Using Implementation Intentions Prompts to Enhance Influenza Vaccination Rates Targeted mailing of information to improve uptake of measles, mumps, and rubella vaccine: a randomised controlled trial. Effectiveness and Net Cost of Reminder/Recall for Adolescent Immunizations Randomized Trial of a Program to Increase Staff Influenza Vaccination in Primary Care Clinics Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Effect of reminder notices on the timeliness of early childhood immunizations. Implementation of Universal Influenza Immunization Recommendations for Healthy Young Children: Results of a Randomized, Controlled Trial With Registry-Based Recall Improving Physician Coverage of Pneumococcal Vaccine: A Randomized Trial of a Telephone Intervention The effect of a combined influenza/pneumococcal immunization reminder letter. Text messages for influenza vaccination among pregnant women: A randomized controlled trial. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Parental Choice of Recall Method for HPV Vaccination: A Pragmatic Trial Effectiveness and Cost of Bidirectional Text Messaging for Adolescent Vaccines and Well Care Text message reminders for timely routine MMR vaccination: A randomized controlled trial. Impacting delayed pediatric influenza vaccination: a randomized controlled trial of text message reminders. Effect of an audiovisual message for tetanus booster vaccination broadcast in the waiting room Randomised controlled trial of the use of a modified postal reminder card on the uptake of measles vaccination Promoting HPV Vaccination in Safety-Net Clinics: A Randomized Trial Human Papillomavirus Vaccine Intent and Uptake Among Female College Students Patient-carried card prompts vs computer-generated prompts to remind private practice physicians to perform health maintenance measures. Effectiveness of recall systems for improving influenza vaccination coverage in children with oncohematological malignancies Boosting uptake of influenza immunisation: a randomised controlled trial of telephone appointing in general practice. Increasing immunization rates among inner-city, African American children. A randomized trial of case management. Impact of community volunteers on immunization rates of children younger than 2 years. 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Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. Effectiveness and Cost of Immunization Recall at School-Based Health Centers Effectiveness and Cost-effectiveness of Letters, Automated Telephone Messages, or Both for Underimmunized Children in a Health Maintenance Organization Effectiveness of a smartphone app on improving immunization of children in rural Sichuan Province, China: a cluster randomized controlled trial Parental Perspectives on Influenza Vaccination among Children with Asthma Lay Health Worker Intervention Improved Compliance with Hepatitis B Vaccination in Asian Americans: Randomized Controlled Trial The impact of reminder-recall interventions on low vaccination coverage in an inner-city population. The impact of interventions by a community-based organization on inner-city vaccination coverage: Fulton County, Georgia, 1992-1993. A novel approach to improve influenza vaccination rates among health care professionals: a prospective randomized controlled trial. Identification and recall of children with chronic medical conditions for influenza vaccination. Effectiveness of centralized text message reminders on human papillomavirus immunization coverage for publicly insured adolescents. Effects of Community Health Nurse-Led Intervention on Childhood Routine Immunization Completion in Primary Health Care Centers in Ibadan, Nigeria Use of reminders to increase compliance with tetanus booster vaccination. A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents. Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion. A target-based model for increasing influenza immunizations in private practice Immunization registry-based recall for a new vaccine. Improving influenza vaccination rates in children with asthma: a test of a computerized reminder system and an analysis of factors predicting vaccination compliance. Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial. Population-based versus practice-based recall for childhood immunizations: a randomized controlled comparative effectiveness trial. The role of mobile phones in improving vaccination rates in travelers. Increasing the immunization of preschool children; an evaluation of applied community interventions. Raising adult vaccination rates over 4 years among racially diverse patients at inner-city health centers. Vaccination of high-risk patients for influenza. A comparison of telephone and mail reminder methods. Factors conditioning effectiveness of a reminder/recall system to improve influenza vaccination in asthmatic children. Use of reminders for preventive procedures in family medicine. 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. A randomised intervention study to examine the effect on immunisation coverage of making influenza vaccine available at no cost. Influenza immunization in a managed care organization Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention. Patient-Specific Reminder Letters and Pediatric Well-Child-Care Show Rates Feasibility of a randomized controlled trial to evaluate Text Reminders for Immunization Compliance in Kids (TRICKs). The organization and evaluation of a computer-assisted, centralized immunization registry. Results of a Multilevel Intervention Trial to Increase Human Papillomavirus (HPV) Vaccine Uptake among Adolescent Girls The impact of inactive infants on clinic-based immunization rates. Seasonal influenza vaccination reminders for children with high-risk conditions: a registry-based randomized trial. Cost and utilization avoidance with mail prompts: a randomized controlled trial. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. A randomized controlled trial. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Drinking water and cancer in Louisiana. A retrospective mortality study. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. Impact of appointment reminders on vaccination coverage at an urban clinic. The effect of patient education on pediatric immunization rates. 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Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education. Effect of telephone reminder/recall on adolescent immunization and preventive visits: results from a randomized clinical trial. The cost of tracking a cohort of women in a general practice using rubella immune status as an example. Efficacy of informational letters on hepatitis B immunization rates in university students. A Randomised, Clinical Trial Comparing the Effectiveness of Hospital and Community-Based Reminder Systems for Increasing Uptake of Influenza and Pneumococcal Vaccine in Hospitalised Patients Aged 65 Years and Over Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. Postcard reminders from GPs for influenza vaccine: Are they more effective than an ad hoc approach? Practice based education to improve delivery systems for prevention in primary care: randomised trial Improving Influenza Vaccination Rates in Pregnancy Through Text Messaging: A Randomized Controlled Trial A group-randomized evaluation of a quality improvement intervention to improve influenza vaccination rates in dialysis centers. Early results from the Northland immunisation register. The effects of framing and action instructions on whether older adults obtain flu shots. Does reminder-recall augment the impact of voucher incentives on immunization rates among inner-city infants enrolled in WIC? Special Supplemental Program for Women, Infants, and Children. Evaluation of telephoned computer-generated reminders to improve immunization coverage at inner-city clinics. Requiring elderly patients to give signed consent for influenza vaccine. Does it affect acceptance? Hepatitis A and B Vaccination in a Sexually Transmitted Disease Clinic for Men Who Have Sex With Men Initiatives to improve childhood immunisation uptake: a randomised controlled trial The influence of health professionals on the uptake of the influenza immunization. Effect of Telephone Follow-up on Frequency of Health Maintenance Visits Among Children Attending Free Immunization Clinics:A Randomized, Controlled Trial A randomized intervention study to evaluate whether electronic messaging can increase human papillomavirus vaccine completion and knowledge among college students Adoption of reminder and recall messages for immunizations by pediatricians and public health clinics. Influenza vaccination in community elderly. A controlled trial of postcard reminders. The impact of the standards for pediatric immunization practices on vaccination coverage levels. Are reminder stickers effective in reducing immunization dropout rates in Addis Ababa, Ethiopia? Randomized Controlled Trial of Health Maintenance Reminders Provided Directly to Patients Through an Electronic PHR Computer-based vs manual health maintenance tracking. A controlled trial. Increasing influenza vaccination among high-risk elderly: a randomized controlled trial of a mail cue in an HMO setting. Public health in managed care: a randomized controlled trial of the effectiveness of postcard reminders. Impact of postal invitations and user fee on influenza vaccination rates among the elderly. A randomized controlled trial in general practice. Publication bias in clinical research Assessment of immunization status in hospitalized children followed by counseling of parents and primary care physicians improves vaccination coverage: an interventional study. Registry-driven, community-based immunization outreach: a randomized controlled trial. Opportunistic electronic reminders. Improving performance of preventive care in general practice. Age-specific strategies for immunization reminders and recalls: a registry-based randomized trial. The impact of outreach efforts in reaching underimmunized children in a Medicaid managed care practice. Educational content and the effectiveness of influenza vaccination reminders Computer-generated recall letters for underimmunized children: how cost-effective? Immunization recall: effectiveness and barriers to success in an urban teaching clinic. Understanding and enhancing compliance with the second dose of hepatitis B vaccine: a cohort analysis and a randomized controlled trial. Compliance with hepatitis B virus vaccination in a high-risk population. A Stepped Intervention Increases Well-Child Care and Immunization Rates in a Disadvantaged Population Quality improvement in immunization delivery following an unsuccessful immunization recall. Mailed reminders for area-wide influenza immunization: a randomized controlled trial. Improving influenza vaccination rates in the workplace: a randomized trial. The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites. Language bias in randomised controlled trials published in English and German Enhancing Routine Immunization Performance using Innovative Technology in an Urban Area of Nigeria. A comprehensive patient assessment and physician reminder tool for adult immunization: effect on vaccine administration. Infant immunization surveillance: cost vs effect. A prospective, controlled evaluation of a large-scale program in Rhode Island. Effect of the frequency of delivery of reminders and an influenza tool kit on increasing influenza vaccination rates among adults with high-risk conditions. Effectiveness of a mailed reminder on the immunization levels of infants at high risk of failure to complete immunizations. Randomized controlled study of customized preventive medicine reminder letters in a community practice. Vaccines4Kids: Assessing the impact of text message reminders on immunization rates in infants. Minimizing the three stages of publication bias. Centralized Reminder/Recall to Increase Immunization Rates in Young Children: How Much Bang for the Buck? Feasibility of completing an accelerated vaccine series for homeless adults. Accuracy and quality of immunization information systems in forty-one low income countries. Encouraging Influenza Vaccination Among Text4baby Pregnant Women and Mothers. Improving influenza vaccination rates by targeting individuals not seeking early seasonal vaccination. Effects of Phone and Text Message Reminders on Completion of the Human Papillomavirus Vaccine Series. Text4Health: impact of text message reminder-recalls for pediatric and adolescent immunizations.
We evaluate the results of a field experiment design ed to measure the effect of prompts to form implementation intentions on realized behavioral outcomes . The outcome of interest is influenza vaccination receipt at free on-site clinics offered by a large firm to its employees . All employees eligible for study participation received reminder mailings that listed the times and locations of the relevant vaccination clinics . Mailings to employees r and omly assigned to the treatment conditions additionally included a prompt to write down either ( 1 ) the date the employee planned to be vaccinated or ( 2 ) the date and time the employee planned to be vaccinated .  Vaccination rates increased when these implementation intentions prompts were included in the mailing . The vaccination rate among control condition employees was 33.1 % . Employees who received the prompt to write down just a date had a vaccination rate 1.5 percentage points higher than the control group , a difference that is not statistically significant . Employees who received the more specific prompt to write down both a date and a time had a 4.2 percentage point higher vaccination rate , a difference that is both statistically significant and of meaningful magnitude 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 OBJECTIVE : To assess the effectiveness of reminder/recall ( R/R ) for immunizing adolescents in private pediatric practice s and to describe the associated costs and revenues . METHODS : We conducted a r and omized controlled trial in 4 private pediatric practice s in metropolitan Denver . In each practice , 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations ( tetanus-diphtheria-acellular pertussis , meningococcal conjugate , or first dose of human papillomavirus vaccine for female patients ) were r and omly selected and r and omized to intervention ( 2 letters and 2 telephone calls ) or  control  ( usual care ) groups . Primary outcomes were receipt of > 1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention . We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines . RESULTS : Eight hundred adolescents were r and omized to the intervention and 800 to the control group . Baseline rates of having already received tetanus-diphtheria-acellular pertussis , meningococcal conjugate , and first dose of human papillomavirus vaccine before R/R ranged from 33 % to 54 % . Postintervention , the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine ( 47.1 % vs 34.6 % , P < .0001 ) and receipt of all targeted vaccines ( 36.2 % vs 25.2 % , P < .0001 ) compared with the control group . Three practice s had positive net revenues from R/R ; 1 showed net losses . CONCLUSIONS : R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children . Practice s conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low PURPOSE Although vaccination of health care workers against influenza is widely recommended , vaccination uptake is low . Data on interventions to increase staff immunization in primary care are lacking . We examine the effect of a promotional and educational intervention program , not addressing vaccine availability , to raise the influenza vaccination rate among staff in primary care clinics . METHODS The study included all 344 staff members with direct patient contact ( physicians , nurses , pharmacists , and administrative and ancillary staff ) in 27 primary care community clinics in the Jerusalem area during the 2007–2008 influenza season . Thirteen clinics were r and omly selected for an intervention that consisted of a lecture session given by a family physician , e-mail-distributed literature and reminders , and a key figure from the local staff who personally approached each staff member .  RESULTS Influenza immunization rate was 52.8 % ( 86 of 163 ) in the intervention group compared with 26.5 % ( 48 of 181 ) in the control group ( P<.001 ) . When compared with the rate of immunization for the previous season , the absolute increase in immunization rate was 25.8 % in the intervention clinics and 6.6 % in the control clinics . Multivariate analysis showed a highly significant ( P<.001 ) independent association between intervention and immunization , with an odds ratio of 3.51 ( 95 % confidence interval , 2.03–6.09 ) . CONCLUSION We have developed an effective intervention program to increase previously low vaccination rates among primary health care workers . This simple intervention could be reproduced easily in other clinics and organizations with an expected substantial increase in influenza immunization rates PURPOSE Influenza and pneumococcal vaccines are underused . Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates . Little has been published on the long-term success and durability of such efforts . METHODS We performed a 10-year time-series study to examine the durability and success of an ongoing , multifaceted , institution-wide influenza and pneumococcal vaccination program . The program was first implemented at the Minneapolis Department of Veterans Affairs ( VA ) Medical Center in 1987 - 88 following the demonstration that a clinic-based st and ing order policy was much more successful than provider education for improving vaccine delivery . The program ensures that vaccine is offered to all high-risk patients followed up at the medical center , promotes convenient access for patients , and facilitates efficient administration of vaccine . Specific elements include an annual mailing to patients , st and ing orders for nurses , walk-in clinics , and the use of st and ardized , preprinted documentation forms . Initially the program targeted high-risk out patients for influenza vaccination .  It was extended to include in patients in 1989 - 90 .  Pneumococcal vaccinations were added to the program in 1994 - 95 . Vaccination rates are estimated each year from surveys mailed to r and omly selected patients , and vaccine utilization is monitored through pharmacy logs . RESULTS The survey response rates have exceeded 75 % each year .  Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58 % following the 1987 - 88 vaccination season to 84 % in 1996 - 97 ( P < 0.001 ) . Pneumococcal vaccination rates have also increased from 34 % in 1994 - 95 to 63 % in 1996 - 97 ( P < 0.001 ) . Vaccination rates are similar for in patients and out patients , but rates for high-risk patients < 65 years of age remain lower than for the elderly : 69 % versus 89 % for influenza , 1996 - 97 ( P < 0.001 ) ; 52 % versus 66 % for pneumococcal , 1996 - 97 ( P = 0.05 ) . For elderly patients followed up at the medical center , influenza ( 89 % versus 67 % , P < 0.0001 ) and pneumococcal ( 66 % versus 43 % , P < 0.0001 ) vaccination rates significantly exceeded those for the state of Minnesota in 1996 - 97 . The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987 - 88 to more than 22,000 in 1996 - 97 ; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994 - 95 through 1996 - 97 . CONCLUSION This simple , multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid . Similar strategies if implemented in other setting s may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized OBJECTIVE To determine whether reminder notices would improve the timeliness of toddler-age vaccinations . DESIGN Prospect i ve , r and omized , controlled trial . POPULATION STUDIED Two convenience cohorts of 320 children due to receive either measles-mumps-rubella ( MMR ) vaccine ( at 12 months of age ) or diphtheria-pertussis-tetanus (DPT)-inactivated polio (IPV)- Haemophilus influenzae type b ( Hib ) booster vaccine ( at 18 months of age ) . SETTING Suburban community . INTERVENTIONS Parents of the identified children were r and omly assigned either to a group to receive a reminder notice of pending vaccinations or a control group that did not receive a notice at a ratio of 1:1 . Immunization uptake was assessed eights weeks after the initial due date for vaccination . RESULTS Information was obtained for 224 children in the MMR group and 227 children in the DPT-IPV-Hib  booster group . MMR uptake within eight weeks of the due date was about 90 % in both the test and control groups , probably because of publicity surrounding a local college-based measles outbreak . In the DPT-IPV-Hib group , reminder notices had no effect ; the uptake rates within eight weeks of the due date were 73.7 % to 75.2 % . Delays in immunization result ed mostly from parents ' scheduling problems and provider-recommended delays . More than half of the parents whose child had delayed immunization did not recall receiving the reminder notice . CONCLUSIONS Mailed reminders did not increase on-time immunization rates in the second year of a child 's life . A telephone call or a more memorable reminder notice may be better suited to catch the attention of parents Background . An Advisory Committee on Immunization Practice s policy of encouraging influenza vaccination for healthy 6- to 23-month-old children was in effect during the 2003–2004 influenza season , which was unusually severe in Colorado . We collaborated with 5 pediatric practice s to attempt universal influenza immunization in this age group . Objectives . The objectives were ( 1 ) to assess the maximal influenza immunization rates that could be achieved for healthy young children in private practice setting s , ( 2 ) to evaluate the efficacy of registry-based reminder/recall for influenza vaccination , and ( 3 ) to describe methods used by private practice s to implement the recommendations . Methods . The study was conducted in 5 private pediatric practice s in Denver , Colorado , with a common billing system and immunization registry . Although recommendations by the Advisory Committee on Immunization Practice s included children who were 6 to 23 months of age at any point during the influenza season , our practice s chose not to recall children 22 to 23 months of age , because they would have become > 24 months of age during the study period . Therefore , our study population consisted of all healthy children 6 to 21 months of age from the 5 practice s ( N = 5193 ) , who were r and omized to intervention groups ( n = 2595 ) that received up to 3 reminder/recall letters or to control groups ( n = 2598 ) that received usual care . The primary outcome was receipt of ≥1 influenza immunization , as noted either in the immunization registry or in billing data . Results . Immunization rates for ≥1 dose of influenza vaccine for the intervention groups in the 5 practice s were 75.9 % , 75.4 % , 68.1 % , 55.6 % , and 44.3 % at the end of the season . Overall , 62.4 % of children in the intervention groups and 58.0 % of children in the control groups were immunized ( 4.4 % absolute difference ) , with absolute differences , compared with control values , ranging from 1.0 % to 9.1 % according to practice . However , before intensive media coverage of the influenza outbreak began ( November 15 , 2003 ) , absolute differences , compared with control values , ranged from 5.1 % to 15.3 % and were 9.6 % overall . Before November 15 , significant effects of recall were seen for children in the intervention groups , in both the 12- to 21-month age category ( 10.4 % increase over control ) and the 6- to 11-month category ( 8.1 % increase over control ) ; at the end of the season , however , significant effects of recall were seen only for the older age group ( 6.2 % increase over control ) . The rates of receipt of 2 vaccine doses ≥1 month apart for eligible children ranged from 21 % to 48 % among the practice s. Four of the 5 practice s held influenza immunization clinics during office hours , evenings , or weekends , and these clinics achieved higher coverage rates . Conclusions . These results demonstrated that , in an epidemic influenza year , private practice s were able to immunize the majority of 6- to 21-month-old children in a timely manner . Although media coverage regarding the epidemic blunted the effect of registry-based recall , recall was effective in increasing rates early in the epidemic , especially for children between 1 and 2 years of age . The practice s that achieved the highest immunization rates were proactive in planning influenza clinics to h and le the extra volume of immunizations required Improved pneumococcal vaccine ( PPV ) immunization for seniors is a national goal of the Medicare program . This study examined whether adding a simple telephone follow-up to an existing mailed physician performance feedback under the Medicare program would increase the impact on billed pneumococcal immunizations . Medicare fee-for-service cl aims data were used to select New York primary care physicians with high volume ( n = 732 ) or African-American serving ( n = 329 ) practice s. All practice s received mailed feedback on their 1999 Medicare practice specific PPV coverage rates , along with educational material s and offers of assistance . Practice s were also r and omized to receive telephone calls directing attention to the mailing and further promoting improvements in PPV coverage or no active follow-up . Physicians r and omized to telephone follow-up showed significantly higher rates of practice specific PPV coverage in 2000 than those receiving the routine mailing only , and 27 % vs. 17 % ( p = 0.01 ) of high volume physicians and 34 % vs. 22 % ( p = .052 ) of African American serving physicians achieved at least a 5 % increase in their cumulative PPV cl aims coverage . This study concludes that telephone follow-up is an effective and straightforward method to enhance the impact of practice specific feedback to promote improvements in Medicare PPV immunization . However , improved methods may be needed to induce a large percentage of physicians to change BACKGROUND The effect of a combined influenza and pneumococcal immunization reminder letter on increasing influenza and pneumococcal immunization rates , and the timeliness of receiving immunizations after receipt of a reminder letter , have not been examined . This study addresses these issues using a sample of new Medicare beneficiaries residing in Hawaii . METHODS Newly enrolled Medicare beneficiaries in Hawaii from 25 September 1995 through 31 August 1996 were r and omly assigned to one of three groups : Group 1 , no letter ( n=2144 ) ; Group 2 , influenza immunization reminder letter only ( n=2213 ) ; or Group 3 , pneumococcal and influenza immunization reminder letter ( n=2171 ) . Health Care Financing Administration cl aims data were compared among groups . RESULTS In Group 3 , the influenza immunization rate increased 3.8 percentage points ( n=87 ; p=0.017 ) compared with Group 1 . The Group 3 pneumococcal immunization rate increased 3.5 percentage points ( n=78 ; p<0.001 ) compared to Group 1 and 4.0 percentage points ( n=86 ; p<0.001 ) compared to Group 2 . Sixty-six beneficiaries in Group 3 received simultaneous pneumococcal and influenza immunizations , a significant difference compared to Group 1 or Group 2 . Increases in immunizations were observed immediately following the reminder letters and the effect persisted for 5 to 7 weeks . CONCLUSIONS The combination letter increased both influenza and pneumococcal immunization rates and the simultaneous administration of immunizations without detrimental effect to influenza immunization rates . A combined reminder letter is inexpensive and recommended as part of a multicomponent campaign for adult immunization OBJECTIVE To evaluate if text message reminders increase the likelihood of receiving the influenza vaccine among pregnant women . METHODS Pregnant women were r and omized to either receive or not receive weekly text messages . Women were told the messages would be about health-related behavior in pregnancy . Those r and omized to the intervention group received two messages weekly for four consecutive weeks reinforcing that the influenza vaccine is recommended for all pregnant women and safe during pregnancy and breastfeeding . Women were contacted six weeks postpartum to determine if they had received the vaccine . Sample size calculation determined that 108 women were required in both groups to see a 75 % increase in vaccination rates over baseline in the text message group compared to the control group . RESULTS Recruitment began November 4 , 2013 , and 317 women were r and omized . The mean gestational age at recruitment was 22weeks . There were 40/129 ( 31 % ) women in the text message group and 41/152 ( 27 % ) women in the control group who received the vaccine ( p=0.51 ) . Significant predictors of vaccine acceptance were being married compared to single ( 95 % vs. 67 % , p<0.001 ) , having higher household income ( 55 % vs. 39 % , p=0.03 ) and having received the vaccine before ( 77 % vs. 36 % , p<0.001 ) . Among women receiving text messages , the majority were satisfied , with only 15/129 ( 12 % ) reporting that they did not like receiving the messages , and 24/129 ( 19 % ) stating that the information in the messages was not helpful . CONCLUSION Weekly text messages reinforcing the recommendation for and safety of the influenza vaccine in pregnancy did not increase the likelihood of actually receiving the vaccine among pregnant women .  Overall vaccination rates were low , highlighting the need for patient education and innovative techniques to improve vaccine acceptance . Registered with Clinical Trials.gov at http://www . clinical trials.gov , registration number NCT 02428738 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 OBJECTIVES : Completion rates for the human papillomavirus vaccine ( HPV ) series among adolescents remain low . Effectiveness of recall with parents choosing the method ( preference-based recall ) for increasing HPV series completion is unstudied . Within a cluster-r and omized trial , we examined effectiveness of preference-based recall compared with usual care for increasing series completion and the association of recall choices with completion . METHODS : All Kaiser Permanente Colorado pediatric practice s ( n = 7 ) were r and omized to intervention ( n = 4 ) or control ( n = 3 ) by using covariate-constrained r and omization . From January to June 2013 , parents at intervention practice s whose adolescents received HPV 1  were asked the recall method they preferred for subsequent doses and if they also wanted their child reminded . Completion rates were assessed 1 year after HPV 1 . RESULTS : At intervention practice s , 374 ( 43 % ) of 867 patients were enrolled ; 39 % preferred text , 18 % e-mail , 9 % auto-dialer , and 34 % 2- methods ; 19 % chose to have adolescent also recalled . Intervention adolescents were more likely to complete ( 63 % vs 38 % ) than were controls ( adjusted risk ratio 1.47 [ 1.38–1.57 ] ) and less likely to be late in completing the series ( 45 % vs 57 % , P = .02 ) . Rates of completion were similar between different recall methods , but significantly higher for those preferring e-mail and phone compared withother methods ( 90 % vs 60 % . P = .008 ) . Completion rates were similar for adolescents who also received recalls ( 62 % ) versus those who did not ( 63 % ) . CONCLUSIONS : Preference-based recall was effective in increasing HPV series completion rates , with point estimates substantially higher than for most published studies of reminder/recall OBJECTIVE : To evaluate the effectiveness and cost of bidirectional short messaging service in increasing rates of vaccination and well child care ( WCC ) among adolescents . METHODS : We included all adolescents needing a recommended adolescent vaccine ( n = 4587 ) whose parents had a cell-phone number in 5 private and 2 safety-net pediatric practice s. Adolescents were r and omized to intervention ( n = 2228 ) or control ( n = 2359 ) . Parents in the intervention group received up to 3 personalized short messaging services with response options 1 ( clinic will call to schedule ) , 2 ( parent will call clinic ) , or STOP ( no further short messaging service ) . Primary outcomes included completion of all needed services , WCC only , all needed vaccinations , any vaccination , and missed opportunity for vaccination . RESULTS : Intervention patients were more likely to complete all needed services ( risk ratio [ RR ] 1.31 , 95 % confidence interval [ CI ] 1.12–1.53 ) , all needed vaccinations ( RR 1.29 , 95 % CI 1.12–1.50 ) , and any vaccination ( RR 1.36 , 95 % CI 1.20–1.54 ) . Seventy-five percent of control patients had a missed opportunity versus 69 % of intervention ( P = .002 ) . There was not a significant difference for WCC visits . Responding that the clinic should call to schedule ( “ 1 ” ) was associated with the highest effect size for completion of all needed services ( RR 1.89 , 95 % CI 1.41–2.54 ) . Net cost ranged from $ 855 to $ 3394 per practice . CONCLUSIONS : Bidirectional short messaging service to parents was effective at improving rates for all adolescent vaccinations and for all needed services , especially among parents who responded they desired a call from the practice OBJECTIVE Measles-mumps-rubella ( MMR ) vaccination is important for preventing disease outbreaks , yet pockets of under-vaccination persist . Text message reminders have been employed successfully for other pediatric vaccines , but studies examining their use for MMR vaccination are limited . This study assessed the impact of text message reminders on timely MMR vaccination . STUDY DESIGN Parents ( n=2054 ) of 9.5 - 10.5-month-old children from four urban academically-affiliated pediatric clinics were r and omized to scheduling plus appointment text message reminders , appointment text message reminder-only , or usual care . The former included up to three text reminders to schedule the one-year preventive care visit . Both text messaging arms included a text reminder sent 2 days before that visit . Outcomes included appointment scheduling , appointment attendance , and MMR vaccination by age 13 months , the st and ard of care at study sites . RESULTS Children of parents in the scheduling plus appointment text message reminders arm were more likely to have a scheduled one-year visit than those in the other arms ( 71.9 % vs. 67.4 % , relative risk ratio ( RRR ) 1.07 [ 95 % CI 1.005 - 1.13 ] ) , particularly if no appointment was scheduled before r and omization ( i.e. , no baseline appointment ) ( 62.1 % vs. 54.7 % , RRR 1.14 [ 95 % CI 1.04 - 1.24 ] ) . One-year visit attendance and timely MMR vaccination were similar between arms . However , among children without a baseline appointment , those with parents in the scheduling plus appointment text message reminders arm were more likely to undergo timely MMR vaccination ( 61.1 % vs. 55.1 % , RRR 1.11 [ 95 % CI 1.01 - 1.21 ] ) . CONCLUSION Text message reminders improved timely MMR vaccination of high-risk children without a baseline one-year visit BACKGROUND Influenza vaccination coverage is low , especially among low-income population s. Most doses are generally administered early in the influenza season , yet sustained vaccination efforts are crucial for achieving optimal coverage . The impact of text message influenza vaccination reminders was recently demonstrated in a low-income population . Little is known about their effect on children with delayed influenza vaccination  or the most effective message type . PURPOSE To determine the impact of educational plus interactive text message reminders on influenza vaccination of urban low-income children unvaccinated by late fall . DESIGN R and omized controlled trial . SETTING / PARTICIPANTS Parents of 5,462 children aged 6 months-17 years from four academically affiliated pediatric clinics who were unvaccinated by mid-November 2011 . INTERVENTION Eligible parents were stratified by their child 's age and pediatric clinic site and r and omized using a 1:1:1 allocation to educational plus interactive text message reminders , educational-only text message reminders , or usual care . Using an immunization registry-linked text messaging system , parents of intervention children received up to seven weekly text message reminders . One of the messages sent to parents in the educational plus interactive text message arm allowed selection of more information about influenza and influenza vaccination . MAIN OUTCOME MEASURES Influenza vaccination by March 31 , 2012 . Data were collected and analyzed between 2012 and 2014 . RESULTS Most children were publicly insured and Spanish speaking . Baseline demographics were similar between groups . More children of parents in the educational plus interactive text message arm were vaccinated ( 38.5 % ) versus those in the educational-only text message ( 35.3 % ; difference=3.3 % , 95 % CI=0.02 % , 6.5 % ; relative risk ratio (RRR)=1.09 , 95 % CI=1.002 , 1.19 ) and usual care ( 34.8 % ; difference=3.8 % , 95 % CI=0.6 % , 7.0 % ; RRR=1.11 , 95 % CI=1.02 - 1.21 ) arms . CONCLUSIONS Text message reminders with embedded educational information and options for interactivity have a small positive effect on influenza vaccination of urban , low-income , minority children who remain unvaccinated by late fall Background General practitioners ( GPs ) often lack time and re sources to invest in health education ; audiovisual messages broadcast in the waiting room may be a useful educational tool . This work was design ed to assess the effect of a message inviting patients to ask for a tetanus booster vaccination . Methods A quasi experimental study was conducted in a Belgian medical practice consisting of 6 GPs and 4 waiting rooms ( total : 20,000 contacts/year ) . A tetanus booster vaccination audiovisual message was continuously broadcast for 6 months in 2 r and omly selected waiting rooms ( intervention group - 3 GPs ) while the other 2 waiting rooms remained unequipped ( control group - 3 GPs )  . At the end of the 6-month period , the number of vaccine adult-doses delivered by local pharmacies in response to GPs ' prescriptions was recorded . As a reference , the same data were also collected retrospectively for the general practice during the same 6-month period of the previous year . Results During the 6-month reference period where no audiovisual message was broadcast in the 4 waiting rooms , the number of prescriptions presented for tetanus vaccines was respectively 52 ( 0.44 % ) in the intervention group and 33 ( 0.38 % ) in the control group ( p = 0.50 ) . By contrast , during the 6-month study period , the number of prescriptions differed between the two groups ( p < 0.0001 ) , rising significantly to 91 ( 0.79 % ) in the intervention group ( p = 0.0005 ) while remaining constant in the control group ( 0.38 % vs 0.39 % ; p = 0.90 ) . Conclusions Broadcasting an audiovisual health education message in the GPs ' waiting room was associated with a significant increase in the number of adult tetanus booster vaccination prescriptions delivered by local pharmacies 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 OBJECTIVES : Evaluate effects of a multicomponent intervention ( human papillomavirus [ HPV ] vaccine-specific brochure and recalls ) on HPV vaccination and secondarily examine if race/ethnicity moderates effects . METHODS : Unvaccinated girls aged 11 to 18 years attending 4 safety-net pediatric clinics and their parent/guardian ( n = 814 dyads ) were r and omized to ( 1 ) active comparison ( general adolescent vaccine brochure ) , or ( 2 ) intervention consisting of a HPV vaccine-specific brochure , telephone recalls to parents who declined , and recalls to patients overdue for doses 2 and 3 . HPV 1-dose and 3-dose coverages were assessed via electronic health records 12 months after r and omization . Multivariate logistic regressions estimated adjusted odds and marginal predicted vaccine coverage by study arm and race/ethnicity . RESULTS : Intent-to-treat analyses found no main effect of the HPV vaccine-specific brochure on 1-dose coverage ( 42.0 % vs 40.6 % ) ; however , secondary analyses found race/ethnicity was a significant moderator such that the intervention was effective only for Hispanic individuals ( adjusted odds ratio [ AOR ] 1.43 ; 95 % confidence interval [ CI ] 1.02–2.02 ) , and not effective for black individuals ( AOR 0.64 ; 95 % CI 0.41–1.13 ) . Recalls to parents who declined the vaccine during the index visit were not effective , but recalls to patients overdue for doses 2 and 3 were effective at increasing 3-dose coverage regardless of race/ethnicity ( AOR 1.99 ; 95 % CI 1.16–3.45 ) . CONCLUSIONS : Educational material s describing only the HPV vaccine were effective for Hispanic but not black individuals . Future research should test mechanisms that may mediate intervention effects for different racial/ethnic groups , such as different informational needs or vaccine schemas ( experiences , beliefs , norms ) Abstract Objective : To examine human papillomavirus ( HPV ) vaccine intent and the effect of an educational intervention on vaccine uptake among female college students . Participants : Females aged 18 to 26 attending a university health service gynecology clinic ( n = 256 ) . Methods : Participants were r and omized to receive either HPV-specific education with a mailed reminder or st and ard care . Predictors of HPV vaccine intent and uptake at 6 months following enrollment were identified . Results : At baseline , 41 % intended to undergo HPV vaccination . Participants who were currently sexually active and lacked supplemental health insurance had decreased intent . Perceived parental approval regarding HPV vaccination , perceived vulnerability to HPV infection , and belief in health benefits of HPV vaccine were associated with increased intent . HPV vaccine uptake was low ( 5.5 % ) and did not differ by study group . However , baseline intent was significantly associated with HPV vaccine uptake . Conclusions : Interventions to increase HPV vaccine uptake in college students should address HPV-related beliefs and broader barriers to vaccination BACKGROUND We compared the efficacy of a computer-generated prompt sheet placed on the front of patients ' charts with a patient-carried prompt card to remind physicians to perform selected health maintenance items . METHODS A r and omized prospect i ve single-blind study was performed in private practice offices in rural eastern North Carolina , with 28 family practitioners and nine general internists participating . Twenty-two physicians were r and omized to the computer prompt group and 22 to the card prompt group .  Four physicians in the computer group did not complete the study because of computer software problems , and three physicians did not complete the study because their limited staff was unable to enter patient data into the computer . Before the intervention , 20 patient charts ( 10 males and 10 females ) from each physician were audited for the performance of influenza vaccinations , stool for occult blood , pap smears , breast examinations performed by the physicians , and mammograms . One year after the intervention was instituted , chart audits for the above five items were done again on 20 different patient charts for each physician . RESULTS There was a 7 % increase in the performance of influenza vaccinations  in the card group ( 17 % vs 24 % ) compared with a 6 % increase in the computer group ( 20 % vs 26 % ) . There was a 5 % decrease in the performance of stool for occult blood in the card group ( 28 % vs 23 % ) compared with a 1 % increase in the computer group ( 30 % vs 31 % ) . There was an 11 % decrease in the performance of pap smears in the card group ( 26 % vs 15 % ) compared with a 3 % increase in the computer group ( 23 % vs 26 % ) . There was a 2 % decrease in the performance of breast examinations by the physician in the card group ( 35 % vs 33 % ) compared with a 3 % increase in the computer group ( 30 % vs 33 % ) . Finally , there was a 3 % increase in the performance of mammograms in the card group ( 22 % vs 25 % ) compared with an 11 % increase in the computer group ( 15 % vs 26 % ) . CONCLUSIONS Our data show a greater increase in performance of health maintenance items in the computer-prompted group . The performance of stool for occult blood , pap smears , breast examinations performed by the physician , and mammograms were increased more in the computer-prompted group than in the card group . However , there was not a statistically significant difference after intervention for any of the audited health maintenance items for either the computer group or the card group . Overall , health maintenance measures were performed in only a minority of appropriate patients In order to verify whether a telephone recall system directly managed by the pediatricians who usually follow up the children for their cancer , with influenza vaccine administered in the oncological clinic , is more effective than an anonymous recall system , 205 children with oncohematological malignancies were r and omised to one of three intervention strategies for increasing influenza vaccination coverage .  The results showed that all of the strategies were useful in increasing influenza vaccination coverage , but the efficacy of recall was optimal only in the children who had completed chemotherapy since less than six months BACKGROUND Immunisation against influenza is an effective intervention that reduces serologically confirmed cases by between 60 % and 70 % . Almost all influenza immunisation in the UK is done within general practice . Current evidence on the effectiveness of patient reminders for all types of immunisation programmes is largely based on North American studies . AIM To determine whether telephone appointments offered bygeneral practice receptionists increase the uptake of irfluenza immunisation among the registered population aged over 65 years in east London practice s. DESIGN OF STUDY R and omised controlled trial . SETTING Three research general practice s within the East London and Essex network of research ers ( ELENoR ) . METHOD Participants were 1,820 low-risk patients aged 65 to 74 years who had not previously been in a recall system for influenza immunisation at their general practice . The intervention , during October 2000 , was a telephone call from the practice receptionist to intervention group households , offering an appointment for influenza immunisation at a nurse-run . clinic Main outcome measures were the numbers of individuals in each group receiving immunisation , and practice costs of a telephone-appointing programme . RESULTS intention to treat analysis showed an immunisation rate in the control group of 44 % , compared with 50 % in the intervention group ( odds ratio = 1.29 , 95 % confidence interval = 1.03 to 1.63 ) . Of the patients making a telephone appointment  , 88 % recieved immunisation , while 22 % of those not wanting an appointment went on to be immunised . In the controlgroup , income generated was 11.35 pounds per immunisation , for each additional immunisation in the intervention group the income was 5.20 pounds . The ' number needed to telephone ' was 17 . CONCLUSION Uptake of influenza immunisation among the low-risk older population in inner-city areas can be boosted by around 6 % using a simple intervention by receptionists . Immunisation rates in this low-risk group fell well short of the 60 % government target . Improving immunisation rates will require a sustained public health campaign . Retaining the item-of-service payments to practice s should support costs of practice -based interventions 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 assess the effectiveness of a volunteer-driven outreach program on immunization rates in children younger than 2 years . DESIGN R and omized controlled trial . SETTING Pediatric ambulatory clinics in New York , NY . PATIENTS A total of 163 children were r and omly assigned to receive services from the volunteer-driven outreach program  or to serve as control subjects . All children were ( 1 ) younger than 2 years , ( 2 ) no-shows for a scheduled appointment in the pediatric clinic , and ( 3 ) due or overdue for a vaccine . INTERVENTION Immunization outreach , tracking , and follow-up were provided by community volunteers throughout follow-up ( mean , 6.5 months ) . Control children were notified of immunization status at enrollment but received no further contact until the conclusion of follow-up ( mean , 6.4 months ) . MAIN OUTCOME MEASURE Immunization status 6 months after enrollment . RESULTS Significantly more intervention children were up-to- date with their vaccination series than controls ( 75 % vs. 54 % ; P = .03 ) . Children in the control group were 2.8 times more likely to be late for a vaccine than intervention children ( odds ratio = 2.8 ; P = .02 ) . In addition , an immunization delay of longer than 30 days at enrollment was a significant predictor of final immunization delay ( odds ratio = 2.6 ; P = .02 ) . CONCLUSIONS This volunteer-driven program significantly improved immunization rates among intervention children compared with controls . Results confirm previous findings that indicate an increased risk of an incomplete immunization series by 2 years of age among children who fall behind early in their primary vaccination series . However , control children were almost 3 times more likely to be late ( for > or = 1 vaccines ) than intervention children , regardless of whether an earlier immunization delay was present PURPOSE To assess whether we could export a successful multifaceted influenza vaccination program from an academic medical center to a community setting . DESIGN Pre/post study using concurrent control groups . SETTING Clinics in a staff model Health Maintenance Organization ( HMO ) . One urban and one suburban clinic were chosen as intervention clinics , while two similar clinics were selected as control clinics . PATIENTS All patients aged 65 and over enrolled in the four clinics . INTERVENTIONS An informational mailing to patients , a st and ing-order policy allowing nurses to administer vaccine , a vaccination reminder on daily appointment lists , and availability of walk-in visits for vaccination .  Patients in the control clinics received usual care . MEASUREMENTS Vaccination rates were determined using a vali date d postcard survey of 150 r and omly selected patients at each clinic both at baseline ( 1988 - 89 ) and after the intervention ( 1989 - 90 ) . RESULTS The baseline vaccination rates ranged from 51.4 % to 74.6 % , with nearly all vaccinations taking place at the HMO . In one intervention clinic , the vaccination rate improved from 56.4 % to 72.3 % , P = 0.01 . In the other , the baseline rate was 74.6 % and did not change significantly after the intervention . There was no change in the vaccination rate in the control clinics after the intervention period . CONCLUSIONS An influenza vaccination program that combines several organizational interventions may be successfully exported from an academic to a community setting and may serve as a useful model for others 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 BACKGROUND Vaccination against influenza is associated with reductions in hospitalizations for  heart  disease , cerebrovascular disease , pneumonia , or influenza , and the risk of death from all causes during the influenza season . DESIGN R and omized controlled trial . PARTICIPANTS All members enrolled in the Blue Cross Blue Shield Association 's Government Wide Service Benefit Program in the states of Oklahoma , Rhode Isl and , Kentucky , California , Arizona , Utah , and Colorado in October 2002 . The sample size was 339,220 members . INTERVENTION Two identical influenza/pneumonia direct mail marketing pieces that encouraged members to receive influenza and pneumococcal vaccinations . The study period was October 15 , 2002 through March 15 , 2003 when most influenza cases occur . Data were collected in July 2003 and analyzed during August 2003 . MAIN OUTCOME MEASURES Administrative cl aims based on influenza/pneumonia inpatient admissions and emergency department ( ED ) visits . RESULTS The intervention group experienced a 2.62 % ( p=0.010 ) higher rate of influenza vaccinations ; 4.61 % ( p=0.080 ) higher rate of pneumonia vaccinations ; 9.67 % ( p=0.136 ) lower rate of influenza/pneumonia inpatient admissions ; and 22.64 % ( p=0.002 ) lower rate of influenza/pneumonia ED visits compared to the control group . The benefit-cost ratio ( return on investment ) from this intervention was estimated to be US dollar 2.21 per dollar spent . CONCLUSIONS Administrative cl aims data suggest that members respond to health plan mailings with an increase in influenza vaccination rates . Health plans can cost-effectively impact medical service utilization and vaccination rates by mailing information to their members Computers have been used in general practice to issue reminders to patients overdue for preventive procedures . Although effective , issuing reminders may be inconsistent with the belief that patients should take responsibility for their own health . To assess the effect of a reminder on subsequent use of influenza prevention services , this study examined the three-year immunization behavior of 1,175 patients 65 years or older who were part of a r and omized controlled trial . During the middle year only , reminders were issued to patients in the experimental group . A comparison of immunization patterns over the three years in experimental and control groups indicated that the reminder both promoted independent action and engendered dependency on the reminder . The former , favorable effect was more frequent among younger patients ; the latter , adverse effect was more common among older patients who visited the practice more frequently 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 Objectives ( 1 ) To develop methods for conducting cluster r and omised trials of text messaging interventions utilising routine electronic health records at low cost ; ( 2 ) to assess the effectiveness of text messaging influenza vaccine reminders in increasing vaccine uptake in patients with chronic conditions . Design Cluster r and omised trial with general practice s as clusters . Setting English primary care . Participants 156 general practice s , who used text messaging software , who had not previously used text message influenza vaccination reminders . Eligible patients were aged 18–64 in ‘ at-risk ’ groups . Interventions Practice s were r and omly allocated to either an intervention or st and ard care arm in the 2013 influenza season ( September to December ) . Practice s in the intervention arm were asked to send a text message influenza vaccination reminder to their at-risk patients under 65 . Practice s in the st and ard care arm were asked to continue their influenza campaign as planned . Blinding Practice s were not blinded . Analysis was performed blinded to practice allocation . Main outcome measures Practice -level influenza vaccine uptake among at-risk patients aged 18–64 years . Results 77 practice s were r and omised to the intervention group ( 76 analysed , n at-risk patients = 51 121 ) , 79 to the st and ard care group ( 79 analysed , n at-risk patients = 51 136 ) . The text message increased absolute vaccine uptake by 2.62 % ( 95 % CI −0.09 % to 5.33 % ) , p=0.058 , though this could have been due to chance . Within intervention clusters , a median 21.0 % ( IQR 10.2 % to 47.0 % ) of eligible patients were sent a text message . The number needed to treat was 7.0 ( 95 % CI −0.29 to 14.3 ) . Conclusions Patient follow-up using routine electronic health records is a low cost method of conducting cluster r and omised trials . Text messaging reminders are likely to result in modest improvements in influenza vaccine uptake , but levels of patients being texted need to markedly increase if text messaging reminders are to have much effect . Trial registration number IS RCT N48840025 To improve the  pneumococcal vaccination status of an elderly patients group , those older than 64 years of age were identified from a computer file of all continuing care patients in a general internal medicine clinic . In a r and omly chosen study group ( N = 163 ) , 91 elderly patients ( 56 per cent ) had received the pneumococcal vaccine .  Factors associated with a higher rate of pneumococcal vaccination  included receiving the previous year 's influenza vaccine , a medical problem list attached to the patient 's chart , active clinic status ( i.e. , seen in the year before the study began ) , and more than two problems listed in the computer record . Letters encouraging pneumococcal vaccination were then sent to patients who had not been vaccinated . Twenty of 72 patients ( 28 per cent ) who received the letter were vaccinated during the next year ; 8 per cent of control patients ( three of 39 ) who did not receive the letter were vaccinated . The 95 per cent confidence limit for the relative difference between the study and control group is 6 to 53 per cent . The relative difference was also significant for influenza vaccination  between the intervention group and the portion of the control group that had not been vaccinated at the first chart review . Factors associated with pneumococcal vaccination rate following the mailing of the reminder letter were active clinic status and being up to date for either influenza or tetanus vaccination . ( ABSTRACT TRUNCATED AT 250 WORDS 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 INTRODUCTION Children who have missed or delayed immunisations are at greater risk of vaccine-preventable diseases and getting their first scheduled dose on time strongly predicts subsequent complete immunisation . Developing a relationship with an infant 's parents and general practice staff soon after birth followed by a systematic approach can reduce the number of delayed first immunisations . AIM To assess the effectiveness of a general practice -based pre-call intervention to improve immunisation timeliness . METHODS Clustered controlled trial of general practice s in a large urban district r and omised to either delivery of pre-call intervention to all babies at aged four weeks or usual care . RESULTS Immunisation timeliness for infants receiving the primary series of immunisations among their nominated Auckl and general practice s was higher than expected at 98 % for the six week event . The intervention was statistically but not clinical ly significant . Coverage was significantly lower among infants with no nominated practice which reduced overall coverage rate for the district . DISCUSSION Pre-call letters with telephone follow-up are simple interventions to introduce into the practice management system and can be easily implemented as usual st and ard of care . Early identification of newborn infants , primary care engagement and effective systems including tracking of infants not enrolled in general practice s has the greatest potential to improve immunisation coverage rates even further OBJECTIVE : Determine if  adolescent immunization rates can be improved by contacting the parents or by contacting both the parents and adolescents . METHODS : Thirteen- to 17-year-olds overdue for at least 1 of 3 immunizations were r and omized to ( 1 ) a control arm ( Control ) , ( 2 ) telephone calls to the parent/guardian ( Parent Only ) , or ( 3 ) telephone calls to the parent/guardian and the adolescent ( Parent/Adol ) . Immunization records were assessed 4 weeks and 1 year after the intervention . Two-sided χ2 tests and logistic regression models were used to compare receipt of immunizations by study arm . RESULTS : The intention-to-treat analysis showed improved immunization rates at 4 weeks ( adjusted odds ratio 2.27 , 95 % confidence interval 1.00–5.18 ) , but not at 1 year , in the Parent/Adol group compared with controls . There was a trend toward increased immunization in the Parent Only group ( odds ratio 2.02 , 95 % confidence interval 0.89–4.56 ) . However , phone contact was not achieved for many parents and adolescents in the intervention groups . A post hoc analysis of the impact of actual phone contact showed significant improvement in immunization rates both 4 weeks and 1 year after the intervention among those who were reached successfully . CONCLUSIONS : Improvement in immunization rates was seen in the short term but not the long term after contacting both the parent and adolescent . Although telephone interventions may be effective when rapid immunization is necessary , the difficulty in reaching parents and adolescents by phone highlights the importance of up-to- date contact information and a need to assess the effectiveness of alternative means of communication 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 OBJECTIVE : To compare school- versus provider-based approaches to improving influenza vaccination coverage among adolescents in rural Georgia . METHODS : We used a nonr and omized , 3-armed design : ( 1 ) a  middle- and high school-based influenza vaccination intervention  in 1 county ; ( 2 ) a provider-based influenza vaccination intervention in a second county ; and ( 3 ) a st and ard-of-care condition in a third county . Interventions also included distribution of an educational brochure , school presentations , and community-based outreach to enhance vaccine knowledge and awareness among adolescents and their parents . RESULTS : During the 2008–2009 influenza season , 70 ( 19 % ) of 370 students were vaccinated in the school-based county and 110 ( 15 % ) of 736 students were vaccinated in the provider-based county , compared with 71 ( 8 % ) of 889 students in the st and ard-of-care county ( risk ratio [RR]school : 2.4 [ 95 % confidence interval ( CI ) : 1.7–3.2 ] ; RRprovider : 1.9 [ 95 % CI : 1.4–2.5 ] ) . During 2009–2010 , seasonal influenza vaccination coverage was 114 ( 30.4 % ) of 375 of students in the school-based county , 122 ( 16.9 % ) of 663 of students in the provider-based county , and 131 ( 15.2 % ) of 861 students in the st and ard-of-care county ( RRschool : 2.3 [ 95 % CI : 1.9–2.9 ] ; RRprovider : 1.2 [ 95 % CI : 0.97–1.5 ] ) . CONCLUSIONS : Special efforts to promote influenza vaccination among rural , predominantly black students were associated with increased vaccination coverage . The school-based influenza vaccination intervention was associated with the highest levels of vaccination coverage . This study revealed the efficacy of school-based influenza education to improve vaccination rates among adolescents OBJECTIVE To determine the measles vaccination rate in adolescents that could be achieved with a mailed notification of the recommendation , and to determine if the response rate differed if the mailing was addressed to the parents or to the adolescents . DESIGN R and omized trial . SETTING A family medicine residency training clinic serving a low-socioeconomic population . PATIENTS OR OTHER PARTICIPANTS Four hundred forty-nine adolescents aged 12 through 18 years who were seen in the clinic within the previous 21 months without receiving a documented second dose of measles vaccine were r and omized into two groups . INTERVENTION A letter recommending measles revaccination was sent to the parents in one group ( parent group ) and to the adolescents themselves in the second group ( adolescent group ) . The content of both letters was basically the same , but they differed in style and reading level . MAIN OUTCOME MEASURE Measles vaccinations administered to adolescents during the 2-month period following mailing of the letters . RESULTS Twenty-eight patients were excluded after r and omization . Fifty-six letters were undeliverable after two mailing attempts . Eleven ( 6.3 % ) of 176 adolescents in the parent group and five ( 2.6 % ) of 189 adolescents in the adolescent group received the measles vaccination ( P > .05 ) . CONCLUSIONS Although the adolescents whose parents received the letter were twice as likely to be vaccinated , the response rate was poor in both groups . The letter campaign was not an effective method to reach adolescents for measles revaccination OBJECTIVE To assess cost and cost-effectiveness of immunization reminder/recall systems in the private sector . METHODS A manual postcard system ( mail ) was compared with a computer-based telephone system ( autodialer ) and control .  Costs included time costs and the cost of equipment and supplies . The cost per child and the incremental cost of the intervention relative to control were computed . Cost-effectiveness ratios were computed for return visits and for immunizations delivered . RESULTS The average cost per child was $ 2.28 for the mail group and $ 1.47 for the autodialer group . The incremental visit cost relative to the control was higher for the mail group ( $ 9.52 ) than for the autodialer group ( $ 3.48 ) . The autodialer was more cost-effective in delivering immunizations : $ 4 . 06 per extra immunization ( autodialer ) versus $ 12.82 ( mail ) . CONCLUSIONS Excluding start-up costs , the autodialer system was most cost-effective . Including autodialer equipment costs , the autodialer system is more cost-effective only for larger practice OBJECTIVE To evaluate the effectiveness of computer-generated telephone reminder calls in increasing kept appointment rates in a public health setting . DESIGN R and omized controlled trial . SETTING Public health clinic , Georgia . PATIENTS Five hundred seventeen clients with scheduled appointments during a 4-week period at immunization , women , infant , and children ; well-child ; or family-planning programs . INTERVENTION A single computer-generated telephone reminder 1 day before each client 's scheduled appointment . MAIN OUTCOME MEASURE Rates of kept appointments . RESULTS Of the 277 clients assigned to receive the intervention , 144 ( 52 % ) kept their appointments , compared with only 78 ( 32.5 % ) of 240 who were not assigned to receive a message ( P < .05 ) . Improvement in kept appointment rates associated with receiving the message was highest for the immunization-program ( 183 % increase , P < .05 ) , with increases of 64 % , 53 % , and 44 % for the well-child ; women , infant , and children ; and family-planning programs , respectively . CONCLUSIONS These results suggest a simple and effective method to increase kept appointment rates in a variety of public health programs OBJECTIVE : To determine whether provision of vaccine-health-literacy-promoting information in text message vaccine reminders improves receipt and timeliness of the second dose of influenza vaccine within a season for children in need of 2 doses . METHODS : During the 2012–2013 season , families of eligible 6-month through 8-year-old children were recruited at the time of their first influenza vaccination from 3 community clinics in New York City . Children ( n = 660 ) were r and omly assigned to “ educational ” text message , “ conventional ” text message , and “ written reminder-only ” arms . At enrollment , all arms received a written reminder with next dose due date . Conventional messages included second dose due date and clinic walk-in hours . Educational messages added information regarding the need for a timely second dose . Receipt of second dose by April 30 was assessed by using χ2 tests . Timeliness was assessed by receipt of second dose by 2 weeks after due date ( day 42 ) using χ2 and over time using a Kaplan-Meier analysis . RESULTS : Most families were Latino and publicly insured with no significant between-arm differences between groups . Children in the educational arm were more likely to receive a second dose by April 30 ( 72.7 % ) versus conventional ( 66.7 % ) versus written reminder-only arm ( 57.1 % ; P = .003 ) . They also had more timely receipt by day 42 ( P < .001 ) and over time ( P < .001 ) . CONCLUSIONS : In this low-income , urban , minority population , embedding health literacy information improved the effectiveness of text message reminders in promoting timely delivery of a second dose of influenza vaccine , compared with conventional text messages and written reminder only Objectives . In a population of seniors served by urban primary care centers , we evaluated the effect of the practice -based intervention on influenza immunization rates and disparities in vaccination rates by race/ethnicity and insurance status . Methods . A r and omized controlled trial during 2003–2004 tested patient tracking/recall/outreach and provider prompts on improving influenza immunization rates . Patients aged ≥65 years in six large inner-city primary care practice s were r and omly allocated to study or control group . Influenza immunization coverage was measured prior to enrollment and on the end date . Results . At study end , immunization rates were greater for the intervention group than for the control group ( 64 % vs. 22 % , p<0.0001 ) . When controlling for other factors , the intervention group was more than six times as likely to receive influenza vaccine . The intervention was effective across gender , race/ethnicity , age , and insurance subgroups . Among the intervention group , 3.5 % of African Americans and 3.2 % of white people refused influenza immunization . Conclusions . Patient tracking/recall/outreach and provider prompts were intensive but successful approaches to increasing seasonal influenza immunization rates among this group of inner-city seniors OBJECTIVE To determine whether smokers at clinics providing care for the medically underserved can be characterized according to the transtheoretical stages of change model . STUDY DESIGN Prospect i ve , descriptive study . POPULATION Smokers in the waiting rooms of clinics providing care for the medically underserved . OUTCOMES MEASURED St and ardized question naires that assessed stages of change , processes of change , decisional balance , and self-efficacy and temptation . RESULTS The smoking rate of subjects interviewed at 4 clinics was 44 % . Two hundred current smokers completed the question naires . Smokers cl aim ing that they planned to quit within 6 months scored higher on experiential process statements that are consistent with quitting smoking than did smokers who cl aim ed they were not planning to quit within 6 months . They also scored higher on behavioral statements related to quitting . Concerns about the negative aspects of smoking were more important to smokers planning to quit than to smokers not planning to quit , whereas the statements assessing positive aspects of smoking were rated the same . Fifty-five percent of the smokers were smoking a pack or more each day and reported smoking more during negative situations and from habit than did smokers who smoked less than a pack a day . CONCLUSIONS Smokers planning to quit who still smoke at least a pack a day may benefit from counseling to decrease smoking for specific reasons or from pharmacologic aids . Smokers at the clinics who planned to quit smoking reported experiences and behaviors that were consistent with their stated desire to quit and should be counseled in the same fashion as smokers from more traditional practice In a r and omized controlled trial , an intensive promotional campaign failed to increase the uptake of vaccination against influenza among health care workers . The uptake of vaccination was low BACKGROUND AND OBJECTIVE : Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers ( SBHCs ) . We assessed ( 1 ) immunization rates achieved with recall  among sixth- grade girls ( demonstration study ) ; ( 2 ) effectiveness of recall among sixth- grade boys ( r and omized controlled trial [ RCT ] ) ; and ( 3 ) cost of conducting recall in SBHCs . METHODS : During October 2008 through March 2009 , in 4 Denver public SBHCs , we conducted ( 1 ) a demonstration study among 265 girls needing ≥1 recommended adolescent vaccine and ( 2 ) an RCT among 264 boys needing vaccines , with half r and omized to recall and half receiving usual care . Immunization rates for recommended adolescent vaccines were assessed 6 months after recall . First dose costs were assessed by direct observation and examining invoices . RESULTS : At the end of the demonstration study , 77 % of girls had received ≥1 vaccine and 45 % had received all needed adolescent vaccines . Rates of receipt among those needing each of the vaccines were 68 % ( 160/236 ) for tetanus toxoid , reduced diphtheria toxoid and acellular pertussis vaccine , 57 % ( 142/248 ) for quadrivalent meningococcal conjugate vaccine , and 59 % ( 149/253 ) for the first human papillomavirus vaccine . At the end of the RCT , 66 % of recalled boys had received ≥1 vaccine and 59 % had received all study vaccines , compared with 45 % and 36 % , respectively , of the control group ( P < .001 ) . Cost of conducting recall ranged from $ 1.12 to $ 6.87 per recalled child immunized . CONCLUSIONS : SBHC-based recall was effective in improving immunization rates for all adolescent vaccines , with effects sizes exceeding those achieved with younger children in practice setting 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 The aim of this study was to assess the effectiveness of an EPI smartphone application ( EPI app ) on improving  vaccination coverage in rural Sichuan Province , China . Methods This matched-pair cluster r and omized controlled study included 32 village doctors , matched in 16 pairs , and took place from 2013 to 2015 . Village doctors in the intervention group used the EPI app and reminder text messages while village doctors in the control group used their usual procedures and text messages . The primary outcome was full vaccination coverage with all five vaccines ( 1 dose of BCG , 3 doses of hepatitis B , 3 doses of OPV , 3 doses of DPT and 1 dose of measles vaccine ) , and the secondary outcome was coverage with each dose of the five individual vaccines . We also conducted qualitative interviews with village doctors to underst and perceptions on using the EPI app and how this changed their vaccination work . Results The full vaccination coverage increased statistically significant from baseline to end-line in both the intervention ( 67 % [ 95 % CI:58 - 75 % ] to 84 % [ 95 % CI:76 - 90 % ] , P = 0.028 ) and control group ( 71 % [ 95 % CI:62 - 79 % ] to 82 % [ 95 % CI:74 - 88 % ] , P = 0.014 ) . The intervention group had higher increase in full vaccination coverage from baseline to end-line compared to the control group ( 17 % vs 10 % ) , but this was not statistically significant ( P = 0.164 ) . Village doctors found it more convenient to use the EPI app to manage child vaccination and also reported saving time by looking up information of caregivers and contacting caregivers for overdue vaccinations quicker . However , village doctors found it hard to manage children who migrated out of the counties . Conclusions This study showed that an app and text messages can be used by village doctors to improve full vaccination coverage , though no significant increase in vaccination coverage was found when assessing the effect of the app on its own . Village doctors using EPI app reported having improved their working efficiency of managing childhood vaccination . Future studies should be conducted to evaluate the impact of more integrated approach of mHealth intervention on child immunization . Trial registration Chinese Clinical Trials Registry ( ChiCTR ) : ChiCTR-TRC-13003960 , registered on December 6 , 2013 Objectives . The objectives of this study were to : ( 1 ) identify modifiable factors influencing receipt of influenza vaccination among children with asthma , and ( 2 ) to evaluate the effect of heightened media attention on vaccination rates . Methods . During November and December 2003 , we interviewed parents of children with asthma about their experiences with and beliefs about influenza vaccination . We r and omly selected 500 children from a study population of 2,140 children identified with asthma in a managed care organization in Massachusetts . We obtained data on influenza vaccination status from computerized medical records and determined significant factors influencing receipt of influenza vaccination . Results . Children were more likely to be vaccinated if their parent recalled a physician recommendation ( odds ratio [ OR ] 2.6 ; 95 % confidence interval [ CI ] 1.5 , 4.5 ) , believed the vaccine worked well ( OR 2.0 ; 95 % CI 1.4 , 2.8 ) , or expressed little worry about vaccine adverse effects ( OR 1.3 ; 95 % CI 1.0 , 1.6 ) , or if the child was younger ( OR 1.1 per year of age ; 95 % CI 1.0 , 1.2 ) . During the study period , there was heightened media attention about influenza illness and the vaccine . The  influenza vaccination rate for children with asthma was 43 % in 2003–04 compared with 27 % in 2002–03 . Comparison of weekly influenza vaccination rates in 2003–04 and 2002–03 suggested that the media attention was associated with the increase in vaccination rates . Conclusions . Physician recommendations and parental education about  influenza vaccine availability , effectiveness , and adverse effects are potentially important influences on influenza vaccination . Our findings suggest that media coverage of the risks of influenza was associated with a significant increase in vaccination rates Background This study aim ed to evaluate the effect of a lay health worker ( LHW ) telephone intervention on completing a series of hepatitis B virus ( HBV ) vaccinations among foreign-born Asian Americans in the Baltimore-Washington Metropolitan area . Methods During the period of April 2013 and March 2014 , we recruited Asian Americans who were 18 years of age and older in the community-based organizations . Of the 645 eligible participants , 600 ( 201 Chinese , 198 Korean , 201 Vietnamese ) completed a pretest survey and received hepatitis B screening . Based on the screening results , we conducted a r and omized controlled trial among those unprotected ( HBsAg-/HBsAB- ) by assigning them either to an intervention group ( n = 124 ) or control group ( n = 108 ) . The intervention group received a list of re sources by mails for where to get free vaccinations as well as reminder calls for vaccinations from trained LHWs , while the control group received only list of re sources by mail . Seven months after mailing the HBV screening results , trained LHWs followed up with all participants by phone to ask how many of the recommended series of 3 vaccinations they had received : none , 1 or 2 , or all 3 ( complete ) . Their self-reported vaccinations were verified with the medical records . Multinomial logistic regressions were used to examine the effect of the LHW intervention . Process evaluation was conducted by asking study participants in the intervention group to evaluate the performance of the LHWs . Results After seven months , those in the intervention group were more likely to have 1 or more vaccines than the control group , compared to the no vaccination group ( OR = 3.04 , 95 % CI , 1.16 , 8.00 ) . Also , those in the intervention group were more likely to complete a series of vaccinations than the control group , compared to the no vaccination group ( OR = 7.29 , 95 % CI 3.39 , 15.67 ) . The most important barrier preventing them from seeking hepatitis B vaccinations was lack of time to get the vaccination . The most important promoters to getting vaccinations , among those who had vaccinations ( n = 89 ) , were our intervention program ( 70.8 % ) and self-motivation ( 49.4 % ) . The majority of participants in the intervention group received the phone calls from LHWs ( 93 % ) and almost all of them got the reminder to receive vaccines ( 98 % ) . Conclusion The LHW intervention was successful at increasing HBV vaccinations rates among foreign-born Asian Americans . This study suggests that this culturally integrated intervention program may be useful for reducing liver cancer disparities from chronic HBV infection in high risk Asian Americans . Trial Registration Clinical Trials.gov 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 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 BACKGROUND Although influenza is the leading infections cause of death in the United States , only 40 % of health care workers ( HCW ) comply with Centers for Disease Control and Prevention recommendation for routine influenza vaccination . METHODS This study investigated a novel approach for improving influenza vaccination rates among HCW . Eight hundred employees we selected , 200 each from the following 4 categories : professional staff , resident physicians , registered nurses , and licensed practical nurses . Subjects were r and omly assigned to receive ( 1 ) no intervention , ( 2 ) a letter explaining the importance of influenza vaccine for HCW , ( 3 ) a ticket activated with influenza vaccine administration for a raffle of a free Caribbean vacation for 2 , or ( 4 ) both the educational letter and the raffle ticket . We compared the proportion of employees receiving vaccination and participating in the raffle across groups . RESULTS The influenza vaccination rate for all study subjects was 41 % . The number of subjects receiving vaccine did not differ by occupation ( P = .87 ) or intervention group ( P = .66 ) . CONCLUSIONS This study provides no evidence to support the use of mailed educational letters or a single large raffle prize incentive as a means to boost hospital employee influenza vaccination rates OBJECTIVES Despite long-st and ing recommendations to provide annual influenza vaccination to children with chronic medical conditions , immunization rates are < 10 % in most primary care setting s. Many obstacles impede implementation of these recommendations , including the challenge of identifying targeted children and the need to immunize yearly in a short time interval . The objective of this study was to assess the accuracy of billing data for identifying children who have high-risk conditions ( HRCs ) and need influenza vaccination and 2 ) to evaluate the efficacy of reminder/recall for children with HRCs . METHODS The study was conducted in 4 private pediatric practice s in metropolitan Denver , Colorado , that share a computerized billing system and also participate in an immunization registry . For all children aged 6 to 72 months , registry records were linked with the billing data base . Patients with > or=1 encounters for an HRC in the previous 24 months were selected , with HRCs identified from International Classification of Diseases , Ninth Revision , Clinical Modification diagnostic codes . Using medical records as the " gold st and ard , " we review ed 327 r and omly selected records to determine the sensitivity , specificity , and accuracy of billing data for identifying HRCs . For children with an HRC , we then conducted a r and omized , controlled trial of reminder/recall for influenza vaccination . The primary outcome of the recall trial was receipt of influenza vaccine .  RESULTS Billing data had a sensitivity of 72 % ( 95 % confidence interval [ CI ] : 48%-95 % ) , specificity of 95 % ( 95 % CI : 90%-100 % ) , and overall accuracy of 90 % ( 95 % CI : 84%-96 % ) in determining which children had an HRC . Of the 17,273 patients aged 6 to 72 months , 2007 had > or=1 HRCs ( 12 % overall ; range : 9%-14 % per practice ) . Asthma/reactive airways disease accounted for 87 % of all HRCs . Reminder/recall significantly increased influenza immunization in children with HRCs , with a vaccination rate of 42 % in those recalled , compared with 25 % in control subjects . Recalled subjects were more likely to have an office visit ( 68 % vs 60 % ) and less likely to have a missed opportunity to immunize ( 28 % vs 37 % ) compared with control subjects . CONCLUSIONS Diagnosis-based billing data accurately identified children who had HRCs and needed annual influenza vaccination , and registry-driven reminder/recall significantly increased influenza immunization in targeted children PURPOSE We evaluated a managed care organization (MCO)-generated text message reminder-recall system design ed to improve human papillomavirus ( HPV ) vaccination coverage . METHODS We conducted a r and omized controlled trial of text reminder-recall for parents of 3,812 publicly insured adolescents aged 11 - 16 years with no prior HPV vaccinations who were enrolled in a single MCO and were patients at one of 39 primary care practice s. We determined the rate of HPV receipt for intervention versus control with the Kaplan-Meier failure function and determined hazard ratios using a clustered stratified Cox model , clustering on primary care provider and stratified on practice . We examined results for all subjects , and for those with a valid phone number , stratified by age group ( 11 - 13 years and 14 - 16 years ) and gender . A post hoc analysis included all subjects and controlled for age and gender . RESULTS HPV dose 1 vaccination rates were not significantly different when all participants were included , but for the subset of parents ( 54 % ) able to receive messages , HPV dose 1 rates were 13 % for the control group and 16 % for the intervention group ; hazard ratio , 1.3 ( 95 % confidence interval , 1.0 - 1.6 ; p = .04 ) , when controlling for age and gender . There were no significant findings in the analysis stratified by age and gender . CONCLUSIONS MCO-based text reminders are feasible and have a modest effect on HPV dose 1 vaccination rates for those parents able to receive text messages with valid phone numbers in the MCO data base . Future studies should examine a similar intervention for those parents who already accepted the first HPV vaccine dose Immunization coverage of vulnerable children is often sub-optimal in many low- and middle-income countries . The use of a reminder/recall ( R/R ) system has been one of the strategies shown to be effective in improving immunization rates . In the resent study , we evaluated the effect of R/R and Primary Health Care Immunization Providers ’ Training ( PHCIPT ) intervention on routine immunization completion among 595 infants in Ibadan , Nigeria . The design was a group r and omized controlled trial with Local Government Area ( LGA ) being the unit of r and omization . Four r and omly selected LGAs were r and omized to receive a cellphone R/R only ( A ) , a PHCIPT only ( B ) ; combined R/R and PHCIPT ( C ) intervention or serve as a control group ( D ) . Children aged 0–12 weeks were consecutively recruited into each group and followed up for 12 months . The primary outcome measure was routine immunization completion at 12 months of age . At the study endpoint , immunization completion rates were : group A , 98.6 % ; group B , 70 % ; group C , 97.3 % ; and group D , 57.3 % . Compared to the control group , the cellphone R/R group was 72 % ( RR 1.72 , 95 % CI 1.50–1.98 ) and the combined RR/PHCIPT group 70 % ( RR 1.70 , 95 % CI 1.47–1.95 ) more likely to complete immunization . In contrast , immunization completion in the PHCIPT group was marginally different from the control group ( RR 1.22 , 95 % CI 1.03–1.45 ) . These findings remained robust to adjustment for potential predictors of immunization completion as covariates . In conclusion , cellphone reminder/recall was effective in improving immunization completion in this Nigerian setting . Its use is recommended for large scale implementation OBJECTIVE To assess the effect of three computerized reminder systems on compliance with tetanus vaccination . DESIGN Prospect i ve r and omized controlled trial . SETTING Ottawa Civic Hospital Family Medicine Centre . PARTICIPANTS Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were r and omly assigned , by family , to a control group , a physician reminder group , a telephone reminder group or a letter reminder group .  The remaining 2480 patients were not included in the r and omized portion of the study but were monitored . Results are presented for the 5242 r and omized patients and the 2369 nonr and omized patients for whom there was no up-to- date record of tetanus vaccination at the start of the trial . INTERVENTIONS For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient 's tetanus vaccination status and to recommend vaccination ; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose . MAIN OUTCOME MEASURE Proportion of patients who received tetanus toxoid during the study year or who had a cl aim of vaccination in the previous 10 years . MAIN RESULTS The rate of recorded tetanus vaccination in the r and omized control group was 3.2 % . The difference between that rate and those for the three reminder groups was 19.6 % in the physician reminder group ( 95 % confidence interval [ CI ] 17.1 % to 22.2 % , p less than 0.00001 ) , 20.8 % in the telephone reminder group ( 95 % CI 18.3 % to 23.5 % , p less than 0.00001 ) and 27.4 % in the letter reminder group ( 95 % CI 24.8 % to 30.2 % , p less than 0.00001 ) ) . The letter reminders were more effective than either the telephone reminders ( p = 0.00013 ) or the physician reminders ( p less than 0.00001 ) in improving compliance . The cost to the practice per additional vaccination recorded was 43 for the physician reminders , $ 5.43 for the telephone reminders and $ 6.05 for the letter reminders . CONCLUSIONS Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage . More intensive interventions would be required to approach that goal . However , such interventions do not appear to be justified given the rarity of tetanus OBJECTIVE To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents . METHODS We conducted a r and omized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11 - 17 years to one of three groups : mailed letter , telephone reminders , or control .  Publicly insured youths ( n = 4115 ) were identified in 37 participating primary care practice s. The main outcome measures were immunization rates for routine vaccines ( meningococcus , pertussis , HPV ) and preventive visit rates at study end . RESULTS Intervention and control groups were similar at baseline for demographics , immunization rates , and preventive visits . Among adolescents who were behind at the start , immunization rates at study end increased by 21 % for mailed ( P < .01 vs control ) , 17 % for telephone ( P < .05 ) , and 13 % for control groups . The proportion of adolescents with a preventive visit ( within 12 months ) was : mailed ( 65 % ; P < .01 ) , telephone ( 63 % ; P < .05 ) , and controls ( 59 % ) . The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders ; for an additional preventive visit , it was 17 and 29 . The intervention cost $ 18.78 ( mailed ) or $ 16.68 ( phone ) per adolescent per year to deliver . The cost per additional adolescent fully vaccinated was $ 463.99 for mailed and $ 714.98 for telephone ; the cost per additional adolescent receiving a preventive visit was $ 324.75 and $ 487.03 . CONCLUSIONS Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits , with modest costs and modest impact OBJECTIVES To evaluate whether automated reminders increase on-time completion of the three-dose human papillomavirus ( HPV ) vaccine series . METHODS Ten reproductive health centers enrolled 365 women aged 19 - 26 to receive dose one of the HPV vaccine . Health centers were matched and r and omized so that participants received either routine follow-up ( control ) or automated reminder messages for vaccine doses two and three ( intervention ) . Intervention participants selected their preferred method of reminders - text , e-mail , phone , private Facebook message , or st and ard mail . We compared vaccine completion rates between groups over a period of 32 weeks . RESULTS The reminder system did not increase completion rates , which overall were low at 17.2 % in the intervention group and 18.9 % in the control group ( p=0.881 ) . Exploratory analyses revealed that participants who completed the series on-time were more likely to be older ( OR=1.15 , 95 % CI 1.01 - 1.31 ) , report having completed a four-year college degree or more ( age-adjusted OR=2.51 , 95 % CI 1.29 - 4.90 ) , and report three or more lifetime sexual partners ( age-adjusted OR=3.45 , 95 % CI 1.20 - 9.92 ) . CONCLUSIONS The study intervention did not increase HPV vaccine series completion . Despite great public health interest in HPV vaccine completion and reminder technologies , completion rates remain low Objective : To measure the impact of a population -based tracking system on influenza immunization rates . Design : Thirteen practice s with 45 physicians were r and omized to a control and two intervention groups . Setting : Private practice s. Patients : All patients aged 65 years and over who were seen in participating physicians ’ practice s within the preceding two years . Intervention : In both intervention groups influenza immunization rates for physicians were recorded weekly as cumulative percentages of their target population s , using a specially prepared poster . In addition , postcard reminders were sent to all the patients in one of the intervention groups . Measurements and main results : Immunization rates in the two intervention groups were 30 % higher than in the control group ; the control group immunized 50 % ( 2,405/4,772 ) of its target population , while the poster and poster/postcard groups immunized 66 % ( 1,420/2,149 ) and 67 % ( 2,427/3,604 ) , respectively . Conclusion : A population -based strategy that monitors performance can significantly improve rates of influenza immunization in private practice 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 Fewer than 10 % of children with moderate or severe asthma receive an annual influenza vaccination despite their heightened susceptibility to severe infections and recommendations by the American Academy of Pediatrics and the Immunization Practice s Advisory Committee that all such children be vaccinated annually . Patient , provider , and system factors leading to this poor vaccination rate are not well understood . This study tested the effectiveness of a computerized reminder system in improving  influenza vaccination rates in children with asthma and examined patient barriers to vaccination at one pediatric clinic in an urban teaching hospital . A computer data base identified 124 children with moderate or severe asthma . Patients were r and omly assigned either to study group ( n = 63 ) , who were sent a personalized letter reminder about the need for an influenza vaccination , or to a control group ( n = 61 ) , who received no reminder . Study group mothers were interviewed 2 months after the letter was sent to assess factors associated with receipt of vaccination , including demographic features , parental worry about asthma and vaccine side effects , the four dimensions of the Health Belief Model , and health locus of control beliefs .  Nineteen study group patients ( 30 % ) received an  influenza vaccination  , compared with only 4 control patients ( 7 % ) ( P < .01 ) . Forty-three mothers of children in the study group were interviewed ; 14 ( 33 % ) of these children had received the vaccination . Of the characteristics investigated , two significantly correlated with vaccination compliance : high levels of parental worry about asthma ( positively correlated : odds ratio = 23.3 , P < .01 ) and high levels of parental worry about vaccine side effects ( negatively correlated : odds ratio = 0.087 , P = .025 ) . ( ABSTRACT TRUNCATED AT 250 WORDS CONTEXT Influenza infection results in substantial costs , morbidity , and mortality . Vaccination against influenza is particularly important in children and adolescents who are a significant source of transmission to other high-risk population s , yet pediatric and adolescent vaccine coverage remains low . Traditional vaccine reminders have had a limited effect on low-income population s ; however , text messaging is a novel , scalable approach to promote influenza vaccination . OBJECTIVE To evaluate targeted text message reminders for low-income , urban parents to promote receipt of influenza vaccination among children and adolescents . DESIGN , SETTING , AND PARTICIPANTS R and omized controlled trial of 9213 children and adolescents aged 6 months to 18 years receiving care at 4 community-based clinics in the United States during the 2010 - 2011 influenza season . Of the 9213 children and adolescents , 7574 had not received influenza vaccine prior to the intervention start date and were included in the primary analysis . INTERVENTION  Parents of children assigned to the intervention received up to 5 weekly immunization registry-linked text messages providing educational information and instructions regarding Saturday clinics . Both the intervention and usual care groups received the usual care , an automated telephone reminder , and access to informational flyers posted at the study sites . MAIN OUTCOME MEASURES Receipt of an influenza vaccine dose recorded in the immunization registry via an electronic health record by March 31 , 2011 . Receipt was secondarily assessed at an earlier fall review date prior to typical widespread influenza activity . RESULTS Study children and adolescents were primarily minority , 88 % were publicly insured , and 58 % were from Spanish-speaking families . As of March 31 , 2011 , a higher proportion of children and adolescents in the intervention group ( 43.6 % ; n = 1653 ) compared with the usual care group ( 39.9 % ; n = 1509 ) had received influenza vaccine ( difference , 3.7 % [ 95 % CI , 1.5%-5.9 % ] ; relative rate ratio [ RRR ] , 1.09 [ 95 % CI , 1.04 - 1.15 ] ; P = .001 ) . At the fall review date , 27.1 % ( n = 1026 ) of the intervention group compared with 22.8 % ( n = 864 ) of the usual care group had received influenza vaccine ( difference , 4.3 % [ 95 % CI , 2.3%-6.3 % ] ; RRR , 1.19 [ 95 % CI , 1.10 - 1.28 ] ; P < .001 ) . CONCLUSIONS Among children and adolescents in a low-income , urban population , a text messaging intervention compared with usual care was associated with an increased rate of influenza vaccination . However , the overall influenza vaccination rate remained low . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01146912 OBJECTIVES We compared the effectiveness and cost-effectiveness of population -based recall ( Pop-recall ) versus practice -based recall ( PCP-recall ) at increasing immunizations among preschool children . METHODS This cluster-r and omized trial involved children aged 19 to 35 months needing immunizations in 8 rural and 6 urban Colorado counties . In Pop-recall counties , recall was conducted central ly using the Colorado Immunization Information System ( CIIS ) . In PCP-recall counties , practice s were invited to attend webinar training using CIIS and offered financial support for mailings . The percentage of up-to- date ( UTD ) and vaccine documentation were compared 6 months after recall . A mixed-effects model assessed the association between intervention and whether a child became UTD . RESULTS Ten of 195 practice s ( 5 % ) implemented recall in PCP-recall counties . Among children needing immunizations , 18.7 % became UTD in Pop-recall versus 12.8 % in PCP-recall counties ( P < .001 ) ; 31.8 % had documented receipt of 1 or more vaccines in Pop-recall versus 22.6 % in PCP-recall counties ( P < .001 ) . Relative risk estimates from multivariable modeling were 1.23 ( 95 % confidence interval [ CI ] = 1.10 , 1.37 ) for becoming UTD and 1.26 ( 95 % CI = 1.15 , 1.38 ) for receipt of any vaccine . Costs for Pop-recall versus PCP-recall were $ 215 versus $ 1981 per practice and $ 17 versus $ 62 per child brought UTD . CONCLUSIONS Population -based recall conducted central ly was more effective and cost-effective at increasing immunization rates in preschool children RATIONALE Noncompliance with vaccination schedules undermines the potential benefits of immunization . The purpose of this study was to evaluate whether a reminder of the next vaccine dose sent by the Short Messaging Service ( SMS ) to the vaccinee 's mobile phone increases compliance with hepatitis A + B and hepatitis A vaccination schedule . SUBJECTS AND METHODS In this experimental , controlled study , the study group comprised travelers who went to the Internacional-Clínic Vaccination Centre between the 1st June and 30th September of 2001 for the st and ard immunization schedule against hepatitis A + B and against hepatitis A. Trained health-care workers entered the data into a computer to generate text messages reminding vaccinees of their scheduled doses . Two control groups , one from the same period of the same year including travelers from the third office ( Control 2001 ) and the second , all travelers seen in the same period of the previous year ( Control 2000 ) , were used . RESULTS For the second hepatitis A + B dose , compliance in the study group ( Message Groups ) was 88.4 % ( 83.3 - 92.2 ) ; in the Control 2001 , 80.7 % ( 76.3 - 84.4 , relative risk [ RR ] 1.10 [ 1.02 - 1.17 ] ) ; and in the Control 2000 , 77.2 % ( 73.3 - 80.5 , RR 1.15 [ 1.07 - 1.22 ] ) . For the third hepatitis A + B vaccine dose , results were 47.1 % ( 40.5 - 53.8 ) ; 26.9 % ( 22.8 - 31.7 , RR 1.75 [ 1.41 - 2.17 ] ) ; and 23.6 % ( 20.1 - 27.4 , RR 2.00 [ 1.63 - 2.45 ] ) , respectively . As for the hepatitis A vaccine , compliance rates for the second dose were 27.7 % ( 23.9 - 31.9 ) ; 16.4 % ( 14.4 - 18.6 , RR 1.69 [ 1.40 - 2.04 ] ) ; and 13.2 % ( 11.6 - 14.9 , RR 2.10 [ 1.75 - 2.54 ] ) ; respectively . CONCLUSIONS SMS seems to be an effective tool for increasing compliance with vaccination schedules 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 OBJECTIVES To increase adult immunizations at inner-city health centers serving primarily minority patients . DESIGN A before-after trial with a concurrent control . SETTING Five inner-city health centers . PARTICIPANTS All adult patients at the health centers eligible for influenza and pneumococcal vaccines . INTERVENTION Four intervention sites chose from a menu of culturally appropriate interventions based on the unique features of their respective health centers . MEASUREMENTS Immunization and demographic data from medical records of a r and om sample of 568 patients aged 50 and older who had been patients at their health centers since 2000 . RESULTS The preintervention influenza vaccination rate of 27.1 % increased to 48.9 % ( P<.001 ) in intervention sites in Year 4 , whereas the concurrent control rate remained low ( 19.7 % ) . The pneumococcal polysaccharide vaccine ( PPV ) rate in subjects aged 65 and older increased from 48.3 % to 81.3 % ( P<.001 ) in intervention sites in Year 4 . Increase in PPV in the concurrent control was not significant . In logistic regression analysis , the likelihood of influenza vaccination was significantly associated with the intervention ( odds ratio (OR)=2.07 , 95 % confidence interval (CI)=1.77 - 2.41 ) and with age of 65 and older ( OR=2.0 , 95 % CI=1.62 - 2.48 ) but not with race . Likelihood of receiving the pneumococcal vaccination was also associated with older age and , to a lesser degree , with intervention . CONCLUSION Culturally appropriate , evidence -based interventions selected by intervention sites result ed in increased adult vaccinations in disadvantaged , racially diverse , inner-city population s over 2 to 4 years During the 1984 - 1985 influenza season two study groups were used to compare telephone and letter reminder methods with a control group that received no reminder to determine which was the most effective strategy to increase influenza vaccination rates among the high-risk patient population of a university-based family practice . Seven hundred eighty-seven high-risk patients were r and omly assigned to one of the three study groups : a mailed-reminder group , a telephone-reminder group , and a control group .  Vaccination rates for both reminder methods were significantly higher than for the control group ( P less than .02 ) , and if successfully contacted , the telephone-reminder group had a significantly better vaccination rate than the mailed-reminder group ( P less than .05 ) . If successful telephone contact can be made , this reminder method is more effective than a letter reminder to increase influenza vaccination rates among high-risk patients In order to verify whether a telephone recall system directly managed by pediatricians who usually follow up children for their asthma is more effective than an anonymous recall system , we r and omly assigned 285 asthmatic children ( 177 males ; mean age 10.3+/-3.4 years ) to one of three groups : those whose mothers were to be called by a pediatrician not previously involved in caring for their asthmatic children and who received the vaccine in our immunisation clinic ( group 1 ) ; those whose mothers were to be called by a pediatrician from our asthma clinic and who received the vaccine in the immunisation clinic ( group 2 ) ; and those whose mothers were to be called by a pediatrician from our asthma clinic and who received the vaccine in the same clinic ( group 3 ) . Our findings highlight that the use of a reminder/recall system  increases vaccination rates in asthmatic children , and show that the best results are obtained when the mothers are contacted and the vaccine administered by the pediatricians who usually follow up the child for asthma OBJECTIVE To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice . DESIGN Prospect i ve , r and omized , controlled study . SETTING Ottawa Civic Hospital Family Medicine Centre . PARTICIPANTS Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were r and omly assigned , by family , to a control group , a physician reminder group ( passive ) or a telephone or letter reminder group ( active ) . The remaining 2619 patients were not included in the r and omized portion of the study but were monitored . INTERVENTION During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures ; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service . OUTCOME MEASURE Rates of completion of the preventive procedures required . MAIN RESULTS All three reminder systems significantly improved the delivery of preventive services ( p less than 0.001 ) . The procedure completion rates were 42.0 % in the letter reminder group , 42.0 % in the telephone reminder group , 33.7 % in the physician reminder group and 14.1 % in the r and omized control group . The use of a letter was more cost-effective than the telephone system , but the physician reminder system was the most cost-effective . CONCLUSION Computerized reminder systems do improve the delivery of preventive services in family practice 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 AIMS This study aims to assess the effects of two interventions on influenza vaccination coverage : a simple organisational strategy , and making the vaccine available free . METHODS Sixteen general practitioners in the Auckl and region were r and omly selected to participate . Patients over 65 years of these general practitioners were r and omly allocated to control , letter of invitation for a flu vaccine , or offer of a free flu vaccine . Administration of a flu vaccine for each person in the study was documented in each general practitioner surgery . Vaccine coverage for each of the three groups was measured . RESULTS Results were available for 15 of the 16 participating general practitioners , a total of 2791 subjects .  Immunisation coverage rates for control , letter of invitation and vaccine at no cost , were 17 % , 27 % and 45 % respectively . Statistical analysis , allowing for the cluster method used to obtain subjects , showed risk ratios of 1.55 and 2.65 for the two interventions , with p values of < 0.00001 . CONCLUSIONS A potential source of bias in this study is underreporting of administration of vaccine to people in group 1 . Notwithst and ing this potential bias , both interventions were highly effective at increasing the uptake of influenza vaccine in the elderly population . General practitioners should be recommended to routinely invite patients over 65 years to have a flu vaccine . Given the commitment of the Ministry of Health to the vaccination against influenza of people over 65 , this study would suggest that serious consideration should be given to making the vaccine available at no cost to this age group Abstract OBJECTIVE : To compare the effects of different types of computer-generated , mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders . DESIGN : R and omized controlled trial . SETTING : Multispeciality group practice . PATIENTS : We studied 24,743 high-risk adult patients aligned with a primary care physician . INTERVENTION : Patients were r and omized to one of four interventions : ( 1 ) no reminder , which served as control ; ( 2 ) a generic postcard ; ( 3 ) a personalized postcard from their physician ; and ( 4 ) a personalized letter from their physician , tailored to their health risk . MEASUREMENTS : The immunization rate was measured using billing data . A telephone survey was conducted in a subgroup of patients to measure reactions to the mailed reminders . To evaluate the cost-effectiveness , a model was constructed that integrated the observed effect of the interventions with published data on the effect of immunization on future inpatient health care costs . MAIN RESULTS : All three of the reminders studied increased the influenza vaccination rate when compared with the control group . The vaccination rate was 40.6 % in the control group , 43.5 % in the generic postcard group , 44.7 % in the personalized postcard group , and 45.2 % in the tailored letter group . The rates of immunization increased as the intensity of the intervention increased ( p < .0001 ) . Seventy-eight percent of patients in the letter group deemed the intervention useful , and 86 % reported that they would like to get reminders in the future . The cost-effectiveness analysis estimated that in a nonepidemic year , the net savings per 100 reminders sent would be $ 659 for the personalized postcard intervention and $ 735 for the tailored letter intervention . When these net cost-savings rates were each applied to the entire high-risk cohort of 24,743 patients , the estimated total net savings was $ 162,940 for the postcard and $ 181,858 for the tailored letter . CONCLUSIONS : Although the absolute increase in immunization rates with the use of reminders appeared small , the increases translated into substantial cost savings when applied to a large high-risk population . Personalized reminders were somewhat more effective in increasing immunization , and personalized letters tailored to the patients ’ condition were deemed useful and important by the individuals who received them and had a beneficial indirect effect on patient satisfaction BACKGROUND Immunizations decrease morbidity from influenza and pneumococcal infections . Immunization levels remain below desired levels despite clinic-based and public education efforts . This paper describes a r and omized , controlled trial of a senior center-based program , which used peer-to-peer outreach to increase pneumococcal and influenza immunization rates among an urban senior population . METHODS Seniors were r and omized to intervention or control groups . The intervention group received educational brochures mailed with reply cards to report immunization status , telephone calls from senior volunteers to unimmunized participants , and computerized immunization tracking .  Immunization rates were obtained before and after the intervention by self-report . RESULTS Among participants without prior pneumococcal immunization , the pneumococcal immunization rate among the intervention group ( 52.0 % ; 95 % CI = 46.6%-57.4 % ) was significantly higher than that of the control group ( 30.9 % ; 95 % CI = 26.6%-35.2 % ) ( rate ratio = 1.68 ; 95 % CI = 1.40 - 2.03 ) . Among those without influenza immunization in the prior year , significantly more ( 50.0 % ; 95 % CI = 40.0%-60.0 % ) were immunized against influenza in the intervention group than in the control group ( 23.0 % ; 95 % CI = 15.2%-33.3 % ) ( rate ratio = 2.17 ; 95 % CI = 1.42 - 3.31 ) . Among those with influenza immunization in the prior year , the rate ratio was 1.04 ( 95 % CI = 1.01 - 1.07 ) . CONCLUSIONS The intervention increased both influenza and pneumococcal immunization rates to high levels , suggesting that further progress in increasing adult immunization coverage is possible The objective of this study was to determine whether patient-specific letters , which describe the content of an upcoming well-child appointment , improve the show rate of well-child appointments better than postcard reminders . In this prospect i ve clinical trial conducted at a pediatric continuity clinic in a teaching hospital , 288 newborns were r and omized to a letter , postcard , or control group . For every well-child appointment , families were sent either a letter pertaining to the particular well-child appointment or a postcard ; the control group received no reminders . There were no differences in demographics among the groups . The show rates between the letter and postcard groups were not different , but were significantly higher than the show rate for the control group ( 75.0 % , 73.7 % , and 67.5 % , respectively ; P < .05 ) . A cost comparison between the use of postcards versus not using postcards revealed a benefit in the former . We concluded postcard reminders are effective in improving show rates for well-child-care visits , and that patient-specific letters have no additional benefit above that of postcard reminders OBJECTIVE To pilot test the Text Reminders for Immunization Compliance in Kids ( TRICKs ) program to evaluate its feasibility and potential to increase immunization coverage . DESIGN R and omized controlled trial ( RCT ) . SETTING Pediatric clinic . PARTICIPANTS Parents of newborns being discharged from a local hospital who intended to seek child health care at the University-sponsored pediatric resident and faculty clinic . INTERVENTION Text message immunization reminders prior to immunization due date s. MAIN OUTCOME MEASURES Receipt and timeliness of immunizations at 2 , 4 and 6 months of age . RESULTS Participants ( N=90 ) were English ( 83 % ) or Spanish ( 17 % ) speaking . The majority were female ( 83 % ) , on public insurance ( 59 % ) , and had adequate health literacy ( 96 % ) . Parents were married or a member of an unmarried couple ( 62 % ) . Over 66 % had a high school diploma or less . Greater numbers of intervention children received immunizations and were " on time " using per protocol analysis ; though not statistically significance . Limitations include sample size , problematic text messaging software , and loss of phone service at 7 months for 40 % of intervention parents . However , post-intervention interviews ( N=18 ) indicated strong support for TRICKs ; 83 % found the text message reminders very helpful and 17 % somewhat helpful . DISCUSSION Pilot testing allowed us to assess processes , including recruitment , retention , and software , which will increase the success of an RCT . Software with built-in backup systems is needed for follow-up when mobile service is interrupted . However , in spite of limitations , immunization rates were higher in the text message reminder group , though not statistically significant . Parent support and interest was high . A fully powered RCT is needed with follow-up over the full 4 - 3 - 1 - 3 - 3 - 1 series . Based on our results , for 80 % power where we expected 90 % compliance in the intervention group and 80 % in the control group we need 219 per group , plus increases to address drop out and loss of follow-up The rationale for , and establishment of , a computer-assisted , central ized immunization registry are described . This registry was created to improve the quality and quantity of information regarding immunization status for a defined population receiving primary care from a variety of providers , principally public clinics and private practitioners . An evaluation of the feasibility of the registry after one year 's function shows that 93 per cent of eligible providers initially agreed to participate and 73 per cent continue to do so . Their reports have result ed in the creation of 17,500 individual patient files . Of a prospect i ve cohort of newborns , 23 per cent were identified as " high-risk " for overdue immunizations . After one year , the immunization rates in audited groups improved significantly . The direct cost of this registry is less than 65 cents per currently registered child per year Background : Uptake of the human papillomavirus ( HPV ) vaccine is low in Appalachian Ohio and areas with high cervical cancer rates . Methods : We conducted a group-r and omized trial among 12 counties in Appalachian Ohio r and omized to receive either an HPV vaccine ( intervention counties ) or influenza vaccine ( comparison  counties ) multilevel intervention ( MLI ) . Parents ( n = 337 ) who had a daughter aged 9 to 17 years who had not received the HPV vaccine were recruited from commercial lists . Clinics ( N = 24 ) and 119 providers from these clinics were also recruited . The primary outcome was medical record – confirmed receipt of the first shot of the HPV vaccine 3 months after receiving the intervention among daughters of parents enrolled in the study . Secondary outcomes included receipt of the first HPV vaccine shot by 6 months and changes in provider knowledge . Results : According to medical records , 10 ( 7.7 % ) daughters of intervention participants received the first shot of the HPV vaccine  within 3 months of being sent the intervention material s compared with 4 ( 3.2 % ) daughters of comparison group participants ( P = 0.061 ) . By 6 months , 17 ( 13.1 % ) daughters of intervention participants received the first HPV vaccine shot compared with eight ( 6.5 % ) daughters of comparison group participants ( P = 0.002 ) . Provider knowledge about HPV increased ( P < 0.001 , from baseline to after education ) . Conclusions : The MLI increased uptake of the HPV vaccine among girls aged 9 to 17 years ; however , uptake was low . Impact : To improve HPV vaccine uptake , attention to additional levels of influence ( e.g. , policy , community ) and more elements within levels ( e.g. , reminders , automated prompts ) may be needed . Cancer Epidemiol Biomarkers Prev ; 25(4 ) ; 593–602 . © 2016 AACR . See all articles in this CEBP Focus section , “ Multilevel Approaches to Addressing Cancer Health Disparities . OBJECTIVE Clinic-based immunization rates are used to evaluate clinic performance and immunization interventions , but they typically exclude so-called inactive patients ( ie , those who no longer receive care at the clinic ) . We assessed the effect of enhanced ascertainment of inactive patients on clinic-based immunization rates and on the conclusions of a r and omized controlled trial . METHODS The study was a post hoc analysis of a cluster-r and omized controlled trial . Infant r and omization to the immunization intervention ( 4 clinics ) or control group ( 4 clinics ) was based on the site of their 2-week well-child care visit . The study was conducted at an integrated inner-city health care system serving a low-income population . A total of 2190 infants born between July 1 , 1998 , and June 30 , 1999 , who attended at least 1 postnatal visit , participated . In control sites , clinic staff documented inactive infants in the immunization registry and medical charts . The research staff undertook additional patient tracking efforts in the intervention clinics . RESULTS Control clinics identified 155 ( 13.4 % ) of 1160 children as inactive within 1 year of birth , whereas 284 ( 27.6 % ) of 1030 intervention infants were documented as inactive ( P < .001 ) . In bivariate analyses from the r and omized trial , immunization rates differed between intervention and control branches . In multivariate models , immunization rates were significantly higher in the intervention branch when inactive infants were removed ( adjusted relative risk 1.58 ; 95 % confidence interval , 1.28 - 1.89 ) , but not when they were included ( adjusted relative risk 1.09 ; 95 % confidence interval , 0.97 - 1.21 ) . CONCLUSIONS Additional patient tracking efforts can dramatically influence inactive patient documentation and clinic-based immunization rates used for various purpose BACKGROUND Children with chronic conditions have an increased risk of complications from influenza and have low influenza vaccination rates . PURPOSE To assess the feasibility and effectiveness of using a statewide immunization information system ( IIS ) for seasonal influenza vaccine reminders from local health departments ( LHDs ) targeting children with high-risk conditions . DESIGN A r and omized community intervention . SETTING / PARTICIPANTS The study was conducted in a population of 3618 children aged 24 - 60 months with a high-risk condition residing in three Michigan counties . Children were identified using a statewide IIS in October 2008 . INTERVENTION Children were r and omized to intervention ( reminder ) or control ( no reminder ) groups . Reminders for seasonal influenza vaccination were mailed by LHDs in November 2008 . MAIN OUTCOME MEASURES Feasibility of notification ( address validity , address deliverability ) was assessed ( November 2008-February 2009 ) , and frequencies of notification feasibility measures were determined ( analyses conducted in 2010 ) . Effectiveness of notification ( seasonal influenza vaccine receipt ) was assessed using bivariate logistic regression . RESULTS Among 3618 children with a high-risk condition , 2730 ( 75.5 % ) had not received a 2008 - 2009 influenza vaccination and were eligible at the time of notification . Among children assigned to the reminder group ( n=1374 ) , 42.6 % had an address determined to be either invalid , undeliverable , or both . Among those with valid addresses ( n=2001 ) , a greater percentage of children with deliverable reminders received at least one influenza vaccination ( 30.8 % ) during the outcome observation period than did children assigned to no reminder ( 24.3 % , OR=1.39 , 95 % CI=1.13 , 1.72 ) ; children with an undeliverable reminder had an influenza vaccination rate ( 22.8 % ) similar to children assigned to no reminder . CONCLUSIONS Receipt of a reminder was positively associated with seasonal influenza vaccination . However , more than 40 % of children assigned to receive a reminder were determined to have an invalid or undeliverable address , emphasizing the need for increased quality of IIS contact information . TRIAL REGISTRATION This study is registered at www . Clinical Trials.gov NCT01431183 OBJECTIVE To study the medical service utilization changes and return on investment from a health plan 's direct mailings that either encouraged members to receive influenza vaccinations or encouraged members to call a nurse advice service . STUDY DESIGN R and omized controlled trial with 2 intervention groups and 1 control group consisting of all members over age 65 years who were enrolled in 5 states in the Blue Cross and Blue Shield Government-wide Service Benefit Plan . Sample size was 134,791 individuals . METHODS Administrative cl aims -based influenza , pneumonia , heart failure , and respiratory inpatient bed days , emergency department ( ED ) visits , physician evaluation and management visits , other outpatient visits , and nurse advice call rates were compared between the intervention and control groups . RESULTS The influenza mailing intervention group experienced 2.87 % ( P = .033 ) fewer conditionrelated inpatient bed days and 7.25 % ( P = .101 ) fewer condition-related ED visits . The nurse advice service mailing intervention group experienced 7.65 % ( P < .001 ) fewer condition-related inpatient bed days and 6.75 % ( P = .125 ) fewer condition-related ED visits . Per dollar spent , the return on investment was estimated to be $ 2.51 for the influenza mailing intervention and $ 24.24 for the nurse advice mailing intervention . CONCLUSIONS Administrative cl aims data suggest that members respond to health plan mailings . By mailing information to their members , health plans can affect rates of medical service utilization and generate cost savings CONTEXT Pneumococcal immunization rates for elderly and high-risk patients are only one third to one half the target rate of 60 % established by the US Public Health Service . Limited or marginal literacy , which affects nearly 100 million Americans , especially the elderly , may contribute to these low rates of immunization . OBJECTIVE To determine whether the use of a simple , low-literacy educational tool enhances patient-physician dialogue about pneumococcal vaccination and increases rates of immunization . DESIGN A r and omized controlled trial conducted between May and June of 1998 . SETTING Ambulatory care clinic of a 900-bed public teaching hospital serving a predominantly indigent , low-literate , African American , inner-city population . PARTICIPANTS Of 433 patients who presented for routine primary care , had vaccine indications ( age > or = 65 years or chronic disease ) , and had not been previously vaccinated , 221 were r and omly assigned to the intervention group and 212 to the control group .  Of the total patient population ( mean age , 63 years ) , 280 ( 64.7 % ) had less than a high school education , 401 ( 92.6 % ) were African American , and 300 ( 69.3 % ) were female . INTERVENTION One-page , low-literacy ( below fifth- grade level ) educational h and out encouraging patients to " ask your doctor about the pneumonia shot " vs a control group ( 1 -page , low-literacy educational h and out conveying information about nutrition ) . MAIN OUTCOME MEASURES Vaccination rates ( documented by chart audit ) of patients who received pneumococcal vaccination and rates of patients who self-reported having discussed vaccination with their physicians . RESULTS Patients in the intervention group were 4 times more likely to have discussed the pneumococcal vaccine with their physicians than patients in the control group ( 87/221 [ 39.4 % ] vs 21/212 [ 9.9 % ] ; relative risk [ RR ] , 3.97 [ 95 % confidence interval [ CI ] , 2.71 - 5.83 ] ) , and were more than 5 times as likely to have received the pneumococcal vaccine than the control group ( 44/221 [ 19.9 % ] vs 8/212 [ 3.8 % ] ; RR , 5.28 [ 95 % CI , 2.80 - 9.93 ] ) . In a multivariate analysis controlling for race , sex , education , insurance status , age , level of physician training , health status , and vaccine indication , only assignment to the intervention group was statistically significantly related to the probability of being immunized or discussing the issue with their physicians ( P<.001 for both trends ) . CONCLUSIONS A simple , low-literacy educational tool increased pneumococcal vaccination rates and patient-physician discussion s about the vaccine in an elderly , low-literate , indigent , minority population PURPOSE To enhance influenza vaccination rates for high-risk out patients at the Department of Veterans Affairs Medical Center ( VAMC ) in Minneapolis , Minnesota , an institution-wide immunization program was implemented during 1987 . PATIENTS AND METHODS The program consisted of : ( 1 ) a hospital policy allowing nurses to vaccinate without a signed physician 's order ; ( 2 ) stamped reminders on all clinic progress notes ; ( 3 ) a 2-week walk-in flu shot clinic ; ( 4 ) influenza vaccination " stations " in the busiest clinic areas ; and ( 5 ) a mailing to all out patients . Risk characteristics and vaccination rates for patients were estimated from a vali date d self-administered postcard question naire mailed to 500 r and omly selected out patients . For comparison , 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs . RESULTS Overall , 70.6 % of Minneapolis patients were high-risk and 58.3 % of them were vaccinated . In contrast , 69.9 % of patients at the comparison medical centers were high-risk , but only 29.9 % of them were vaccinated . CONCLUSION The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization Thirteen Louisiana parishes ( counties ) using the  Mississippi river  as a source of potable water have the highest mortality rates ( 1950 - 1969 ) in the drinking water source , a comparison of cancer deaths and noncancer deaths from 1960 - 1975 in selected southern Louisiana parishes was conducted . Parishes were grouped for similarities in industrialization and approximately equal exposure of the population to surface water and ground water . Cancers were studied in groups by hypothesized risk : high for bladder , colon , kidney , liver , lymphoma , rectum , and stomach ; low for Hodgkin 's lymphoma , leukemia , lung , malignant melanoma , multiple myeloma , and prostate ; and question able for breast , brain , esophagus , and pancreas . Noncancer deaths were r and omly selected and matched 1:1 to cancer deaths on age , race , sex , and year and parish group of death . Water source at death was based on residence at death , surface or ground water , and chlorinated or nonchlorinated water . The risk associated with using surface water least likely due solely to change occurred for cancer of the rectum . Other risks which were lower but still greater than 1.0 occurred for cancer of the kidney and breast . No risk was observed for other cancers of the gastrointestinal or urinary tract . Risk for multiple myeloma was associated with use of ground water PURPOSE Completion rate for the three-dose series of the human papillomavirus ( HPV ) vaccine has generally been low . This study evaluated the effectiveness of a reminder letter intervention on HPV vaccine three-dose series completion . METHODS Female members of Kaiser Permanente Southern California Health Plan who received at least one dose , but not more than two doses , of the HPV vaccine by February 13 , 2013 , and who were between ages 9 and 26 years at the time of first HPV vaccination were included . Eighty percent of these females were r and omized to receive the reminder letter , and 20 % were r and omized to receive st and ard of care ( control ) . The reminder letters were mailed quarterly to those who had not completed the series . The proportion of series completion at the end of the 12-month evaluation period was compared using chi-square test . RESULTS A total of 9,760 females were included in the intervention group and 2,445 in the control group .  HPV vaccine series completion was 56.4 % in the intervention group and 46.6 % in the control groups ( p < .001 ) . The effect of the intervention appeared to be stronger in girls aged 9 - 17 years compared with young women aged 18 - 26 years at the first dose and in blacks compared with whites . CONCLUSIONS Reminder letters scheduled quarterly were effective to enhance HPV vaccine series completion among those who initiated the vaccine . However , a large gap in series completion remained despite the intervention . Future studies should address other barriers to series completion , including those at the providers and the health care system level 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 BACKGROUND The uptake of influenza vaccination  among older people is suboptimal . Contact with a doctor or nurse is associated with older people deciding to accept influenza vaccination . AIM To compare different forms of approach in improving uptake of influenza vaccination  among patients aged 75 years and over in primary care . DESIGN OF STUDY R and omised controlled trial . SETTING One large rural general practice serving the town and surrounding area of Melton Mowbray , Leicestershire . METHOD All 2,052 patients aged 75 years and over , registered with the practice and not living in nursing/residential homes or sheltered accommodation , were included in the study . One-third of patients were r and omised to receive an offer of influenza vaccination as part of an over-75 health check administered by a practice nurse in the patient 's home , and two-thirds of patients were r and omised to receive a personal letter of invitation to attend an influenza vaccination clinic held at the surgery . The main outcome measure was uptake of influenza vaccination .  RESULTS Six hundred and eighty patients were r and omised to the health check arm of the trial and 1,372 were r and omised to receive a personal letter . Of those r and omised to the health check arm , 468 received the health check from the nurse . Overall , the difference in influenza vaccination uptake was 6.4 % ( 95 % confidence interval [ CI ] = 2.2 % to 10.4 % ) with 67.9 % ( n = 932 ) of those who were sent a personal letter actually receiving the vaccine , compared with 74.3 % ( n = 505 ) of those offered a combined health check and influenza vaccination ( P = 0.003 ) . CONCLUSION Combining home-based over- 75 health checks with influenza vaccination can improve uptake among older patients . However this intervention is likely to be costly and its effect on influenza vaccination rates is modest . The difference in uptake is greater among those who do not routinely comeforwardfor vaccination and a more viable option may be to target these patients OBJECTIVES We evaluated the impact of influenza vaccine text message reminders in a low-income obstetric population . METHODS We conducted a r and omized controlled trial that enrolled 1187 obstetric patients from 5 community-based clinics in New York City . The intervention group received 5 weekly text messages regarding influenza vaccination starting mid-September 2011 and 2 text message appointment reminders . Both groups received st and ard automated telephone appointment reminders . The prespecified endpoints were receipt of either pre- or postpartum influenza vaccination calculated cumulatively at the end of each month ( September-December 2011 ) . RESULTS After adjusting for gestational age and number of clinic visits , women who received the intervention were 30 % more likely to be vaccinated as of December 2011 ( adjusted odds ratio [ AOR ] = 1.30 ; 95 % confidence interval [ CI ] = 1.003 , 1.69 end of September : AOR = 1.34 ; 95 % CI = 0.98 , 1.85 ; October : AOR = 1.35 ; 95 % CI = 1.05 , 1.75 ; November : AOR = 1.27 ; 95 % CI = 0.98 , 1.65 ) . The subgroup of women early in the third trimester at r and omization showed the greatest intervention effect ( December 31 : 61.9 % intervention vs 49.0 % control ; AOR = 1.88 ; 95 % CI = 1.12 , 3.15 ) . CONCLUSIONS In this low-income obstetric population , text messaging was associated with increased influenza vaccination , especially in those who received messages early in their third trimester 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 In New South Wales , health screening of school entrants provides the only mechanism for routine monitoring of immunisation uptake in children . School health nurses are in the best position to improve the compliance with immunisation at this age . We compared two interventions to be used by the nurses to increase immunisation uptake in school entrants who reported missing either the measles-mumps vaccine and /or the pre-school diphtheria-tetanus toxoid and oral polio vaccine boosters . Parents in the passive intervention group were sent a letter and leaflet encouraging immunisation ; the active intervention group received a telephone reminder from the nurse in addition to the written material s. Both groups were followed up at a later date to assess final immunisation outcome . Of 817 children screened , 88.2 % had been immunised against measles and 73.6 % had received the booster ; 239 children were r and omised to the two interventions . Excluding children lost to follow up and those fully immunised at the start of the study , 20 ( 37 % ) of 54 were immunised following the passive intervention , and 35 ( 71 % ) out of 49 following the active intervention ( P = 0.001 ) . Receipt of the letter and leaflet was associated with an increased uptake of booster vaccination ( P = 0.036 ) . The active intervention required 14.7 telephone calls and 1.6 uses of the interpreter service per completed immunisation . The passive intervention result ed in worthwhile increases in immunisation rate with minimum cost . A greater improvement in immunisation outcome was achieved by the active intervention , but its use was labour intensive and may only be warranted if high immunisation rates in this age-group are given priority 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 OBJECTIVES To determine the effectiveness of a telephone reminder to increase pneumococcal vaccination in a population that had received mailed reminders and to evaluate whether the intervention effect is similar for clinics serving primarily non-Hispanic black or non-Hispanic white patient population s. STUDY DESIGN R and omized trial within a managed care network . METHODS All unvaccinated patients 18 years and older with chronic medical conditions and 65 years and older without chronic medical conditions ( N = 6106 ) were r and omized to receive telephone intervention or st and ard care and followed up for 6-month vaccination status . The intervention was a telephone call initiated by a nurse to inform patients that pneumococcal vaccination was recommended and was a covered benefit of their insurance . RESULTS Intervention patients were 2.3 times as likely to be vaccinated during the study period than control patients ( P < .001 ) . The success of telephone intervention versus control was similar across clinics ( P = .16 ) and across the chronic disease and elderly groups ( P = .14 ) . In subanalyses of individuals reached by telephone intervention , unvaccinated black subjects were less likely to be vaccinated during the study than unvaccinated white subjects ( 34 % vs 25 % , P = .03 ) . Nurse staff time for telephone intervention cost $ 147.35 per additional patient vaccinated . CONCLUSIONS Telephone intervention was successful at increasing vaccination rates in a diverse managed care population that had already received mailed reminders . Tailored messaging for pneumococcal vaccination through telephone reminders increases patient dem and for vaccination and should be implemented by managed care organizations seeking to increase their vaccination rates OBJECTIVE To assess the effectiveness of computer-generated telephone reminder and recall messages in increasing  preschool immunization visits . DESIGN R and omized , controlled trial . SETTING Fourteen counties in urban and rural Georgia . STUDY PARTICIPANTS Children ( N = 8002 ) who were younger than 2 years ; had telephone numbers listed in preexisting computerized immunization data bases ; and were due or late for immunization(s ) during the 4-month enrollment period . INTERVENTION Households of children were r and omized to receive or not receive a general or vaccine-specific computer-generated telephone reminder or recall message the day before the child was due , or immediately after r and omization if the child was late . MAIN OUTCOME MEASURE The rates of immunization visits during the 30-day follow-up period . RESULTS Of the 4636 children whose households were r and omized to receive a message , 1684 ( 36.3 % ) visited the health department within 30 days compared with 955 ( 28.4 % ) of the 3366 children whose households were not contacted ( risk ratio [ RR ] = 1.28 ; 95 % confidence interval [ CI ] = 1.20 to 1.37 ; P < .01 ) . Immunization visits were more frequent ( 41.1 % ) among the 3257 children whose households actually received the message ( RR = 1.45 ; 95 % CI = 1.36 to 1.56 ; P < .01 ) . Improvement in immunization visits was similar for general and specific messages , greater for recall than reminder messages , and greatest for children who were late for the third dose of the diphtheria-tetanus-pertussis vaccine and the measles-mumps-rubella vaccine . CONCLUSION These data suggest a simple and effective way to increase preschool immunization visits , particularly for vaccines associated with the lowest immunization rates AIMS To estimate the cost-effectiveness of three behavioral interventions provided to enhance hepatitis A virus ( HAV ) and hepatitis B virus ( HBV ) joint vaccination ( HAV/HBV ) compliance among homeless persons living in Los Angeles County . SCOPE A cost-effectiveness analysis ( CEA ) based on data from a r and omized trial where the costs and compliance data from the trial are incorporated into two Markov models , simulating the natural history of acute and chronic hepatitis infection , following HAV/HBV vaccination . CONCLUSIONS Reductions in HBV-related disease is cost-effective to society and is associated with substantial improvements in quality of life IMPORTANCE Reminder/recall notifications used by primary care practice s increase the rates of childhood immunizations , but fewer than 20 % of primary care practitioners nationally deliver such reminders . A reminder/recall notification conducted central ly by health departments in collaboration with primary care practice s may reduce practice burden , reach children without a primary care practitioner , and decrease the cost of reminders/recalls . OBJECTIVE To assess the effectiveness and cost-effectiveness of collaborative central ized ( CC ) vs practice -based ( PB ) reminder/recall approaches using the Colorado Immunization Information System ( CIIS ) . DESIGN , SETTING , AND PARTICIPANTS We performed a r and omized pragmatic trial from September 7 , 2012 , through March 17 , 2013 , including 18,235 children aged 19 to 35 months in 15 Colorado counties . INTERVENTIONS In CC counties , children who needed at least 1 immunization were sent as many as 4 reminders/recalls by mail or autodialed telephone calls by the CIIS . Primary care practice s in these counties were given the option of endorsing the reminder/recall notification by adding the practice name to the message . In PB counties , primary care practice s were invited to web-based reminder/recall training and offered financial support for sending notifications . MAIN OUTCOMES AND MEASURES Documentation of any new immunization within 6 months constituted the primary outcome ; achieving up-to- date ( UTD ) immunization status was secondary . We assessed the cost and cost-effectiveness of each approach and used a generalized linear mixed-effects model to assess the effect of the intervention on outcomes . RESULTS In PB counties , 24 of 308 primary care practice s ( 7.8 % ) attended reminder/recall training and 2 primary care practice s ( 0.6 % ) endorsed reminder/recall notifications . Within CC counties , 129 of 229 practice s ( 56.3 % ) endorsed the reminder/recall letter . Documentation rates for at least 1 immunization were 26.9 % for CC vs 21.7 % for PB counties ( P < .001 ) ; 12.8 % vs 9.3 % of patients , respectively , achieved UTD status ( P < .001 ) . The effect of CC counties on children 's UTD status was greater when the reminder/recall notification was endorsed by the primary care practice ( 19.2 % vs 9.8 % ; P < .001 ) . The total cost of the CC reminder/recall was $ 28 620 or $ 11.75 per child for any new immunization and $ 24.72 per child achieving UTD status ; the total cost to the 2 practice s that conducted PB reminders/recalls was $ 74.00 per child for any immunization and $ 124.45 per child achieving UTD status . The modeling result ed in an adjusted odds ratio of 1.31 ( 95 % CI , 1.16 - 1.48 ) for any new immunization in CC vs PB counties . CONCLUSIONS AND RELEVANCE A CC reminder/recall notification was more effective and more cost-effective than a PB system , although the effect size was modest . Endorsement by practice s may further increase the effectiveness of CC reminder/recall . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01557621 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 OBJECTIVE To measure the effect of telephone-based reminder/recall on immunization and well-child care ( WCC ) visit rates among adolescents in urban practice s. DESIGN R and omized clinical trial of telephone-based reminder/recall over 18 months . SETTING Four urban primary care practice s. PARTICIPANTS Adolescents aged 11 to 14 years . Intervention Adolescents within practice s were r and omized to study ( n = 1496 ) or control groups ( n = 1510 ) . The study group was sent audiotaped telephone reminders about a scheduled or needed immunization or WCC visit . Households were called weekly if there was no response ; telephone numbers were up date d weekly . Controls received st and ard care . RESULTS Baseline demographics and immunization and WCC visit rates were similar for study and control groups . The intervention was largely ineffective in improving immunization or WCC visit rates . Although at the end of the study , the study group had slightly higher hepatitis B coverage ( 3 vaccinations ) ( 62 % vs 57.8 % ; P = .02 ) , WCC visits were the same ( 53 % and 54 % ) , and impact on other vaccinations was minimal . The effect of reminder/recall was equivalent across demographic subgroups ( e.g. , age , race/ethnicity , insurance ) . The major factor limiting intervention effectiveness was inaccurate telephone numbers . Seventy-one percent of study subjects with single telephone numbers throughout the study had a WCC visit vs 25 % of study subjects with multiple/changed telephone numbers and 54 % of controls ( P<.001 ) . CONCLUSIONS An intensive telephone reminder and recall system was only minimally successful in improving immunization and WCC visit rates among urban adolescents . Lack of success was largely owing to changed or inaccurate telephone numbers AIM To measure the cost of tracking for rubella immunisation status . METHOD A 6 month prospect i ve cohort study tracking all 25 and 26 year old women registered with suburban middle class general practice . RESULTS 357 women were registered as at 12 October 1992 . 44 % lived more than 3 km from the general practice building and 14 % had no contact telephone .  Culling the clinical records gave the general practice information on rubella status for 28 % of women . Sending two letters and two telephone calls to the remainder result ed in an increase to 59 % of women where the general practice had information about rubella status ( chi 2 = 71.26 , df = 1 , p < 0.001 ) . An inability to contact women was the major reason why 143 women did not have their rubella status known by the general practice . Information on rubella status was available in only 20 % of women who had not given a contact telephone number to the general practice , compared to 67 % of women who had given a contact telephone number ( chi 2 = 38.38 , df = 1 , p < 0.001 ) . Culling records and sending one letter was the most efficient use of re sources . The total cost per woman screened in this study was $ 9.94 . CONCLUSION More general practice research is needed to determine all the costs of screening for important medical conditions A r and omized , controlled trial was conducted at a private university to determine whether students who received an informational letter ( n = 366 ) would be more likely to receive a hepatitis B vaccination than students in a control group ( n = 366 ) .  Surveys were conducted to determine the students ' reasons for deciding to be vaccinated . Rates of hepatitis B immunization were significantly higher among students assigned to the intervention group ( 10.7 % ) than among the control group ( 1.9 % ) . Vaccinated students were more likely than unvaccinated students to report having had 3 or more sexual partners in the past 6 months . Students at higher risk for hepatitis B infection were more likely than others to be vaccinated . Although the overall rate of immunization was low , informational letters about the hepatitis B virus and vaccine were found to be efficacious in increasing hepatitis B immunization rates among students in the setting of a concurrent educational campaign Hospitalisation represents an opportunity to identify unimmunised people at risk for the complications of influenza and pneumococcal disease . We conducted a r and omised controlled trial of two strategies to increase uptake of influenza and pneumococcal vaccines in eligible , hospitalised subjects aged 65 years or more , admitted between May and September 1998 to a Melbourne hospital . Unvaccinated participants were allocated r and omly to alert systems for hospital staff or community general practitioners ( GPs ) . Follow-up occurred at 1 and 3 months . The baseline vaccination rates were 70 % for influenza ( 426/606 ) and 41 % ( 248/606 ) for pneumococcal disease . For unvaccinated subjects , the hospital alert result ed in 67 % uptake compared to 55 % following a GP alert for pneumococcal vaccine ; and 63 % in hospital compared to 53 % following a GP alert for influenza vaccine . Although there was a trend toward a higher uptake in hospital , neither of these differences was statistically significant . The majority ( 75 % ) of vaccinations following a GP alert occurred within 1 month of discharge . Despite hospital and community-based reminder systems , there are still significant missed opportunities for vaccination . We did not demonstrate significant differences between hospital and GP reminder systems , but there was a trend towards higher uptake with opportunistic vaccination in hospital Despite an emerging consensus on appropriate preventive services , a minority of patients receive them . A study was undertaken to assess the impact of computer-generated reminders to adult patients , their physicians , or both patients and physicians on adherence to five recommended preventive services : cholesterol measurements , fecal occult blood testing , mammography , Papanicolaou smears , and tetanus immunization . During the academic year 1988 - 1989 , all 7397 adult patients and their 49 physicians in a university family medicine clinical practice were r and omized by practice group into one of four study groups : control , physician reminders , patient reminders , and both physician and patient reminders . Adherence was defined in community-oriented terms : the percentage of patients within each group who had received the preventive service in the recommended interval . During the study period , adherence to four of the five preventive services increased significantly , with the largest increases in the physician and patient reminder group : cholesterol measurements increased from 19.5 % to 38.1 % , fecal occult blood testing 9.3 % to 27.0 % , mammography 11.4 % to 27.1 % , and tetanus immunization 23.4 % to 35.4 % ( for each increase , P less than .0001 , McNemar 's chi-square test ) . In general , increases were greater in blacks and in patients with any form of insurance coverage .  Computer-based physician and patient reminder systems have great promise of improving adherence to preventive services in primary care setting All persons 65 years and older are recommended to be immunised against influenza each autumn . As immunisation rates remain low , we conducted a r and omised control trial in a three‐partner urban general practice to evaluate the differential effectiveness of a single postcard reminder in a general practice setting compared to usual care . All non‐residential patients aged 65 years and over were identified from the age/sex/disease register . After exclusions , 325 patients were stratified by sex ( 125 men and 200 women ) and r and omised to receive either a postcard reminder in large print mailed in April or usual care . General practitioners ( GPs ) were blind to the r and omisation . A blinded record audit performed in July demonstrated that the postcard was effective in increasing immunisation for men ( X21df=3.85 ; p=0.05 ) but not for women ( X21df=0.45 ; p=0.50 ) . After adjusting for 1995 immunisation status , the effect of the  postcard  on immunisation rates was even stronger in men ( Wald X21df=6.20 ; p=0.01 ) but remained non‐significant in women ( Wald x21df=1.38 ; p=0.24 ) . With this adjustment , the odds of having the 1996 flu vaccine for men sent the postcard reminder were three times that of men in the control group ( OR=3.0 ; 95 % Cl 1.3–6.9 ) . In a general practice setting , a single postcard reminder appears to be a promising way to boost influenza immunisation rates among ageing men . Replication of the study is recommended 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 OBJECTIVE : To estimate whether text messages sent to ambulatory pregnant women could improve influenza vaccine uptake . METHODS : Obstetric patients at less than 28 weeks of gestation were enrolled in a r and omized controlled trial from an academic center 's outpatient clinic during two consecutive influenza seasons ( 2010–2011 and 2011–2012 ) . Potential participants were excluded if they had already received that season 's influenza vaccine . Participants were r and omized to receive 12 weekly text messages encouraging general pregnancy health ( General ) or general pregnancy health plus influenza vaccination ( Flu ) . Study participants completed preintervention and postintervention surveys about preventive health beliefs . Influenza vaccine receipt was assessed using prenatal record review . The study was powered to detect a 55 % increase in the vaccination rate in the intervention group . RESULTS : Two hundred sixteen women were enrolled , 204 of whom were available for intention-to-treat analysis ( n=100 General , n=104 Flu ) . Participants were primarily African American ( 66 % ) with low educational attainment ( 90 % equivalent to or less than high school education ) and predominantly with either public or no insurance ( 88 % )  . The overall influenza vaccination rate among participants was 32 % with no difference between participants in the General ( 31 % [ n=31 ] ) compared with Flu ( 33 % [ n=34 ] ) groups ( difference 1.7 % , 95 % confidence interval −11.1 to 14.5 % ) . CONCLUSION : Text messaging prompts were not effective at increasing influenza vaccination rates among a low-income , urban , ambulatory obstetric population . Ongoing efforts are needed to improve vaccine uptake among pregnant women unsure about or unwilling to receive influenza vaccination . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT01248520 . LEVEL OF EVIDENCE : BACKGROUND Patients with end-stage renal disease ( ESRD ) are at high risk of complications from influenza , but many dialysis centers report < 50 % influenza immunization coverage . STUDY DESIGN A group-r and omized evaluation of a multicomponent intervention to increase  influenza vaccination rates in poorly performing dialysis centers in ESRD Networks 6 , 11 , and 15 . SETTING & PARTICIPANTS Facilities with the lowest immunization percentages in 2006 - 2007 were selected from each network and r and omly assigned to a st and ard ( n = 39 ) or intensive intervention ( n = 38 ) . INTERVENTION St and ard intervention included a feedback report with comparison to other centers in their network and educational material s for staff and patients . Intensive-intervention centers also received 3 educational seminars , assistance with and review of center-specific action plans , and monthly monitoring of vaccination plan and rates . OUTCOMES Change in vaccination rate in following year . MEASUREMENTS  Dialysis center records of patient vaccination status . RESULTS There was an 8.9 % ( P = 0.04 ) adjusted mean absolute difference in improvement between intensive- and st and ard-intervention centers . LIMITATIONS Some vaccinations were self-reported by patients . The vaccination data form does not have an option for patient data unavailable , which may have caused patients without data to be coded as unvaccinated . CONCLUSIONS Multicomponent interventions may serve as a successful strategy to increase influenza vaccination rates at poorly performing centers , with a benefit beyond that provided by usual oversight and support 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 tested the effects of cues to action -- messages intended to increase flu immunizations .  North Dakota counties were r and omly assigned to reminder letters , action letters , or no letters . Within the reminder-letter counties , Medicare recipients received either ( a ) a reminder from the state peer review organization ( PRO ) to obtain a flu shot or ( b ) a reminder from the PRO , framed either in terms of the loss associated with failing to get a shot or ( c ) the benefits associated with getting a shot . Within the action-letter counties , Medicare recipients leaned where and when to receive a flu shot . Reminder type failed to differentially affect the immunization rate ( overall M = 24.5 % ) . However , the action messages  worked better ( 28.2 % ) than no message ( 19.6 % ) Inner-city infants ( n = 565 ) enrolled in the WIC program were r and omly assigned at 6 months of age to either of 2 groups : ( 1 ) voucher incentive ( frequency of issuance of food vouchers based on immunization status ) plus reminder-recall ( calls and /or letters to families of under-vaccinated children ) or ( 2 ) voucher incentive alone . At 12 months , both groups ' immunization levels were high and not significantly different : 80 % + /- 4 % versus 79 % + /- 5 % ( P = .749 ) 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 This study aim ed to determine whether requiring signed consent before influenza vaccination affected vaccine acceptance by elderly patients . Previous influenza vaccination was determined by chart review . All subjects agreed to sign the consent . Requiring signed consent did not affect influenza vaccine acceptance in this population . Mailed reminder letters and information packages in patients ' charts significantly increased vaccination rates Background Sexually transmitted disease clinics can deliver hepatitis vaccines to men who have sex with men , but have been reluctant to do so because of perceived low vaccination completion rates . Goal The goal was to evaluate  hepatitis A and B vaccination eligibility , acceptance , and completion and the effectiveness of reminder/recall in a sexually transmitted disease clinic serving men who have sex with men . Design Clients self-reported their eligibility for free vaccine .  Consenting clients who accepted a first dose of vaccine were systematic ally assigned to receive telephone reminder/recall or st and ard follow-up . Results Of 1203 clients , 71.8 % were eligible for both vaccines ; 62.6 % of those eligible accepted both . Reminder/recall was associated with increased receipt of the second dose of hepatitis B vaccine ( 86.7 % versus 80.4 % among intervention and control groups , respectively ) , but not with completion of both vaccine series ( 55.9 % versus 58.8 % ) . Conclusion The majority of clients were eligible for both hepatitis vaccines , and most eligible clients accepted a first dose of both vaccines . Reminder/recall , as delivered at this clinic , failed to increase the proportion of clients who received all vaccine doses . New delivery mechanisms should be explored 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 Influenced by the Department of Health 's aim to increase the uptake of the influenza immunization  to 70 % among those eligible , this study aim ed to compare three methods of promoting influenza immunization among over 65 year old patients in a GP practice , and to identify if a particular promotion method was more effective among either of two defined age groups . The sample ( n = 90 ) was r and omly allocated into three intervention groups , and then subdivided into two age groups . A different subject experimental design was used to compare the groups . Statistical analysis of the data showed no significant difference in influenza immunization uptake between the three intervention groups , or the age-defined sub-groups . However , although not significant at 5 % significance level , participants aged 72 years and over showed a greater uptake among those visited by a health professional . The findings suggest that a larger study using the same interventions would produce significant results 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 ABSTRACT Objective : To evaluate an intervention aim ed at increasing human papillomavirus ( HPV ) vaccine completion of the 3-dose series and knowledge . Participants : Two hundred sixty-four male and female US college students 18–26 years old who were receiving HPV vaccine dose 1 . Methods : Students were r and omly assigned to the intervention or  control  group . Intervention participants received the electronic intervention ( text/e-mail appointment reminders and education messages ) and controls received st and ard-of-care . Baseline/follow-up survey data were collected . Main outcome measures included vaccine completion and knowledge . Results : HPV vaccine completion across groups were not significantly different for HPV dose 2 ( 53 % vs 52 % ) and dose 3 ( 34 % vs 32 % ) . Mean knowledge score at follow-up for intervention group was significantly higher ( p = .01 ) than at baseline . No significant differences in knowledge were found for the control group . The biggest predictor of HPV vaccine completion was female gender . Conclusions : The intervention increased knowledge but not vaccine completion . More research with catch-up age population s is needed OBJECTIVE Strong scientific evidence and national recommendations support the use of reminder and recall messages to improve immunization coverage rates , yet reports have suggested that only a minority of pediatric practice s use such messages . Our aims were to 1 ) determine the proportions of pediatric practice s and public clinics that currently use practice -based reminder or recall messages and routinely undergo immunization assessment efforts , 2 ) evaluate barriers and supports to implementing these practice s , and 3 ) identify predictors of either current use or plans for future adoption of these practice s. METHODS This study combined qualitative and quantitative methods in sequential phases . In the qualitative phase , we conducted semistructured , open-ended interviews with a convenience sample of 18 clinician-administrators representing adopters and nonadopters of these messages in both private practice s and public health clinics . In the subsequent quantitative phase , we mailed a structured , closed-ended survey to national sample s of r and omly selected pediatricians ( n = 600 ) and public clinics ( n = 600 ) . RESULTS  Response rates were 75 % for pediatricians and 77 % for public clinics . Among pediatricians , 38 % were conducting regular assessment s of immunization coverage but only 16 % were currently using routine reminder or recall messages . Among public clinics , 85 % were conducting regular assessment s and 51 % were using reminder or recall messages . Among pediatricians ' practice s , the most commonly reported barriers to the adoption of reminder or recall messages were lack of time and funding and the inability to identify children at specified ages . For pediatricians ' practice s , the strongest predictors of current use of reminder or recall messages were having a champion who led efforts to improve immunization delivery ( odds ratio : 1.85 ; 95 % confidence interval : 1.08 - 3.18 ) and current use of regular immunization assessment s ( odds ratio : 2.30 ; 95 % confidence interval : 1.33 - 3.84 ) . Likewise , for public health clinics , having a champion to lead immunization improvement efforts and believing that their current system needed improvement was associated with current use of reminder or recall messages . CONCLUSIONS Reminder and recall messages remain underused by both pediatricians and public health clinics . Promising strategies to promote adoption of these approaches in both the private and the public sectors include identifying and training champions to promote immunization delivery improvement efforts and helping practice s develop methods to identify children at specific ages Available strategies to increase  influenza vaccination rates in the elderly have not been tested in the private sector where most elderly receive care . We performed a r and omized controlled trial of a postcard reminder in the three private general internal medicine practice s. The observed vaccination rates of 55 % in experimental patients ( N = 262 ) and 54 % in control patients ( N = 278 ) were similar , though much higher than estimated national rates of 20 % . The data indicated that the baseline ( control group ) vaccination rate was high probably because study participants were exposed to many community vaccination cues , separate from the study cue . That vaccination rates were not higher after additional exposure to the study cue suggests that a " ceiling effect " occurred . Including 70 patients not r and omized into the trial because they received flu shots prior to r and omization , the vaccination rate in patients who had a clinic visit during autumn months was 75 % compared to a rate of 52 % in patients not visiting the clinic ( P less than .001 ) . Our results suggest that vaccination rates can be considerably higher in the private sector than those reported in the past , and that both vaccination cues and direct patient contact appear important to promote vaccination . This and other studies suggest that traditional cues may have a ceiling effect , yielding vaccination rates no higher than 55 to 65 % ; further increases in rates will require other approaches OBJECTIVE To assess the impact on clinic-specific vaccination coverage of implementing the St and ards for Pediatric Immunization Practice s. DESIGN A nonr and omized intervention trial conducted for 1 year . SETTING Two public health clinics in Albuquerque , NM : 1 intervention site and 1 control site , each serving 1 of 4 city quadrants . PARTICIPANTS All children enrolled in the 2 city public health clinics . INTERVENTIONS Implementation of the St and ards for Pediatric Immunization Practice s. OUTCOME MEASURES Assessment of up-to- date vaccination coverage levels  prior to and at the conclusion of the project . The impact on the proportion of children who dropped out of vaccination services after receiving 1 dose by 3 months of age . RESULTS At the intervention site , up-to- date coverage at 12 months of age rose from 57.5 % to 80.4 % , while levels at the control site decreased from 42.1 % to 41.9 % . Before the intervention , 24 % of children at the intervention site who received the first dose of diphtheria and tetanus toxoids and pertussis vaccine ( DTP 1 ) by 3 months of age failed to receive the third dose of  DTP ( DTP 3 ) by 12 months of age vs 5 % after the intervention . At the control site , the proportion of children who received DTP 1 by 3 months of age , but not DTP 3 by 12 months of age , increased from 39 % to 51 % . CONCLUSION Implementation of the St and ards for Pediatric Immunization Practice s in a public health clinic was associated with important increases in vaccination coverage levels and a reduction in the proportion of children who dropped out of vaccination services A field trial to assess the effectiveness of a reminder sticker in reducing immunization dropout rates was conducted in two districts of Addis Ababa between 14 October 1991 and 31 January 1992 . A total of 703 children were entered into the study . The study population was r and omly divided into intervention and control groups . The intervention group received a reminder sticker and the control group did not . All other services were identical . A baseline interview documented the socio-demographic and maternal characteristics potentially related to immunization services utilization and revealed no statistically significant differences between the two groups . The dropout rates were 7.3 and 13.3 % in the intervention and control groups respectively . This difference is clinical ly and statistically ( P < 0.01 ) significant . Therefore , it is concluded that the reminder sticker is effective in reducing immunization dropout rates . Further investigations under operational conditions are recommended prior to the routine introduction of stickers into the immunization services BACKGROUND Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations . However , the effect of patient-directed electronic reminders is understudied . OBJECTIVE To determine whether providing reminders directly to patients via an electronic Personal Health Record ( PHR ) improved adherence to care recommendations . DESIGN We conducted a cluster r and omized trial without blinding from 2005 to 2007 at 11 primary care practice s in the Partners HealthCare system . PARTICIPANTS A total of 21,533 patients with access to a PHR were invited to the study , and 3,979 ( 18.5 % ) consented to enroll . INTERVENTIONS Patients in the intervention arm received health maintenance ( HM ) reminders via a secure PHR “ eJournal , ” which allowed them to review and up date HM and family history information . Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications , allergies and diabetes management . MAIN MEASURES The primary outcome measure was adherence to guideline -based care recommendations .KEY RESULTS Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography ( 48.6 % vs 29.5 % , p = 0.006 ) and influenza vaccinations ( 22.0 % vs 14.0 % , p = 0.018 ) . No significant improvement was observed in rates of other screenings . Although Pap smear completion rates were higher in the intervention arm ( 41.0 % vs 10.4 % , p < 0.001 ) , this finding was no longer significant after excluding women ’s health clinics . Additional on-treatment analysis showed significant increases in mammography ( p = 0.019 ) and influenza vaccination ( p = 0.015 ) for intervention arm patients who opened an eJournal compared to control arm patients , but no differences for any measure among patients who did not open an eJournal . CONCLUSIONS Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care OBJECTIVE To compare computer-based with manual health maintenance tracking systems to determine whether ( 1 ) a computer-based system will result in better provider compliance with the practice health maintenance protocol , ( 2 ) the incremental cost of operating a computer-based vs a manual health maintenance tracking system differs , and ( 3 ) inactive patients will respond to health maintenance reminders . DESIGN Two-year prospect i ve , r and omized , controlled trial . SETTING Rural , multiple-office , nonprofit , fee-for-service family practice . PATIENTS Adult members of families in which at least one member had been seen by the practice within the past 2 years . INTERVENTION A computer-based health maintenance tracking system that generated annual provider and patient reminders for all patients regardless of appointment status compared with a manual flowchart-based tracking system in which patient reminders were triggered by provider request . OUTCOME MEASURES Provider compliance with the health maintenance protocol determined by preintervention and postintervention chart audits , costs of computer-based tracking , and response of inactive patients to health maintenance reminders . RESULTS Overall provider compliance with the health maintenance protocol increased 15 percentage points in the computer-based tracking group and four percentage points in the manual group . The computer-based tracking group had significantly higher provider compliance than the manual group for eight of 11 procedures . The computer-based tracking system cost 78 cents per patient per year to operate . It was not associated with increased office visits or patient billings . CONCLUSIONS Computer-based health maintenance tracking improved provider health maintenance compliance compared with a manual system . The finding that health maintenance compliance improved without a significant increase in patient visits or billings requires confirmation in other setting s but suggests that considerable health maintenance can be incorporated into ongoing patient care A r and omized controlled trial demonstrated that a single mailed influenza vaccination cue increased the vaccination rate among elderly HMO members with high-risk chronic conditions ( n = 2217 ) from 30 per cent to 39 per cent during the fall and winter of 1984/85 OBJECTIVES This study evaluated the effectiveness of an annual public health intervention in a managed care setting . METHODS Managed care organization members 65 years and older who received influenza immunization in 1996 were r and omized to an intervention group ( mailed a postcard reminder to receive an influenza vaccination in 1997 ) or a control group ( no postcard ) .  Vaccination rates for both groups were assessed monthly . RESULTS Members receiving the intervention were no more likely to be immunized ( 78.6 % ) than members of the control group ( 77.2 % , P = .222 ) . Members were vaccinated at the same pace regardless of vaccination history and postcard intervention status . CONCLUSIONS Postcard reminders were not an effective intervention among seniors who had been vaccinated the previous year OBJECTIVE To examine the impact of postal invitations and user fee on influenza vaccination rates . DESIGN A controlled r and omized trial in 13 general practice s. One third of the participating patients received postal invitations to influenza vaccination free of charge . Another third received postal invitations to influenza vaccination on paying the usual fee ( US$ 40 - 60 ) . The last third served as a control group , being vaccinated at their own request and paying the usual fee . SETTING General practice in the Counties of Funen and Vejle , Denmark . PATIENTS Five hundred and eighty-five patients aged 65 years or older , recognized by their general practitioner ( GP ) as being in the risk group for whom influenza vaccination is recommended . MAIN OUTCOME MEASURES Influenza vaccination rates . RESULTS In the control group 25 % ( 19 - 31 % , 95 % confidence interval ) of the patients were vaccinated , compared with 49 % ( 42 - 56 % ) in the group who received a postal reminder and paid the usual fee , and 72 % ( 65 - 78 % ) in the group invited to be vaccinated free of charge . CONCLUSION It is suggested that GPs send postal invitations to their elderly patients in the risk groups urgently recommending influenza vaccination . Attention should also be given to offering free influenza vaccination to elderly patients who have recognized indications for vaccination In a retrospective survey , 487 research projects approved by the Central Oxford Research Ethics Committee between 1984 and 1987 , were studied for evidence of publication bias . As of May , 1990 , 285 of the studies had been analysed by the investigators , and 52 % of these had been published . Studies with statistically significant results were more likely to be published than those finding no difference between the study groups ( adjusted odds ratio [ OR ] 2.32 ; 95 % confidence interval [ Cl ] 1.25 - 4.28 ) . Studies with significant results were also more likely to lead to a greater number of publications and presentations and to be published in journals with a high citation impact factor . An increased likelihood of publication was also associated with a high rating by the investigator of the importance of the study results , and with increasing sample size . The tendency towards publication bias was greater with observational and laboratory-based experimental studies ( OR = 3.79 ; 95 % Cl = 1.47 - 9.76 ) than with r and omised clinical trials ( OR = 0.84 ; 95 % Cl = 0.34 - 2.09 ) . We have confirmed the presence of publication bias in a cohort of clinical research studies . These findings suggest that conclusions based only on a review of published data should be interpreted cautiously , especially for observational studies . Improved strategies are needed to identify the results of unpublished as well as published studies 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 Preventive care is an important role for general practitioners , yet opportunities for prevention are often missed . METHOD We provided an automatic electronic record preventive care reminder system for  12 preventive care activities for one 10 doctor practice . All patients who attended were r and omised by the terminal digit of their record number . RESULTS The control uptake of opportunistic prevention was low ; ranging from 1.5 % ( tetanus immunisation ) to 27 % ( influenza immunisation ) . The reminders increased this by significant but small amounts for four out of 12 activities ( immunisation for tetanus and pneumococcus and recording of allergies and weight ) , insignificant increases for four ( mumps , measles and rubella immunisation , recording of smoking , and taking of cervical smears and of blood pressure ) , and insignificantly decreased influenza immunisation , and screening for diabetes and hyperlipidaemia . DISCUSSION Opportunistic electronic reminders have the potential to increase preventive care in general practice BACKGROUND Although previous studies have found reminder/recall to be effective in increasing immunization rates , little guidance exists regarding the specific ages at which it is optimal to send reminder/recall notices . PURPOSE To assess the relative effectiveness of central ized reminder/recall strategies targeting age-specific vaccination milestones among children in urban areas during June 2008-June 2009 . METHODS Three reminder/recall strategies used capabilities of the Michigan Care Improvement Registry ( MCIR ) , a statewide immunization information system : a 7-month recall strategy , a 12-month reminder strategy , and a 19-month recall strategy .  Eligible children were r and omized to notification ( intervention ) or no notification groups ( control ) . Primary study outcomes included MCIR-recorded immunization activity ( administration of ≥1 new dose , entry of ≥1 historic dose , entry of immunization waiver ) within 60 days following each notification cycle . RESULTS A total of 10,175 children were included : 2,072 for the 7-month recall , 3,502 for the 12-month reminder , and 4,601 for the 19-month recall . Immunization activity was similar between notification versus no notification groups at both 7 and 12 months . Significantly more 19-month-old children in the recall group ( 26 % ) had immunization activity compared to their counterparts who did not receive a recall notification ( 19 % ) . CONCLUSIONS Although recall notifications can positively affect immunization activity , the effect may vary by targeted age group . Many 7- and 12-month-olds had immunization activity following reminder/recall ; however , levels of activity were similar irrespective of notification , suggesting that these groups were likely to receive medical care or immunization services without prompting 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 Abstract OBJECTIVE : To determine if a mailed patient education brochure ( addressing demonstrated reasons for vaccination refusal ) would result in a higher rate of influenza vaccination  than a mailed postcard reminder without educational content . DESIGN : R and omized , controlled trial . SETTING : Urban , predominantly African-American , low-income community . PARTICIPANTS : There were 740 community-dwelling individuals aged 65 years and older in the study . MEASUREMENTS : Receipt of influenza vaccination and beliefs about influenza and influenza vaccination were measured by telephone survey self-report . MAIN RESULTS : We successfully contacted 202 individuals ( 69.9 % ) who received the postcard reminder and 229 individuals ( 71.1 % ) who received the educational brochure . People receiving the educational brochure were more likely to report influenza vaccination during the previous vaccination season than those who received the postcard reminder ( 66.4 % vs 56.9 % , p=.04 ) . They also reported more interest in influenza vaccination in the coming year . ( 66.5 % vs 57.1 % , p=.05 ) . CONCLUSIONS : A mailed educational brochure is more effective than a simple reminder in increasing influenza vaccination rates among inner-city , elderly patients 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 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 OBJECTIVE To determine the predictors and extent of noncompliance with a second dose of hepatitis B vaccine and the effectiveness of a compliance enhancement strategy . DESIGN Cohort analysis and r and omized clinical trial . SUBJECTS A total of 256 consecutive adults attending a sexually transmitted diseases clinic from October 1992 to July 1993 who were seronegative for hepatitis B virus and agreed to receive hepatitis B vaccination . SETTING Hamilton , Ont . INTERVENTION Subjects were followed up for 4 months . Those who did not return for the second dose of vaccine by 6 weeks after the first ( 2 weeks overdue ) were r and omly assigned to the enhanced intervention group ( telephone and mail reminders ) or the regular intervention group ( mail reminder only ) . Subjects were considered noncompliant if they did not return for the second dose by 4 months after the first . RESULTS The risk of not returning for the second dose of vaccine within 4 months after the first was strongly and linearly associated with level of education ( p = 0.004 ) . The noncompliance rate among those with less than a grade 10 education was 50 % , grade 10 - 13 education 34 % , some college education 15 % and some university education 9 % . In the r and omized controlled trial the enhanced intervention group had twice the compliance rate of the regular intervention group ( 48 % v. 25 % ; p = 0.008 ) . Subjects with no post secondary education were highly responsive to the enhanced intervention ( relative risk 2.1 ; p = 0.02 ) compared with those with a higher level of education ( relative risk 1.0 ; p = 1.0 ) . CONCLUSION Hepatitis B vaccine recipients with lower educational levels are at increased risk of noncompliance with the second dose of vaccine but are highly responsive to telephone reminders OBJECTIVE To quantify cultural barriers to hepatitis B virus ( HBV ) vaccination and parental compliance with a specific vaccination protocol among a primarily among population of infants born at a community hospital . METHODS This study was concurrent with an immunogenicity study of two vaccination schedules and occurred prior to the inception of universal infant vaccination with hepatitis B vaccine ( HepB ) . In this study , parental pairs were interviewed , consent obtained , subjects were r and omly assigned to each group , and first immunization was administered in the hospital . Follow-up contacts required for completion were documented . RESULTS Of 260 eligible parental pairs interviewed , 175 ( 67 % ) declined participation , mainly because of fears of vaccine side effects ( 55 % ) or ignorance of the hepatitis B virus ( HBV ) ( 30 % ) . Of 85 infants enrolled in the study , 28 ( 33 % ) were later withdrawn from the study ; 13 ( 46 % ) of these 28 infants were withdrawn at the request of parents . Each infant who completed the study received 5 postcards , 10 phone calls , and 3 home visits . CONCLUSIONS Families were unaware of the risk of HBV infection and feared vaccination . Aversion to subjecting an infant to pain was a principal reason for failure to complete the study , and frequent contacts were required to ensure adherence . Existence of a safe and effective hepatitis B vaccine and universal vaccination is unlikely to change deeply felt attitudes against vaccination . Current vaccination strategies must take these prejudices into account OBJECTIVE : To test a stepped intervention of reminder/recall/case management to increase infant well-child visits and immunization rates . METHODS : We conducted a r and omized , controlled , practical , clinical trial with 811 infants born in an urban safety-net hospital and followed through 15 months of life . Step 1 ( all infants ) involved language -appropriate reminder postcards for every well-child visit . Step 2 ( infants who missed an appointment or immunization ) involved telephone reminders plus postcard and telephone recall . Step 3 ( infants still behind on preventive care after steps 1 and 2 ) involved intensive case management and home visitation . RESULTS : Infants in the intervention arm , compared with control infants , had significantly fewer days without immunization coverage in the first 15 months of life ( 109 vs 192 days P < .01 ) and were more likely to have ≥5 well-child visits ( 65 % vs 47 % P < .01 ) . In multivariate analyses , infants in the intervention arm were more likely than control infants to be up to date with 12-month immunizations and to have had ≥5 well-child visits . The cost per child was $ 23.30 per month . CONCLUSION : This stepped intervention of tracking and case management improved infant immunization status and receipt of preventive care in a population of high-risk urban infants of low socioeconomic status OBJECTIVES Within a clinic serving disadvantaged children , 1 ) to evaluate a multifaceted quality improvement ( QI ) project to improve immunization ( IZ ) up-to- date ( UTD ) rates and 2 ) to assess the efficacy of IZ reminder/recall performed following QI . METHODS A year-long QI project followed by a trial of reminder/recall . QI interventions were targeted at previously identified barriers to IZ and were design ed specifically to improve the efficacy of reminder/recall . QI interventions were design ed to 1 ) increase the use of medical record releases to document IZs received elsewhere ; 2 ) improve the accuracy of parental contact information ; and 3 ) reduce missed opportunities by utilizing chart prompts , provider education , and provider reminders . Following QI , we conducted a r and omized trial of reminder/recall . RESULTS UTD rates for 7 - 11 month olds increased from 21 % before the QI project to 52 % after ( P < .0001 ) ; rates for 12 - 18 month olds increased from 16 % before QI to 44 % after ( P < .0001 ) ; 19 - 25 month olds 18 % before to 33 % after ( P < .001 ) . After QI , an average of 61 records per month were up date d with IZs received elsewhere . However , the accuracy of parental contact information worsened ( 29 % unreachable before QI vs 44 % after , P < .001 ) and missed opportunities did not improve ( 8 % before vs 6 % after , P = not significant [ NS ] ) . A subsequent trial of reminder/recall did not increase UTD rates , with 17 % of recalled children brought UTD vs 16 % of controls ( P = NS ) . CONCLUSIONS Clinic-based QI increased documented UTD rates in a disadvantaged patient population . However , IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process OBJECTIVE To determine if mailed reminders would increase area-wide influenza immunization for persons aged 65 and older . DESIGN A r and omized , controlled trial . SETTING Ten counties in Indiana . PARTICIPANTS Using a Medicare data base , 10,000 subjects were selected r and omly from 10 counties in Indiana and r and omized for the study . Using pre-established criteria , 4503 persons in the control group and 4508 in the intervention group were eligible for study . INTERVENTION Intervention subjects received mailed reminders during the immunization season of 1995 . MEASUREMENTS Data from mailed surveys , Medicare cl aims , and phone calls were used to determine immunization rates . RESULTS Of those surveyed who received immunization , only 63.4 % filed a Medicare cl aim . Immunization rates were high in both groups but higher in the intervention group , 69.0 % versus 64.2 % . Age , presence of lung disease , assignment to the intervention group , presence of heart disease , and an age-sex interaction term were significantly and independently related to immunization . CONCLUSIONS The Healthy People Year 2000 goal ( 60 % immunization for persons 65 and older ) was exceeded in this population . Medicare cl aims data do not reflect immunization rates accurately . Mailed reminders , an inexpensive intervention , increased immunization rates area-wide and have potential for cost savings BACKGROUND To minimize absenteeism result ing from influenza , employers frequently offer on-site  influenza vaccination to employees . Yet the level of uptake of vaccine is low among working adults . This study was design ed to increase workplace influenza vaccination rates by offering both a choice of intranasal ( LAIV ) and injectable ( TIV ) influenza vaccines to eligible employees , and an incentive for being vaccinated , and by increasing awareness of the vaccine clinic . DESIGN This study used a stratified r and omized cluster trial . SETTING / PARTICIPANTS A total of 12,222 employees in 53 U.S. companies with previous influenza vaccine clinics were examined . INTERVENTIONS Control sites advertised and offered vaccine clinics as previously done . Choice sites offered LAIV or TIV and maintained their previous advertising level but promoted the choice of vaccines . Choice Plus sites increased advertising and promoted and offered a choice of vaccines and a nominal incentive . MAIN OUTCOME MEASURES These included vaccination rates among eligible employees . Hierarchic linear modeling ( HLM ) was used to determine factors associated with vaccination . RESULTS The overall vaccination rate increased from 39 % in 2007 - 2008 to 46 % in 2008 - 2009 ( p<0.001 ) . The difference in vaccination rates for LAIV was 6.5 % for Choice versus Control and 9.9 % for Choice Plus versus Control ( both p<0.001 ) . Rates of TIV increased by 15.9 percentage points in the Choice Plus arm versus Control for workers aged > or = 50 years ( p=0.024 ) . Rates of TIV did not change in workers aged 18 - 49 years in either intervention arm or in workers aged > or = 50 years in the Choice arm . In HLM analyses , factors significantly associated with increased vaccination were older age , female gender , previous company vaccination rate , and the Choice Plus intervention . CONCLUSIONS An incentive for vaccination , an intensified advertising campaign , and offering a choice of influenza vaccines improved vaccination rates in the workplace OBJECTIVE To determine whether the implementation of the Put Prevention Into Practice ( PPIP ) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics . METHODS Chart review was conducted before ( n=372 ) and 33 to 39 months after ( n=376 ) the implementation of the  PPIP office-based system in two community health centers and three family practice residency programs in Texas . The population included all adult patients aged > or = 19 years who had presented to the clinic during the study periods . RESULTS Documentation of timely cholesterol screening increased from 70 % to 84 % ; smoking assessment , from 56 % to 80 % ; for women , up-to- date Papanicolaou smear , from 70 % to 81 % ; annual mammograms ( women aged > or = 51 ) , from 30 % to 48 % ; and up-to- date tetanus-diphtheria immunizations , from 19 % to 59 % . For adults aged > or = 66 years , documentation of pneumococcal immunization increased from 22 % to 48 % , while influenza immunizations improved , although not significantly ( 45 % to 49 % ) . Blood pressure screening was almost universal ( 99 % ) at baseline and at 33- to 39-month follow-up . CONCLUSION PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services BACKGROUND Some r and omised controlled trials ( RCTs ) done in German-speaking Europe are published in international English- language journals and others in national German- language journals . We assessed whether authors are more likely to report trials with statistically significant results in English than in German . METHODS We studied pairs of RCT reports , matched for first author and time of publication , with one report published in German and the other in English . Pairs were identified from reports round in a manual search of five leading German- language journals and from reports published by the same authors in English found on Medline .  Quality of methods and reporting were assessed with two different scales by two investigators who were unaware of authors ' identities , affiliations , and other characteristics of trial reports . Main study endpoints were selected by two investigators who were unaware of trial results . Our main outcome was the number of pairs of studies in which the levels of significance ( shown by p values ) were discordant . FINDINGS 62 eligible pairs of reports were identified but 19 ( 31 % ) were excluded because they were duplicate publications . A further three pairs ( 5 % ) were excluded because no p values were given . The remaining 40 pairs were analysed . Design characteristics and quality features were similar for reports in both language s. Only 35 % of German- language articles , compared with 62 % of English- language articles , reported significant ( p < 0.05 ) differences in the main endpoint between study and control groups ( p = 0.002 by McNemar 's test ) . Logistic regression showed that the only characteristic that predicted publication in an English- language journal was a significant result . The odds ratio for publication of trials with significant results in English was 3.75 ( 95 % CI 1.25 - 11.3 ) . INTERPRETATION Authors were more likely to publish RCTs in an English- language journal if the results were statistically significant . English language bias may , therefore , be introduced in review s and meta-analyses if they include only trials reported in English . The effort of the Cochrane Collaboration to identify as many controlled trials as possible , through the manual search of many medical journals published in different language s will help to reduce such bias BACKGROUND Routine Immunization (RI)is known to beone of the most cost-effective public health strategies ever , and a cornerstone among all primary healthcare efforts but has been bedevilledin Low and Middle Income Countries ( LMICs ) in the last two decadesby poor coverage and lack of timeliness -both due , among other factors , to clients forgetting appointments . These setback RI effectiveness from ensuring herd immunity and preventing disease . Across the world , different cost-effective mobile telephone-based reminder systems are currently in use as strategies for improving coverage and compliance in various health interventions .Their application to RI is thereforehighly recommended . OBJECTIVE This study sought to provide evidence validating the need for development and deployment of automated client Reminder-Recall systems for the Nigerian National Routine Immunisation Program and to compare its projected cost withthe cost of a health personnel-based defaulter tracking system . METHODOLOGY A multi-centre , parallel-group , R and omized Controlled Trial was carried outusing multi-stage sampling . Nine hundred and five child-caregivers were followed-upat 8 health facilities in an urban/sub-urban area in South-South Nigeria . Text messagereminders were sent to the Intervention group only , with concurrent weekly data collection , including that for controls , at each of the enrolled health facilities . Recall messages were sent to defaulters and their responses ( presence at immunization session ) assessed the next RI session . Receipt of DPT3 vaccine on or before the 18th week was categorized early , while receiptafter was categorized delayed . RESULTS Clients in the Interventiongroup were1.5times earlier than Controls intheir receipt of DPT3 . Immunization coverage was also 8.7%better in the Interventiongroup . A first year estimate of cost of deploying this strategy was less than a quarter ofthe estimated cost of using home-visits which is the defaulter tracking method currently recommended by regulatory authorities . CONCLUSION Routine immunization performance was significantly better in the Interventiongroup who received SMS reminders compared to the controls who did not . Since this occurred at a cheaper rate than projected costs of home visits , in a habitual stock-out situation , this is ample evidence for health policy-makers in LMICs to leverage the ever exp and ing mobile telecom platforms for future sustainable improvements in routine immunisation performance and even other disease control efforts in Nigeria We determined if a patient-self assessment /provider reminder tool ( A/R ) would increase administration of the eight vaccines that may be indicated for adults . In three family practice clinics , the A/R was completed by intervention patients and given to their provider . Control patients received an exercise reminder . On the day of the intervention , influenza , pneumococcal polysaccharide , and tetanus-diphtheria ( Td ) vaccines vaccine were administered significantly ( P<0.01 ) more commonly to intervention patients in one clinic , Td in the second , and none in the third . There were no additional significant differences during one year of follow-up . A number of barriers to comprehensive vaccination were encountered A controlled prospect i ve study of an  infant immunization surveillance program  in Rhode Isl and demonstrated significant motivational effects of the program on parents of newborn infants .  Immunizations were initiated more often at the earliest appropriate age and higher overall levels of immunization with certain vaccines were obtained in the portion of the population subjected to the program than among controls . The effect was most pronounced in the lowest social class and diminished successively with increasing social rank . Costs were estimated to be $ 42 per additional child immunized . Strengths and weaknesses revealed by the study suggest that costs could be further reduced by nearly one third with but minor changes in the program , and without diminishing its effectiveness OBJECTIVE To evaluate the incremental effect of a second client reminder postcard or an influenza tool kit targeted toward employers on increasing influenza vaccination rates among adults age < 65 years at high risk for complications from influenza illness . METHODS In this demonstration study , enrollees of 3 managed care organizations ( n = 8881 ) were r and omized at the employer level into 4 arms : 1 postcard , 2 postcards , 1 postcard + tool kit , and 2 postcards + tool kit . The postcards and tool kits were mailed during the fall of 2001 , and their effect on influenza vaccination rates was assessed through a survey . RESULTS Compared with a single postcard , 2 postcards increased vaccination rates by 4 percentage points ( adjusted relative risk = 1.05 ; P < .05 ) among persons aged 50 to 64 years but did not have any effect among younger adults . Older adults had a greater burden of disease and reported more favorable knowledge and attitudes toward the influenza vaccine . The influenza tool kit did not appear to have any incremental effect on vaccination rates . CONCLUSIONS Our findings underscore the necessity of evaluating the effectiveness of interventions in different population subgroups and of identifying factors that modify the effectiveness of interventions . Rigorous assessment of intervention effectiveness in managed care setting s will enable decision makers to optimize use of scarce healthcare dollars for improving the health and well-being of enrollees 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 OBJECTIVE To test the effectiveness of customized , family-oriented reminder letters in activating patients to seek appropriate preventive services . DESIGN R and omized clinical trial . One group received computer-generated , customized letters explaining recommended preventive procedures for each family member . A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups . A third group ( control group ) received no letters .  SETTING A private medical centre , without university affiliation , in rural Quebec . PARTICIPANTS From 8770 patients who met study criteria , 719 families were r and omly selected . Data were available for 1971 of 1998 patients in these families . MAIN OUTCOME MEASURES The Family Received Index is the proportion of all procedures for which a family was overdue that they received . The Family End-of- study Up-to- date Index is the proportion of procedures for which the family was eligible and for which they were up-to- date at the end of the study . RESULTS The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters ( Kruskal-Wallis P = .0139 ) . Comparison of the Family End-of- study Up-to- date indices also demonstrated that families of patients sent customized letters were more likely to be up-to- date than families not sent letters ( Kruskal-Wallis P = .0054 ) . No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group . CONCLUSIONS This study demonstrates a clinical ly small but statistically significant value to customizing reminder letters The purpose of this study was to examine the effect text messages ( TM ) immunization reminders have on immunization rates in the first 7 months of life . This r and omized-control trial enrolled 57 parent/infant dyads and had a 74 % completion rate ( 43 ) at the end of the study period . The study was approved by Committee on Human Subjects at the University of Hawaii Institutional Board Review . All participants completed a demographics form and a  Barriers to Immunization Survey  ( SHOTS survey ) at the start and end of the study . Parents received TM at 4 , 7 , 12 , 15 , 20 , & 23 weeks of child 's age . The intervention group received immunization reminders and the control group received healthy baby messages . In the overall mixed model , between enrollment and 7 months of age , the barriers to immunizations decreased for all parents significantly . There were no significant differences in immunization rates between groups at 7 months of age . Positive responses from regarding TM interventions show this is a promising intervention , but further research is required regarding how to address behavior change and motivation for health prevention behaviors with TM Publication bias can be considered to have three stages : ( 1 ) Prepublication bias occurs in the performance of research , caused by ignorance , sloth , greed , or the double st and ard applied to clinical trials but not to clinical practice . ( 2 ) Publication bias refers to basing acceptance or rejection of a manuscript on whether it supports the treatment tested . Potentially biased review ers are of equal concern . ( 3 ) Postpublication bias occurs in publishing interpretations , review s , and meta-analyses of published clinical trials . Bias can be minimized by ( 1 ) insisting on high- quality research and thorough literature review s , ( 2 ) eliminating the double st and ard concerning peer review and informed consent applied to clinical research and practice , ( 3 ) publishing legitimate trials regardless of their results , ( 4 ) requiring peer review ers to acknowledge conflicts of interest , ( 5 ) replacing ordinary review articles with meta-analyses , and ( 6 ) requiring the authors of review s to acknowledge possible conflicts of interest OBJECTIVE We compared the effectiveness and cost-effectiveness of : 1 ) central ized reminder/recall ( C-R/R ) using the Colorado Immunization Information System ( CIIS ) versus practice -based reminder/recall ( PB-R/R ) approaches to increase immunization rates ; 2 ) different levels of C-R/R intensity ; and 3 ) C-R/R with versus without the name of the child 's provider . METHODS We conducted 3 sequential cluster-r and omized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 ( trial 1 ) , October 2013 ( trial 2 ) , and May 2014 ( trial 3 ) . In C-R/R counties , the intensity of the intervention decreased sequentially in trials 1 through 3 , from 3 to 1 recall messages . In PB-R/R counties , practice s were offered training using CIIS and financial support . The percentage of children with up-to- date ( UTD ) vaccinations was compared 6 months after recall . A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates . RESULTS C-R/R was more effective in trials 1 to 3 ( relative risk = 1.11 ; 95 % confidence interval 1.01 - 1.20 ; P = .009 ) . Effectiveness did not decrease with decreasing intervention intensity ( P = .59 ) . Costs decreased with decreasing intensity in the C-R/R arm , from $ 18.72 per child brought UTD in trial 1 to $ 10.11 in trial 3 . Costs were higher and more variable in the PB-R/R arm , ranging from $ 20.63 to $ 237.81 per child brought UTD . C-R/R was significantly more effective if the child 's practice name was included ( P < .0001 ) . CONCLUSIONS C-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the child 's provider name . Three reminders were not more effective than one , which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials Homeless adults are at high risk for hepatitis B virus ( HBV ) infection . In addition to culturally sensitive programmes design ed to enhance vaccination compliance , accelerated HBV vaccination ( three doses over 21 days ) have also been suggested to improve compliance among high-risk groups . In this paper , we examined predictors of completers of two of three doses of a HAV/HBV vaccine series , normally delivered over a 6-month period , to simulate compliance with an accelerated series , dosed over 4 weeks . A convenience sample of 865 homeless adults was r and omized into a nurse case-managed approach ( NCMIT ) vs st and ard programmes with ( SIT ) and without tracking ( SI ) . Each group was assessed for completion of two of the three dose HAV/HBV vaccine series as well as the full three dose vaccine series . Sixty-eight percent of the NCMIT participants completed the three dose vaccination series at 6 months compared to 61 % of SIT participants and 54 % of SI participants . Eighty-one percent of the NCMIT participants completed two of the vaccinations compared to 78 % of SIT participants and 73 % of SI participants . The NCMIT approach result ed in greater numbers of completers of two of three doses and of the full three dose vaccine series . Predictors of completers of two doses and the full three dose vaccine series are provided . A greater number of homeless persons  completed two doses across the three groups compared to the three dose vaccine series . The use of nurse case-management and tracking , coupled with an accelerated HAV/HBV vaccination schedule , may optimize vaccination compliance in homeless adults OBJECTIVES To measure the accuracy and quality of immunization information systems in a range of low-income countries eligible to receive GAVI support . METHODS The Data Quality Audit ( DQA ) uses a WHO vali date d , st and ard methodology to compare data collected from health unit ( HU ) records of immunizations administered with reports of immunizations at central level and to collect quality indicators of the reporting system . The verification factor ( VF ) , as a measure of accuracy , expresses the proportion of immunizations reported at national level that can be tracked down to the HU . A VF of 80 % or above entitles countries to receive additional GAVI financial support . Quality indicators are assigned points which were summed to obtain quality scores ( QS ) at national , district and HU levels . DQAs included here were conducted between 2002 and 2005 in 41 countries , encompassing 1082 primary healthcare units in 188 r and omly selected districts . RESULTS Almost half of countries obtained a VF below 80 % and only nine showed consistently high VF and QS scores . The most frequent weaknesses in the information systems were inconsistency of denominators used to estimate coverage , poor availability of guidelines ( e.g. for late reporting ) , incorrect estimations of vaccine wastage and lack of feedback on immunization performance . In all six countries that failed a first DQA and undertook a second DQA , the VF and all QSs improved , not all of them statistically significantly . CONCLUSIONS The DQA is a diagnostic tool to reveal a number of crucial problems that affect the quality of immunization data in all tiers of the health system . It identifies good performance at HU and district levels which can be used as examples of best practice s. The DQA methodology brings data quality issues to the top of the agenda to improve the monitoring of immunization coverage INTRODUCTION Pregnant women , postpartum women , and infants are at high risk for complications from influenza . From October to November 2012 , Text4baby , a free national text service for pregnant women and mothers of infants aged < 1 year , implemented a module of interactive messages encouraging maternal influenza vaccination . A program evaluation examined whether a text-based reminder or tailored education improved self-reported influenza vaccination or intent to be vaccinated later in the influenza season among Text4baby participants . METHODS Nearly one third ( 28,609/89,792 ) of enrollees responded to a text asking about their vaccination plans . Those planning to receive vaccination were r and omly assigned to receive an encouragement message or an encouragement message plus the opportunity to schedule a reminder ( n=3,021 at follow-up ) . Those not planning to be vaccinated were r and omly assigned to receive general education or education tailored to their reason for non-vaccination ( n=3,820 at follow-up ) . The effect of the enhanced messages was assessed using multinomial logistic regression in 2013 - 2014 . RESULTS A reminder increased the odds of vaccination at follow-up among mothers ( AOR=2.0 , 95 % CI=1.4 , 2.9 ) and of continued intent to be vaccinated later in the season ( pregnant , AOR=2.1 , 95 % CI=1.4 , 3.1 ; mother , AOR=1.7 , 95 % CI=1.1 , 2.5 ) . Among mothers not planning to be vaccinated because of cost , those who received a tailored message about low-cost vaccination had higher odds of vaccination at follow-up ( AOR=1.9 , 95 % CI=1.1 , 3.5 ) . Other tailored messages were not effective . CONCLUSIONS Text reminders and tailored education may encourage influenza vaccination among this vulnerable population ; both have now been incorporated into Text4baby BACKGROUND Influenza morbidity and mortality remain high in the United States although vaccination clearly improves health outcomes and reduces health expenditures . This study was design ed to assess the effectiveness of mail and telephone reminder strategies on improving existing clinic influenza vaccination rates among those not seeking early seasonal vaccination . METHODS In mid-November , we r and omized 1371 patients at a hypertension clinic into 1 of 2 intervention groups , a mail reminder group ( letter plus the Centers for Disease Control [ CDC ] Influenza Vaccine Information Statement ) or a phone reminder group ( same information via a personal phone call ) , or a control group . The following spring , records were review ed for vaccination documentation . Patients without documentation were contacted by phone to identify whether vaccination for the current season had been obtained . RESULTS The final analysis included 884 patients ( 62 % women , mean age 57.2 years old ) : 325 in the mail reminder group , 246 in the phone reminder group , and 313 represented the control group . Overall , 388 of these patients ( 44 % ) were vaccinated . Vaccination rates were significantly higher in the intervention groups , 46 % for the mail reminder group ( age and sex adjusted odds ratio [ OR ] , 1.8 , 95 % confidence interval [ CI ] , 1.3 - 2.5 ; P=.001 ) and 56 % for the phone reminder group ( OR , 2.8 ; 95 % CI , 1.9 - 4.0 ; P<.0001 ) , compared to 33 % in the control group . Both interventions increased vaccination rates in all age/sex groups . CONCLUSION In contrast to earlier studies , this intervention occurred later in the influenza vaccination period excluding those who seek early vaccination and allowing interventions to target those less likely to receive vaccination . Compared to previous studies demonstrating only trivial or modest benefits , both mail and phone reminders effectively increased clinic vaccination rates in our group of patients PURPOSE To assess the effect of phone or text message reminders to parents of adolescents on human papillomavirus ( HPV ) vaccine series completion in Rochester , NY . METHODS We performed parallel r and omized controlled trials of phone and text reminders for HPV vaccine for parents of 11- to 17-year olds in three urban primary care clinics . The main outcome measures were time to receipt of the third dose of HPV vaccine and HPV vaccination rates . RESULTS We enrolled 178 phone intervention ( 180 control ) and 191 text intervention ( 200 control ) participants . In multivariate survival analysis controlling for gender , age , practice , insurance , race , and ethnicity , the time from enrollment to receipt of the third HPV dose for those receiving a phone reminder compared with controls was not significant overall ( hazard ratio [ HR ] = 1.30 , p = .12 ) but was for those enrolling at dose 1 ( HR = 1.91 , p = .007 ) . There was a significant difference in those receiving a text reminder compared with controls ( HR = 2.34 , p < .0001 ; an average of 71 days earlier ) . At the end of the study , 48 % of phone intervention versus 40 % of phone control ( p = .34 ) , and 49 % of text intervention versus 30 % of text control ( p = .001 ) adolescents had received 3 HPV vaccine doses . CONCLUSIONS In this urban population of parents of adolescents , text message reminders for HPV vaccine completion for those who had already started the series were effective , whereas phone message reminders were only effective for those enrolled at dose 1 OBJECTIVES We conducted 2 studies to determine the impact of text message immunization reminder-recalls in an urban , low-income population . METHODS In 1 study , text message immunization reminders were sent to a r and om sample of parents ( n = 195 ) whose children aged 11 to 18 years needed either or both meningococcal ( MCV4 ) and tetanus-diphtheria-acellular pertussis ( Tdap ) immunizations .  We compared receipt of MCV4 or Tdap at 4 , 12 , and 24 weeks with age- and gender-matched controls . In the other study , we compared attendance at a postshortage Haemophilus influenzae B ( Hib ) immunization recall session between parents who received text message and paper-mailed reminders ( n = 87 ) and those who only received paper-mailed reminders ( n = 87 ) . RESULTS Significantly more adolescents with intervention parents received either or both MCV4 and Tdap  at weeks 4 ( 15.4 % vs 4.2 % ; P < .001 ) , 12 ( 26.7 % vs 13.9 % ; P < .005 ) , and 24 ( 36.4 % vs 18.1 % ; P < .001 ) . Significantly more parents who received both Hib reminders attended a recall session compared with parents who only received a mailed reminder ( 21.8 % vs 9.2 % ; P < .05 ) . After controlling for age , gender , race/ethnicity , insurance status , and language , text messaging was still significantly associated with both studies ' outcomes . CONCLUSIONS Text messaging for reminder-recalls improved immunization coverage in a low-income , urban population
BACKGROUND Immunization rates for children and adults are rising , but coverage levels have not reached optimal goals .
As a result , vaccine-preventable diseases still occur .
In an era of increasing complexity of immunization schedules , rising expectations about the performance of primary care , and large dem and s on primary care providers , it is important to underst and and promote interventions that work in primary care setting s to increase immunization coverage .
One common theme across immunization programs in many nations involves the challenge of implementing a population -based approach and identifying all eligible recipients , for example the children who should receive the measles vaccine .
However , this issue is gradually being addressed through the availability of immunization registries and electronic health records .
A second common theme is identifying the best strategies to promote high vaccination rates .
Three types of strategies have been studied : ( 1 ) patient-oriented interventions , such as patient reminder or recall , ( 2 ) provider interventions , and ( 3 ) system interventions , such as school laws .
One of the most prominent intervention strategies , and perhaps best studied , involves patient reminder or recall systems .
OBJECTIVES To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations .