood Immunization Schedule of the Centers for Disease Control and Prevention ) . CONCLUSIONS The chart prompt increased on-time immunizations for some antigens 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 INTRODUCTION Recent evaluations of computer-generated reminder/recall messages have suggested that they are an inexpensive , labor-saving method of improving office visitation rates of childhood immunization providers . This study assesses the sustained impact of computer-generated messages on immunization coverage during the first two years of life . DESIGN R and omized , controlled trial . SETTING County health department in the Denver metropolitan area . STUDY PARTICIPANTS Children ( n = 1227 ) 60 to 90 days of age who had received the first dose of diphtheria-tetanus-pertussis ( DTP ) and /or poliovirus vaccines . INTERVENTION Households of children were r and omized into four groups to receive : telephone messages followed by letters ( Group A ) ; telephone messages alone ( Group B ) ; letters only ( Group C ) ; or no notification ( Group D ) . Households in the intervention groups ( A , B , and C ) received up to five computer-generated telephone messages and /or up to four letters each time their children became due for immunization(s ) . MAIN OUTCOME MEASURE Immunization series completion at 24 months of age . RESULTS Children whose families were r and omized to receive any of the interventions were 21 % more likely to have completed the immunization series by 24 months of age than were children r and omized into the control group ( 49.2 % vs 40.9 % ; RR [ rate ratio ] = .21 ; CI [ confidence interval ] = 1.01 , 1.44 ) . While not statistically significant , children in Group A were 23 % more likely to complete their immunization series by 24 months of age than those in the control group ( 50.2 % vs 40.9 % ; RR = 1.23 ; CI = 1.00 , 1.52 ) . No differences were detected among the intervention groups . The costs per additional child completing the series by 24 months of age in Group A was $ 226 ( $ 79 after start-up costs were discounted ) . CONCLUSION Computer-generated contacts , either by phone or by mail ( or both combined ) , used each time vaccines become due , are efficacious in increasing immunization coverage of children under 2 years of age OBJECTIVE To evaluate the effectiveness and cost effectiveness of computer-generated recall letters to parents of children overdue for immunizations . METHODS This r and omized controlled trial included children of two facilities in a regional health maintenance organization . Parents of 20-month-olds who had not yet received a measles-mumps-rubella ( MMR ) immunization were identified via a computerized immunization tracking system . One half were mailed personalized letters that included the recommended immunization schedule and a request to call for an appointment ; the other half served as a control group . Receipt of the MMR between 20 and 24 months of age was evaluated with the computerized tracking system . A telephone survey was conducted with parents whose children had not received the MMR by 24 months . Decision analysis was used to project the theoretical outcomes and costs of a recall letter policy for other population s. RESULTS Among 20-month-old children 10 % had not received the MMR ; 289 families were included in the analysis . Of families who were mailed letters , 54 % ( 82 of 153 ) received the  MMR  by 24 months of age , compared with 35 % ( 47 of 136 ) of those in the control group ( P = 0.001 ) . The telephone survey was completed with 110 parents of children who still did not appear on the health plan computer as having received the MMR by 24 months . Fifteen percent said the child had received an immunization at an outside provider , and of the rest 62 % said they had not been aware that an immunization was due . In the cost effectiveness analysis it was projected that recall letters would increase the immunization rate for the regional population of approximately 30000 children from 86 % to 90 % at a total cost of $ 5031 annually . The cost per additional child appropriately immunized was $ 4.04 . In sensitivity analyses this cost effectiveness ratio varied depending on the baseline population coverage rate as well as the estimated effectiveness of recall letters . CONCLUSIONS Computer-generated letters to recall children overdue for immunizations result ed in a higher proportion of children appropriately immunized in this setting . However , the strategy was not as cost-effective as intuition might suggest . Further studies in health maintenance organization ( HMO ) setting s should compare the cost effectiveness of letters with other low cost strategies including automated telephone reminders This study was conducted to determine whether implementing a program aim ed at providing a variety of incentives to physicians who provide immunizations to preschool-aged children would help to improve immunization rates and reduce fragmented care for patients . Twenty physicians from 14 private practice s that provide care to preschool-aged children from low income families in suburban Cook County , Illinois participated in the project . A r and omly selected subset of patient case records from the physicians ' offices were audited after the implementation of the project to determine the immunization status of children in the practice s and the nature of services provided . These 310 records of children under three years of age who were treated between 1991 - 1994 ( the intervention sample ) were compared to 310 charts from a 1988 - 1990 cohort of records ( baseline sample ) . The groups did not differ on race or gender ; however , significantly more families in the 1988 through 1990 cohort of children under 3 years of age were insured privately when compared to the 1991 through 1994 cohort . Seventy percent ( 218 ) of the records in the intervention sample were up to date for age on immunizations compared to 45 % ( 141 ) of the baseline records , reflecting a statistically significant difference ( p < .00001 ) . The intervention sample showed significantly more well child visits where immunizations were given and follow up visits where immunizations were given when compared to the baseline sample . Physicians completed surveys before and after implementation of the project . They were question ed about their knowledge and practice s regarding immunizations as well as their opinion of specific project components . All of the physicians viewed the project as an effective means to improve immunization services to low income children . The project demonstrates a potential means of enhancing immunization levels and continuity of care among preschool-aged children . It also highlights the workable nature of the partnership between public and private sectors OBJECTIVE To examine effectiveness of immunization recall in an urban pediatric teaching clinic and to identify barriers to recall effectiveness . DESIGN R and omized , controlled trial . Children aged 5 to 17 months who were not up to date ( UTD ) with recommended immunizations were identified and assigned to intervention ( n = 294 ) or control groups ( n = 309 ) . The intervention consisted of a mailed postcard and up to 4 telephone calls . Two months after intervention , UTD status , visit , and probable missed opportunity rates were assessed . RESULTS Of the intervention group , 30 % could not be reached . In 12-month-old children in the intervention group compared with those in the control group , there was a trend toward higher UTD rates ( 51 % vs 39 % , P = .07 ) and a higher proportion of UTD children receiving immunizations as opposed to getting more complete documentation ( 25 % vs 10 % , P = .005 ) . Similar differences between intervention and control children were not seen in the 7-month and 19-month age categories . More children in the intervention group had a health maintenance visit ( 17 % vs 11 % , P = .03 ) . Of children in the intervention group who were seen when not UTD , 17 of 24 ( 71 % ) of those seen for an illness visit and 5 of 24 ( 21 % ) of those seen for health maintenance probably had missed opportunities to be immunized . CONCLUSIONS Recall efforts were partially successful but were undermined by inability to reach the clinic population , poor documentation of immunizations , and missed opportunities The Ohio Department of Health initiated a program of mailing an immunization reminder to the mothers of six-month-old children predicted to be at high risk of failure to receive vaccinations based on birth certificate information . The evaluation results indicated a 50 % gain in immunizations amongst children whose parents received the letter when compared with those not receiving the letter OBJECTIVES The purpose of this study was to examine the effects on immunization coverage of 3 incentives for physicians -- a cash bonus for practice --wide increases , enhanced fee for service , and feedback . METHODS Incentives were applied at 4-month intervals over 1 year among 60 inner-city office-based pediatricians . At each interval , charts of 50 r and omly selected children between 3 and 35 months of age were review ed per physician . RESULTS The percentage of children who were up to date for diphtheria , tetanus , and pertussis and Haemophilus influenzae type b ; polio ; and measles-mumps-rubella immunization in the study 's bonus group improved by 25.3 percentage points ( P < .01 ) . No significant changes occurred in the other groups . However , percentage of immunizations received outside the participating practice also increased significantly in the bonus group ( P < .01 ) . Levels of missed opportunities to immunize were high in all groups and did not change over time . Physicians ' knowledge of contraindications was low . CONCLUSIONS Bonuses sharply and rapidly increased immunization cover-age in medical records . However , much of the increase was the result of better documentation . A bonus is a powerful incentive , but more structure or education may be necessary to achieve the desired results 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 BACKGROUND Estimated vaccination coverage of Hispanic children is consistently lower than that of white non-Hispanic children . " Hispanic ethnicity " defines a highly heterogeneous group of the U.S. population ; however , vaccination coverage by ancestry group has not been studied . This study explores differences in vaccination coverage among Hispanic children by ancestry group . METHODS The National Immunization Survey ( NIS ) uses a r and om-digit-dial sample of telephone numbers in each state and in 28 urban areas . The NIS provides vaccination coverage information representative of all U.S. children aged 19 to 35 months . We pooled NIS data from 1996 through 1999 and selected Hispanic and white non-Hispanic children for analysis . We categorized Hispanic children into the following ancestry groups : Mexican , Central American , Puerto Rican , Cuban , South American , and Dominican . We used t tests to detect differences in coverage between children of Hispanic ancestry , by group , compared to white non-Hispanic children , by vaccine , and the vaccination series 4:3:1:3 . RESULTS Estimated vaccination coverage with 4:3:1:3 was 80.1 % ( 95 % CI , 79.6 - 80.6 ) among white non-Hispanic children . Estimated coverage was lower among Puerto Rican ( 75.8 % ; 95 % CI , 72.1 - 79.5 ) , Cuban ( 73.1 % ; 95 % CI , 65.1 - 81.1 ) , Mexican ( 71.7 % ; 95 % CI , 69.9 - 73.5 ) , and Central American ( 68.7 % ; 95 % CI , 62.0 - 75.4 ) children , and was higher among South American ( 82.0 % ; 95 % CI , 75.5 - 88.5 ) and Dominican ( 82.2 % ; 95 % CI , 75.5 - 88.5 ) children ; however , these differences were only statistically significant for Puerto Rican , Mexican , and Central American children . Among children living in poverty , estimated coverage with 4:3:1:3 was lower among Mexican ( 68.0 % ; 95 % CI , 65.1 - 70.9 ) , Central American ( 69.7 % ; 95 % CI , 59.8 - 79.6 ) , and South American ( 69.0 % ; 95 % CI , 50.9 - 87.1 ) children than among white non-Hispanic children ( 73.4 % ; 95 % CI , 71.6 - 75.2 ) ; however , this difference was significant only among Mexican children . Coverage was similar or somewhat higher among Puerto Rican ( 72.9 % ; 95 % CI , 65.7 - 80.1 ) and Dominican ( 80.2 % ; 95 % CI , 68.5 - 91.9 ) children than white non-Hispanic children living below poverty . CONCLUSIONS Findings from the NIS strongly suggest that estimated vaccination coverage among children of Hispanic ancestry varies by group . Improved monitoring of vaccination coverage among Hispanics by community is necessary , and where undervaccination is identified , interventions should be matched to community needs
Objectives To conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries .