Randomised cluster trial to support informed parental decision-making for the MMR vaccine Targeted mailing of information to improve uptake of measles, mumps, and rubella vaccine: a randomised controlled trial. A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital. “Communicate to vaccinate”: the development of a taxonomy of communication interventions to improve routine childhood vaccination Household cost-benefit equations and sustainable universal childhood immunisation: a randomised cluster controlled trial in south Pakistan [ISRCTN12421731] Effects of quality improvement in health facilities and community mobilization through women’s groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial Impact of a novel way to communicate information about MMR on uptake of MMR vaccine: a randomized controlled trial. Effect of scaling up women's groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial Cognitive processes and the decisions of some parents to forego pertussis vaccination for their children. Impact of guidelines to alter antitetanus prophylaxis practices and reduce costs in the emergency department. Primary care strategies to improve childhood immunisation uptake in developed countries: systematic review Reducing resistance against polio drops Informing resource-poor populations and the delivery of entitled health and social services in rural India: a cluster randomized controlled trial. Impact of a community-based integrated management of childhood illnesses (IMCI) programme in Gegharkunik, Armenia. Hepatitis B vaccination of newborn infants in rural China: evaluation of a village-based, out-of-cold-chain delivery strategy. Patient communication: a multidisciplinary approach using animated cartoons. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial Evidence-based discussion increases childhood vaccination uptake: a randomised cluster controlled trial of knowledge translation in Pakistan Impact of Health Education on Mothers' Knowledge of Preventive Health Practices Vaccination--coverage of under-fives, validity of records, and the impact of mass campaigns in the Edendale/Vulindlela district of KwaZulu. A media campaign to promote pneumococcal vaccinations: is a telephone survey an effective evaluation strategy? A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level. The effect of patient education on pediatric immunization rates. School health nurse interventions to increase immunisation uptake in school entrants. Successful promotion of hepatitis B vaccinations among Vietnamese-American children ages 3 to 18: results of a controlled trial. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education. Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries. Positive Impact of a Shelter-based Hepatitis B Vaccine Program in Homeless Baltimore Children and Adolescents Initiatives to improve childhood immunisation uptake: a randomised controlled trial Are reminder stickers effective in reducing immunization dropout rates in Addis Ababa, Ethiopia? What do parents learn by reading a DPT vaccine information form? 'Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK. The impact of computer-generated messages on childhood immunization coverage. [Effect of hepatitis health promotion project in schools of Beijing and Gansu]. A Preschool Immunization Project to Enhance Immunization Levels, the Public-Private Relationship, and Continuity of Care [Positive impact of a video and TV documentary on attendance of women to catch-up collective vaccinations and reasons for non-attendance]. Community Mothers Programme--seven year follow-up of a randomized controlled trial of non-professional intervention in parenting.
Background In the UK public concern about the safety of the combined measles , mumps and rubella [ MMR ] vaccine continues to impact on MMR coverage . Whilst the sharp decline in uptake has begun to level out , first and second dose uptake rates remain short of that required for population immunity . Furthermore , international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children . Together , this work suggests that effective interventions are required to support parents to make informed decisions about MMR.This trial assessed the impact of a parent-centred , multi-component intervention ( balanced information , group discussion , coaching exercise ) on informed parental decision-making for MMR . Methods This was a two arm , cluster r and omised trial . One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations . The intervention arm received an MMR information leaflet and participated in the intervention ( parent meeting ) . The control arm received the leaflet only . The primary outcome was decisional conflict . Secondary outcomes were actual and intended MMR choice , knowledge , attitude , concern and necessity beliefs about MMR and anxiety . Results Decisional conflict decreased for both arms to a level where an ' effective ' MMR decision could be made one-week ( effect estimate = -0.54 , p < 0.001 ) and three-months ( effect estimate = -0.60 , p < 0.001 ) post-intervention . There was no significant difference between arms ( effect estimate = 0.07 , p = 0.215 ) . Heightened decisional conflict was evident for parents making the MMR decision for their first child ( effect estimate = -0.25 , p = 0.003 ) , who were concerned ( effect estimate = 0.07 , p < 0.001 ) , had less positive attitudes ( effect estimate = -0.20 , p < 0.001 ) yet stronger intentions ( effect estimate = 0.09 , p = 0.006 ) . Significantly more parents in the intervention arm reported vaccinating their child ( 93 % versus 73 % , p = 0.04 ) . Conclusions Whilst both the leaflet and the parent meeting reduced parents ' decisional conflict , the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake 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 BACKGROUND While the Advisory Committee on Immunization Practice s recommends a st and ing order as the most effective mechanism to increase pneumococcal and influenza vaccination rates , Georgia 's Medical Practice Act does not authorize nurses to screen , order , and administer adult vaccines in inpatient setting s. METHODS The setting was a 1000-bed public teaching hospital in metropolitan Atlanta . A 1-month intervention ( INT1 ) included four wards r and omized to intervention or control . A 5-month hospital-wide intervention ( INT2 ) followed INT1 . The intervention used was provider reminder with in-service training .  Chart review was the measure used . The main outcome was pneumococcal vaccination prior to discharge . RESULTS During INT1 , 534 patients ( 296 intervention and 238 control ) were discharged . Of the 534 patients , 475 ( 89.0 % ) were African American , 188 ( 35.2 % ) were uninsured , and the median age was 48 ( range 19 to 96 ) . Of the 205 intervention patients with vaccine indications and no contraindications , 78 of 205 ( 38 % ) were vaccinated compared to 7 of 143 ( 4.9 % ) of the control patients ( p<0.001 ) . During INT2 , 879 patient charts were review ed . Patient demographics were similar to INT1 . However , of 554 eligible patients , 16 % were vaccinated , significantly higher than control floors during INT1 ( p<0.001 ) . Although nurses initiated the form almost 70 % of the time , physicians assessed fewer than 35 % of patients with indications . CONCLUSIONS Significantly higher proportions of high-risk patients were vaccinated through the use of a preprinted nurse screening and physician order form . However , a significant percentage of patients did not receive the vaccine owing to the physician 's failure to order it . In these cases , use of st and ing orders would have further increased vaccination rates while also promoting a more sustainable program Background Vaccination is a cost-effective public health measure and is central to the Millennium Development Goal of reducing child mortality . However , childhood vaccination coverage remains sub-optimal in many setting s. While communication is a key feature of vaccination programmes , we are not aware of any comprehensive approach to organising the broad range of communication interventions that can be delivered to parents and communities to improve vaccination coverage . Developing a classification system ( taxonomy ) organised into conceptually similar categories will aid in : underst and ing the relationships between different types of communication interventions ; facilitating conceptual mapping of these interventions ; clarifying the key purpose s and features of interventions to aid implementation and evaluation ; and identifying areas where evidence is strong and where there are gaps . This paper reports on the development of the ‘ Communicate to vaccinate ’ taxonomy . Methods The taxonomy was developed in two stages . Stage 1 included : 1 ) forming an advisory group ; 2 ) search ing for descriptions of interventions in trials ( CENTRAL data base ) and general health literature ( Medline ) ; 3 ) developing a sampling strategy ; 4 ) screening the search results ; 5 ) developing a data extraction form ; and 6 ) extracting intervention data . Stage 2 included : 1 ) grouping the interventions according to purpose ; 2 ) holding deliberative forums in English and French with key vaccination stakeholders to gather feedback ; 3 ) conducting a targeted search of grey literature to supplement the taxonomy ; 4 ) finalising the taxonomy based on the input provided . Results The taxonomy includes seven main categories of communication interventions : inform or educate , remind or recall , teach skills , provide support , facilitate decision making , enable communication and enhance community ownership . These categories are broken down into 43 intervention types across three target groups : parents or soon-to-be-parents ; communities , community members or volunteers ; and health care providers . Conclusions Our taxonomy illuminates and organises this field and identifies the range of available communication interventions to increase routine childhood vaccination uptake . We have utilised a variety of data sources , capturing information from rigorous evaluations such as r and omised trials as well as experiences and knowledge of practitioners and vaccination stakeholders . The taxonomy reflects current public health practice and can guide the future development of vaccination programmes Background Household decision-makers decide about service use based largely on the costs and perceived benefits of health interventions . Very often this leads to different decisions than those imagined by health planners , result ing in under-utilisation of public services like immunisation . In the case of Lasbela district in the south of Pakistan , only one in every ten children is immunised despite free immunisation offers by government health services . Methods / design In 32 communities representative of Lasbela district , 3344 households participated in a baseline survey on early child health . In the 18 r and omly selected intervention communities , we will stimulate discussion s on the household cost-benefit equation , as measured in the baseline . The reference ( control ) communities will also participate in the three annual follow-up surveys , feedback of the general survey results and the usual health promotion activities relating to immunisation , but without focussed discussion on the household cost-benefit equations . Discussion This project proposes knowledge translation as a two-way communication that can be augmented by local and international evidence . We will document cultural and context ual barriers to immunisation in the context of household cost-benefit equations . The project makes this information accessible to health managers , and reciprocally , makes information on immunisation effects and side effects available to communities . We will measure the impact of this two-way knowledge translation on immunisation uptake Background Maternal , perinatal and neonatal mortality remains high in low-income countries . We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi . Methods We evaluated a rural participatory women ’s group community intervention ( CI ) and a quality improvement intervention at health centres ( FI ) via a two-by-two factorial cluster r and omized controlled trial . Consenting pregnant women were followed-up to 2 months after birth using key informants . Primary outcomes were maternal , perinatal and neonatal mortality . Clusters were health centre catchment areas assigned using stratified computer-generated r and omization . Following exclusions , including non-birthing facilities , 61 clusters were analysed : control ( 17 clusters , 4912 births ) , FI ( 15 , 5335 ) , CI ( 15 , 5080 ) and FI + CI ( 14 , 5249 ) . This trial was registered as International St and ard R and omised Controlled Trial [ IS RCT N18073903 ] . Outcomes for 14 576 and 20 576 births were recorded during baseline ( June 2007–September 2008 ) and intervention ( October 2008–December 2010 ) periods . Results For control , FI , CI and FI + CI clusters neonatal mortality rates were 34.0 , 28.3 , 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2 , 55.1 , 48.0 and 48.4 per 1000 births , during the intervention period . Adjusting for clustering and stratification , the neonatal mortality rate was 22 % lower in FI + CI than control clusters ( OR = 0.78 , 95 % CI 0.60–1.01 ) , and the perinatal mortality rate was 16 % lower in CI clusters ( OR = 0.84 , 95 % CI 0.72–0.97 ) . We did not observe any intervention effects on maternal mortality . Conclusions Despite implementation problems , a combined community and facility approach using participatory women ’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi BACKGROUND Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years . 90 % of deliveries in the poorest quintile of households happen at home . We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates . METHODS We pair-matched 42 geopolitical clusters in Makwanpur district , Nepal , selected 12 pairs r and omly , and r and omly assigned one of each pair to intervention or control . In each intervention cluster ( average population 7000 ) , a female facilitator convened nine women 's group meetings every month . The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them . We monitored birth outcomes in a cohort of 28?931 women , of whom 8 % joined the groups . The primary outcome was neonatal mortality rate . Other outcomes included stillbirths and maternal deaths , uptake of antenatal and delivery services , home care practice s , infant morbidity , and health-care seeking . Analysis was by intention to treat . The study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N31137309 . FINDINGS From 2001 to 2003 , the neonatal mortality rate was 26.2 per 1000 ( 76 deaths per 2899 livebirths ) in intervention clusters compared with 36.9 per 1000 ( 119 deaths per 3226 livebirths ) in controls ( adjusted odds ratio 0.70 [ 95 % CI 0.53 - 0.94 ] ) . Stillbirth rates were similar in both groups . The maternal mortality ratio was 69 per 100000 ( two deaths per 2899 livebirths ) in intervention clusters compared with 341 per 100000 ( 11 deaths per 3226 livebirths ) in control clusters ( 0.22 [ 0.05 - 0.90 ] ) . Women in intervention clusters were more likely to have antenatal care , institutional delivery , trained birth attendance , and hygienic care than were controls . INTERPRETATION Birth outcomes in a poor rural population improved greatly through a low cost , potentially sustainable and scalable , participatory intervention with women 's groups The widespread decline in uptake of the measles , mumps and rubella ( MMR ) vaccine started when an association between vaccination and Crohn ’s disease was suggested by research ers at the Royal Free Hospital and elsewhere in a series of papers published between 1993 and 1996 . It accelerated after February 1998 when the same workers hypothesized an association with autism through a putative mechanism of enterocolitis and toxin absorption . The widespread media coverage that the papers received result ed in a substantial minority of parents being misled into believing that there was a large body of medical opinion suspicious of MMR .  Uptake of MMR vaccine  began to decline rapidly and the incidence of measles and mumps infections increased . Novel methods of improving uptake of MMR vaccine  have been explored , but the authors ’ approach – to issue teddy bears wearing T-shirts displaying a website address and telephone number that provided information about MMR – has not been described previously . A pragmatic r and omized controlled trial was design ed with prospect i ve selection of subjects . Children eligible for their first dose of MMR vaccine ( MMR1 ) in Flintshire , being seen by their health visitor ( HV ) for the routine 8-month assessment , were recruited to the study . At the time of planning the study , Flintshire had the lowest uptake rate of all childhood immunizations inWales and the lowest uptake of MMR1 ( 69 % ) in North Wales . Children were r and omized to receive normal management plus a teddy bear ( intervention arm of the study ) or normal management alone ( nonintervention arm of the study ) . The bear ’s T-shirt contained three items of information BACKGROUND Two recent trials have shown that women 's groups can reduce neonatal mortality in poor communities . We assessed the effectiveness of a scaled-up development programme with women 's groups to address maternal and neonatal care in three rural districts of Bangladesh . METHODS 18 clusters ( with a mean population of 27 953 [ SD 5953 ] ) in three districts were r and omly assigned to either intervention or control ( nine clusters each ) by use of stratified r and omisation . For each district , cluster names were written on pieces of paper , which were folded and placed in a bottle . The first three cluster names drawn from the bottle were allocated to the intervention group and the remaining three to control . All clusters received health services strengthening and basic training of traditional birth attendants . In intervention clusters , a facilitator convened 18 groups every month to support participatory action and learning for women , and to develop and implement strategies to address maternal and neonatal health problems . Women were eligible to participate if they were aged 15 - 49 years , residing in the project area , and had given birth during the study period ( Feb 1 , 2005 , to Dec 31 , 2007 ) . Neither study investigators nor participants were masked to treatment assignment . In a population of 229 195 people ( intervention clusters only ) , 162 women 's groups provided coverage of one group per 1414 population . The primary outcome was neonatal mortality rate ( NMR ) . Analysis was by intention to treat . This trial is registered as an International St and ard R and omised Controlled Trial , number IS RCT N54792066 . FINDINGS We monitored outcomes for 36 113 births ( intervention clusters , n=17 514 ; control clusters , n=18 599 ) in a population of 503 163 over 3 years . From 2005 to 2007 , there were 570 neonatal deaths in the intervention clusters and 656 in the control clusters . Cluster-level mean NMR ( adjusted for stratification and clustering ) was 33.9 deaths per 1000 livebirths in the intervention clusters compared with 36.5 per 1000 in the control clusters ( risk ratio 0.93 , 95 % CI 0.80 - 1.09 ) . INTERPRETATION For participatory women 's groups to have a significant effect on neonatal mortality in rural Bangladesh , detailed attention to programme design and context ual factors , enhanced population coverage , and increased enrolment of newly pregnant women might be needed . FUNDING Women and Children First , the UK Big Lottery Fund , Saving Newborn Lives , and the UK Department for International Development Public health analyses suggest that , in spite of the possibility that pertussis vaccine may cause rare cases of neurological injury , catastrophic risks to individual children are lower if they are vaccinated . A number of parents , however , choose not to vaccinate their children . The purpose of this study was to investigate the decision processes of some parents who choose to vaccinate and some parents who choose not to do so .  Surveys were mailed to 500 r and omly selected subscribers of Mothering magazine . Two hundred and ninety-four completed question naires were returned ( 59 % ) . In addition to well-recognized factors in vaccination decisions , perceived dangers of the vaccine , and of the disease and susceptibility to the disease , several cognitive processes not previously considered in vaccination decision studies were found to be important predictors in this population of parents : perceived ability to control children 's susceptibility to the disease and the outcome of the disease ; ambiguity or doubts about the reliability of vaccine information ; a preference for errors of omission over errors of commission ; and recognition that if many other children are vaccinated , the risk to unvaccinated children may be lowered . Although perhaps most cases of undervaccination for pertussis reflect more general problems of health care access , some parents choose to forego vaccination for their children for other reasons . Traditional risk-benefit arguments alone will be unlikely to persuade these parents to reassess their decisions . Efforts to increase childhood vaccination must incorporate an underst and ing of the cognitive processes that help drive these decisions The objective of this study was to assess the impact of an intervention to modify antitetanus prophylaxis of open wounds . This prospect i ve , before- and -after study was conducted in an emergency department of a large metropolitan hospital . Consecutive patients with open wounds were managed according to the World Health Organization ( WHO ) guidelines before an intervention , then according to new guidelines afterwards . Locally developed guidelines were introduced and backed up by a teaching program , with emphasis on reducing unwarranted human tetanus immunoglobulins and costs . Serum tetanus antitoxins level was measured in postintervention patients mainly to verify the soundness of the intervention , eventually to complete patients ' protection during follow-up , and to derive more reliable recommendations for the future . Main outcome measures included the number of treatments conforming to each set of guidelines , the rate of tetanus immunoglobulin prescriptions , and the cost of each strategy .  Two groups of 389 and 459 patients were included .  Treatment conforming to guidelines increased from 60 % to 79 % , undertreatment decreased from 31 % to 19 % , and overtreatment decreased from 9 % to 2 % ( P < 0.001 ) .  Tetanus immunoglobulin prescriptions decreased from 23 % to 1 % ( P < 0.001 ) . On the basis of antitoxins level , 60 % of 367 postintervention patients were correctly treated , 29 % were overtreated , and 11 % were undertreated . Nevertheless , with the WHO guidelines , only 49 % would have been correctly treated , 39 % would have been overtreated ( 29 % with immunoglobulins ) , and 12 % would have been undertreated ( P < 0.001 ) . Costs decreased from $ 32 to $ 24 per patient . New guidelines result ed in improved tetanus prophylaxis at reduced costs in an emergency department . Because they rely on immunization history , however , guidelines currently in use are misleading . More reliable recommendations , including a test for tetanus antibody status in some cases , are needed Objectives To conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries . Design Systematic review . Setting Developed countries Participants Preschool children who were due , or overdue , one or more of their routine primary immunisations . Main outcome measures Increase in the proportion of the target population up to date with st and ard recommended universal vaccinations . Results Forty-six studies were included for analysis , published between 1980 and 2009 . Twenty-six studies were r and omized controlled trials , 11 were before and after trials , and nine were controlled intervention trials . Parental reminders showed a statistically significant increase in immunisation rates in 34 % of included intervention arms . These effects were reported with both generic and specific reminders and with all methods of reminders and recall . Strategies aim ed at immunisation providers were also shown to improve immunisation rates with a median change in immunisation rates of 7 % when reminders were used , 8 % when educational programmes were used and 19 % when feedback programmes were used . Conclusion General practitioners are uniquely positioned to influence parental decisions on childhood immunisation . A variety of strategies studied in primary care setting s have been shown to improve immunisation rates , including parental and healthcare provider reminders Aims : The present study was carried out to impart correct health education regarding polio eradication programme and to assess the impact of social mobilization of a Muslim community carried out by medical interns . Methods : One round of a polio immunization campaign was selected r and omly . Five highly resistant areas were included in the study . During house to house A-Team activity , teams of health workers visited the houses and resistant families were identified . These families refused to give polio drops to their children . On the second day of A-Team activity , medical interns visited those identified resistant families . They imparted correct health education and tried to convince them to give polio drops . However , after prolonged persuasion , some of the families were not ready to give polio drops . These more resistant families were again visited by more motivated and enthusiastic teams during B-Team activity , started two to three days after the completion of A-Team activity . Data were collected , tabulated and analysed . Results : Total number of resistant families identified during house to house A-Team activity was 1025 in five high risk areas of Aligarh , India . Out of 1025 resistant houses , 510 ( 49.76 % ) houses were converted to P houses where polio drops were given to the children . Five hundred and fifteen ( 50.24 % ) houses remained resistant even after social mobilization by A-Team members . These most resistant houses were again visited by B-team members . Out of these 515 houses , polio drops were administered in 303 ( 58.83 % ) . The overall number of converted houses was 813 ( 79.32 % ) after A and B-team activities . 20.68 % of families remained resistant and their children could not be given polio drops . Conclusions : In all high risk areas , maximum numbers of resistant houses were converted to P houses . These families were persuaded and convinced by the teams of interns , social workers and influential persons that polio drops did not have any side effects . They were more receptive to the advice given by medical interns compared to other staff members of the Government District Hospital because of quality of health services provided to the community . There is a need to impart correct health education regarding importance of polio drops and routine immunization more vigorously through information , education and communication ( IEC ) activities CONTEXT A lack of awareness about entitled health and social services may contribute to poor delivery of such services in developing countries , especially among individuals of low socioeconomic status . OBJECTIVE To determine the impact of informing re source -poor rural population s about entitled services . DESIGN , SETTING , AND PARTICIPANTS Community-based , cluster r and omized controlled trial conducted from May 2004 to May 2005 in 105 r and omly selected village clusters in Uttar Pradesh state in India . Households ( 548 intervention and 497 control ) were selected by a systematic sampling design , including both low-caste and mid- to high-caste households . INTERVENTION Four to 6 public meetings were held in each intervention village cluster to disseminate information on entitled health services , entitled education services , and village governance requirements . No intervention took place in control village clusters . MAIN OUTCOME MEASURES Visits by nurse midwife ; prenatal examinations , tetanus vaccinations , and prenatal supplements received by pregnant women ; vaccinations received by infants ; excess school fees charged ; occurrence of village council meetings ; and development work in villages . RESULTS At baseline , there were no significant differences in self-reported delivery of health and social services . After 1 year , intervention villagers reported better delivery of several services compared with control villagers : in a multivariate analysis , 30 % more prenatal examinations ( 95 % confidence interval [ CI ] , 17%-43 % ; P < .001 ) , 27 % more tetanus vaccinations ( 95 % CI , 12%-41 % ; P < .001 ) , 24 % more prenatal supplements ( 95 % CI , 8%-39 % ; P = .003 ) , 25 % more infant vaccinations ( 95 % CI , 8%-42 % ; P = .004 ) , and decreased excess school fees of 8 rupees ( 95 % CI , 4 - 13 rupees ; P < .001 ) . In a difference-in-differences analysis , 21 % more village council meetings were reported ( 95 % CI , 5%-36 % ; P = .01 ) . There were no improvements in visits by a nurse midwife or in development work in the villages . Both low-caste and mid- to high-caste intervention households reported significant improvements in service delivery . CONCLUSIONS Informing re source -poor rural population s in India about entitled services enhanced the delivery of health and social services among both low- and mid- to high-caste households . Interventions that emphasize educating re source -poor population s about entitled services may improve the delivery of such services . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00421291 BACKGROUND Maternal and child health status in the Martuni region of Gegharkunik marz , Armenia , precipitously declined following Armenia 's independence in 1991 . In response , the American Red Cross ( ARC ) and the Armenian Red Cross Society ( ARCS ) implemented the WHO community-level Integrated Management of Childhood Illnesses ( IMCI ) strategy , complementing recent clinical IMCI training in the region in which 387 community health volunteers from 16 villages were trained as peer educators , and approximately 5000 caretakers of children under age 5 were counselled on key nutrition and health practice s. METHODS A pre-post independent sample design was used to assess the programme 's impact . The evaluation instrument collected respondent demographic characteristics and knowledge , attitudes and practice s consistent with 10 health indicators typical of child survival interventions . At baseline and at follow-up , 300 mothers were interviewed using a stratified simple r and om sampling of households with at least one child less than age 2 . RESULTS The assessment confirmed the population 's poor health status and limited knowledge and application of recommended child care practice s. The campaign reached its target : at follow-up , 67 % had seen media messages within the past month , 82 % had received the IMCI informational booklet , and 30 % had seen other material s. Evidence of the success of the programme included the following : exclusive breastfeeding increased 31.4 % , maternal knowledge of child illness signs increased 30 % , knowledge of HIV increased 28.5 % , and physician attended deliveries increased 15 % . CONCLUSIONS This evaluation documented the significant and substantial impact of the community IMCI programme on both knowledge and practice in rural areas of Armenia . Consideration should be given to continuing and exp and ing this project as a complement to health sector development activities in this region OBJECTIVE To prevent perinatal transmission of hepatitis B virus ( HBV ) , WHO recommends that the first dose of hepatitis B ( HepB ) vaccine be given within 24 hours after birth . This presents a challenge in remote areas with limited cold-chain infrastructure and where many children are born at home . METHODS Rural townships in three counties in China 's Hunan Province were r and omized into three groups with different strategies for delivery of the first dose of HepB vaccine . In group 1 , vaccine was stored within the cold chain and administered in township hospitals . In group 2 , vaccine was stored out of the cold chain in villages and administered by village-based health workers to infants at home . Group 3 used the same strategy as group 2 , but vaccine was packaged in a prefilled injection device . Training of immunization providers and public communication conveying the importance of the birth dose was performed for all groups . FINDINGS Among children born at home , timely administration ( within 24 hours after birth ) of the first dose of HepB vaccine  increased in all groups after the study : group 1 , from 2.4 % to 25.2 % ; group 2 , from 2.6 % to 51.8 % ; and group 3 , from 0.6 % to 66.7 % ; P < 0.001 in each case . No significant difference in antibody response to vaccine was observed between the groups . CONCLUSION Timely administration of the first dose of HepB vaccine  was improved by communication and training activities , and by out-of-cold-chain storage of vaccine and administration at the village level , especially among children born at home Communication is a major problem in the management of patients . Miscommunication occurs frequently in population s with low reading skills , illiteracy does not completely account for the observed low rates of recall of communicated information . Transmission of the message also plays an important role . Successful strategies to improve communication with patients include the use of videotapes , videotape modeling or cartoon illustrations . Do these products communicate effectively because they overcome illiteracy or because they also transmit a very clear message ? Can good transmission of messages overcome illiteracy ? In this study , we compared the effectiveness of a printed message about polio vaccinations with the same message converted into a production of animated cartoons using marketing and advertising techniques . The production that result ed from using this strategy showed that in the setting of this study , a well- design ed animated cartoon is more effective in delivering a message than the same information provided in written instructional material BACKGROUND Community mobilisation through participatory women 's groups might improve birth outcomes in poor rural communities . We therefore assessed this approach in a largely tribal and rural population in three districts in eastern India . METHODS From 36 clusters in Jharkh and and Orissa , with an estimated population of 228 186 , we assigned 18 clusters to intervention or control using stratified r and omisation . Women were eligible to participate if they were aged 15 - 49 years , residing in the project area , and had given birth during the study . In intervention clusters , a facilitator convened 13 groups every month to support participatory action and learning for women , and facilitated the development and implementation of strategies to address maternal and newborn health problems . The primary outcomes were reductions in neonatal mortality rate ( NMR ) and maternal depression scores . Analysis was by intention to treat . This trial is registered as an International St and ard R and omised Controlled Trial , number IS RCT N21817853 . FINDINGS After baseline surveillance of 4692 births , we monitored outcomes for 19 030 births during 3 years ( 2005 - 08 ) . NMRs per 1000 were 55.6 , 37.1 , and 36.3 during the first , second , and third years , respectively , in intervention clusters , and 53.4 , 59.6 , and 64.3 , respectively , in control clusters . NMR was 32 % lower in intervention clusters adjusted for clustering , stratification , and baseline differences ( odds ratio 0.68 , 95 % CI 0.59 - 0.78 ) during the 3 years , and 45 % lower in years 2 and 3 ( 0.55 , 0.46 - 0.66 ) . Although we did not note a significant effect on maternal depression overall , reduction in moderate depression was 57 % in year 3 ( 0.43 , 0.23 - 0.80 ) . INTERPRETATION This intervention could be used with or as a potential alternative to health-worker-led interventions , and presents new opportunities for policy makers to improve maternal and newborn health outcomes in poor population s. FUNDING Health Foundation , UK Department for International Development , Wellcome Trust , and the Big Lottery Fund ( UK ) Background Childhood vaccination rates are low in Lasbela , one of the poorest districts in Pakistan 's Balochistan province . This r and omised cluster controlled trial tested the effect on uptake of informed discussion of vaccination costs and benefits , without relying on improved health services . Methods Following a baseline survey of r and omly selected representative census enumeration areas , a computer generated r and om number sequence assigned 18 intervention and 14 control clusters . The intervention comprised three structured discussion s separately with male and female groups in each cluster . The first discussion shared findings about vaccine uptake from the baseline study ; the second focussed on the costs and benefits of childhood vaccination ; the third focussed on local action plans . Field teams encouraged the group participants to spread the dialogue to households in their communities . Both intervention and control clusters received a district-wide health promotion programme emphasizing household hygiene . Interviewers in the household surveys were blind of intervention status of different clusters . A follow-up survey after one year measured impact of the intervention on uptake of measles and full DPT vaccinations of children aged 12 - 23 months , as reported by the mother or caregiver . Results In the follow-up survey , measles and DPT vaccination uptake among children aged 12 - 23 months ( 536 in intervention clusters , 422 in control clusters ) was significantly higher in intervention than in control clusters , where uptake fell over the intervention period . Adjusting for baseline differences between intervention and control clusters with generalized estimating equations , the intervention doubled the odds of measles vaccination in the intervention communities ( OR 2.20 , 95 % CI 1.24 - 3.88 ) . It trebled the odds of full DPT vaccination ( OR 3.36 , 95 % CI 2.03 - 5.56 ) . Conclusion The relatively low cost knowledge translation intervention significantly increased vaccine uptake , without relying on improved services , in a poor district with limited access to services . This could have wide relevance in increasing coverage in developing countries . Trial registration IS RCT N12421731 A prospect i ve community-based intervention study was conducted in a slum area of Karachi , Pakistan , with the objective of evaluating the impact of health education on the knowledge of mothers . One hundred and fifty households were studied in the intervention and the same in the non-intervention group . The post intervention knowledge scores of the mothers showed a significant difference of P < 0.05 . Nearly 50.7 % mothers in the intervention group knew of at least four diseases against which vaccination is given as compared to the non-intervention group ( P < 0.05 ) . Similarly , mothers in the intervention group were more aware about the advantages of breast feeding , signs of dehydration , measures for prevention of measles and tuberculosis as compared to the non-intervention group ( P < 0.05 ) . Finally , a comparison was made between the pre- and post-intervention scores between the two groups . The score in the non-intervention group changed from 11.5 to 16.1 ( P > 0.05 ) as compared to the intervention group in which it changed from 10.2 to 32.2 ( P < 0.05 ) Recent epidemics of poliomyelitis and measles in the Edendale/Vulindlela district of KwaZulu spurred an investigation into the causes of vaccination failure . Vaccination coverage  achieved by routine clinic services and by two mass campaigns was assessed . The validity of routine clinic vaccination records was also determined . Using a modified 30 x 7 r and om cluster sampling technique , 224 children aged 1 - 5 years were studied . Of these , 62 % had a ' Road to Health ' card . Best estimates show that 87 % had had BCG , 62 % three doses of diphtheria , pertussis and tetanus and polio , and 55 % measles vaccine . The mass campaigns raised coverage for measles by 26 % , and that for polio by 27 % . Coverage estimates made from routine clinic data were consistently 13 - 25 % higher than from this survey . This discrepancy is unfortunate , since it could lead to complacency if certain targets are apparently achieved using only clinic records , and points to the need for regular population -based surveys in all but the best organised health services . Inadequate vaccination coverage alone can explain the epidemics of polio and measles . The reasons for this , in the presence of an adequate clinic infrastructure , need to be assessed urgently to prevent further outbreaks PURPOSE Media campaigns are used to achieve public health goals but few studies have documented whether the goals were met . METHODS Two communities received community-wide efforts to increase the pneumococcal polysaccharide vaccine  ( PPV ) rate in defined pneumococcal disease-risk groups . One community also received a media campaign consisting of television and newspaper advertisements . A r and om-digit-dial telephone survey was conducted before and after the media campaign in both of the design ated media markets . In addition to direct mailings to a sample of Medicare beneficiaries whose Medicare billing records did not indicate a PPV billing cl aim after 1991 , community-wide campaigns consisting of table tents , brochures , flyers , and posters occurred in both markets . A 29-day television campaign and a 5-week newspaper campaign occurred in one of the markets . RESULTS We were unable to detect a significant effect of the media campaign on either PPV awareness or self-reported receipt of pneumococcal vaccine . CONCLUSION While it is important to evaluate community health intervention efforts , evaluations can be very difficult . Because of financial and other limitations , most feasible evaluation methods will not have the power to detect changes attributable to the intervention nor to provide confidence that there was no important change We used a r and omized trial to compare two polio vaccine pamphlets written on a sixth grade level -- the vaccine information statement prepared by the Centers for Disease Control ( CDC ) and an easy-to-read pamphlet we developed (LSU)--for reading ability , comprehension and preference among 610 parents with a broad range of demographic characteristics . Parents at all reading levels and incomes preferred LSU ( 76 % vs. 21 % , P < 0.001 ) . Although readers of LSU achieved significantly higher comprehension ( 65 % vs. 60 % , P < 0.05 ) this difference may not be clinical ly significant . The information items presented with instructional graphics were the only items on which differences in comprehension levels achieved both clinical and statistical significance . Comprehension was lowest for the CDC m and ated information on risks and the National Injury Compensation . Our findings demonstrate that simplifying written immunization material and making it more suitable will increase appeal , but such modification may not raise comprehension to an acceptable level without use of instructional graphics . Health education material s intended for general parent population s , which are written on a sixth grade reading level , may not adequately educate parents or prepare them for a discussion with their physicians 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 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 OBJECTIVE Chronic infection with the hepatitis B virus is endemic in Southeast Asian population s , including Vietnamese . Previous research has documented low rates of hepatitis B vaccine coverage among Vietnamese-American children and adolescents ages 3 to 18 . To address this problem , we design ed and tested in a controlled trial 2 public health outreach " catch-up " campaigns for this population . DESIGN In the Houston , Texas metropolitan area , we mounted a media-led information and education campaign , and in the Dallas metropolitan area , we organized a community mobilization strategy . We evaluated the success of these interventions in a controlled trial , using the Washington , DC metropolitan area as a control site . To do so , we conducted computer-assisted telephone interviews with r and om sample s of approximately 500 Vietnamese-American households in each of the 3 study sites both before and after the interventions . We assessed respondents ' awareness and knowledge of hepatitis B and asked for hepatitis B vaccination date s for a r and omly selected child in each household . When possible , we vali date d vaccination date s through direct contact with each child 's providers . RESULTS Awareness of hepatitis B increased significantly between the pre- and postintervention surveys in all 3 areas , and the increase in the media education area ( + 21.5 percentage points ) was significantly larger than in the control area ( + 9.0 percentage points ) . At postintervention , significantly more parents knew that free vaccines were available for children in the media education ( + 31.9 percentage points ) and community mobilization ( + 16.7 percentage points ) areas than in the control area ( + 4.7 percentage points ) . An increase in knowledge of sexual transmission of hepatitis B virus was significant in the media education area ( + 14.0 percentage points ) and community mobilization ( + 13.6 percentage points ) areas compared with the control area ( + 5.2 percentage points ) . Parent- or provider-reported data ( n = 783 for pre- and n = 784 for postintervention surveys ) suggest that receipt of 3 hepatitis B vaccinations increased significantly in the community mobilization area ( from 26.6 % at pre- to 38.8 % at postintervention ) and in the media intervention area ( 28.5 % at pre- and 39.4 % at postintervention ) , but declined slightly in the control community ( 37.8 % at pre- and 33.5 % at postintervention ) . Multiple logistic regression analyses estimated that the odds of receiving 3 hepatitis B vaccine doses were significantly greater for both community mobilization ( odds ratio 2.15 , 95 % confidence interval 1.16 - 3.97 ) and media campaign ( odds ratio 3.02 , 95 % confidence interval 1.62 - 5.64 ) interventions compared with the control area . The odds of being vaccinated were significantly greater for children who had had at least 1 diphtheria-tetanus-pertussis shot , and whose parents were married , knew someone with liver disease , had heard of hepatitis B , and had greater knowledge about hepatitis B. The odds of being vaccinated were significantly lower for older children . CONCLUSIONS Both community mobilization and media campaigns significantly increased the knowledge of Vietnamese-American parents about hepatitis B vaccination , and the receipt of " catch-up " vaccinations among their children 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 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 BACKGROUND We review ed published and unpublished studies of mass mailings design ed to increase utilization of  influenza vaccine  among Medicare beneficiaries . METHODS Search of computerized indexes for published studies and the Medicare Peer Review Organization Health Care Quality Improvement Project data base for unpublished studies . Study selection criteria were : use of a controlled trial design and use of mass mailings direct  to Medicare beneficiaries to increase receipt of influenza vaccinations .  Study selection and data extraction were performed in duplicate by physician review ers with consensus resolution . RESULTS Six controlled trials of mass mailings were identified . One study , published in the Morbidity and Mortality Weekly Report ( MMWR ) , reported a modest but statistically significant improvement in influenza vaccination rates among patients who received a letter relative to those who did not . This study was cited as justification for mail interventions performed in five subsequent studies , none of which reported clinical ly meaningful results . None of these five studies was published . CONCLUSIONS Mass mailings have at best had clinical ly trivial effects on increasing influenza vaccination among Medicare beneficiaries . Publication bias has contributed to continued use of a relatively ineffective intervention Homeless youth are at increased risk for hepatitis B virus ( HBV ) infection and HBV vaccine coverage is poor in this group . The purpose of our study was to determine if a shelter-based HBV vaccine program in children and adolescents 2–18 years of age with a r and omized controlled trial using a culturally appropriate HBV video could increase HBV vaccine coverage rates . Subjects were r and omized to an 8 min HBV video or a control , smoking prevention video .  Before exposure to the videos , HBV knowledge , and demographics were assessed in caregivers and adolescents .  HBV vaccine no. 1 was offered to all subjects who did not produce a vaccine record ; subsequently , an accurate HBV vaccine history was obtained from medical providers . Subjects were asked to return 1 and 3 months after visit 1 , HBV vaccine was offered to all with incomplete coverage , and HBV knowledge was reassessed . There were 328 children and adolescents cared for by 170 caregivers enrolled in the study . One hundred and four had incomplete HBV vaccine coverage . Data are reported for all family units with at least one subject needing vaccine . There were 53 children and adolescents r and omized to the HBV video vs. 51 to the smoking video . HBV knowledge scores of caregivers improved at Visit no. 2 vs. no. 1 in the HBV video group ( p = 0.01 ) but not in the smoking group ( p = 0.82 ) . Similar results were observed for adolescents in the HBV video group ( p = 0.05 ) but not in the smoking group ( p = 0.40 ) . Exposure to the HBV video vs the smoking video had a significant effect on return rates for vaccine at Visit no. 2 ( 59 vs. 31 % ; p = 0.05 ) but not at Visit no. 3 ( 47 vs. 18 % , p = 0.06 ) . The shelter-based vaccine program was very effective in increasing HBV coverage rates in the entire group of 328 children and adolescents enrolled in the study , from 68 % coverage at baseline to 85 % at the conclusion of the study . We conclude that shelter-based HBV vaccine programs can be highly effective in increasing vaccine coverage rates in older children and adolescents . A brief exposure to a culturally appropriate HBV video improves HBV knowledge and may improve return rates for vaccine 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 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 OBJECTIVE Information forms are commonly used to inform parents about childhood vaccination . This study assessed the knowledge of mothers about pertussis and pertussis vaccine before and after reading a form about diphtheria-pertussis-tetanus ( dpt ) vaccine . DESIGN A test was administered to mothers before and after the first vaccination of their infant . By r and om allocation , one-half of the mothers received the form ( study group ) in addition to the routine counselling by a public health nurse given to the others ( control group ) . SETTING Public health immunization clinics in suburban Vancouver , British Columbia . SUBJECTS One hundred and fifty-one mothers who were scheduled to bring their infant for the first dpt immunization were recruited , of whom 145 ( 96 % ) completed the study . INTERVENTIONS A test consisting of 20 true/false questions was administered by telephone two weeks before and two weeks after the first dpt vaccination . Additional data about sources of vaccine information , maternal education , number of children and maternal age were obtained . OUTCOME MEASURES Mean scores and mean change in scores on test . RESULTS The mean changes in scores between tests 1 and 2 in study and control groups were + 22.2 % and + 6.9 % , respectively , on the disease-related questions ( P<0.001 ) and + 14.6 % and + 10.7 % , respectively , on the vaccine-related questions ( P=0.16 ) . The forms were considered to be very useful by the mothers and clearly enabled them to score higher on a test of their knowledge of pertussis and pertussis vaccine . CONCLUSIONS Reading a dpt vaccine form enabled mothers to improve their knowledge of pertussis and pertussis vaccine Sociological interest in vaccination has recently increased , largely in response to media coverage of concerns over the safety of the MMR ( measles , mumps and rubella ) vaccine . The result ing body of research highlights the importance of risk and trust in underst and ing parental and professional engagement with vaccination . To date , only limited attention has been paid to organised parental groups that campaign against aspects of vaccination policy . This paper reports findings from a qualitative study of contemporary groups in the UK , and develops three main lines of argument . First , these actors are best analysed as ' Vaccine Critical groups ' and include Radical and Reformist types . Second , Vaccine Critical groups discursively resist vaccination through a reframing that constructs risk as unknown and non-r and om . Third , trust as faith is negatively contrasted with the empowerment that is promised to result from taking personal responsibility for health and decision-making . Whilst representing a challenge to aspects of vaccination policy , this study confirms that the groups are involved in the articulation and promotion of other dominant discourses . These findings have implication s for wider sociological debates about risk and trust in relation to health INTRODUCTION Recent evaluations of computer-generated reminder/recall messages have suggested that they are an inexpensive , labor-saving method of improving office visitation rates of childhood immunization providers . This study assesses the sustained impact of computer-generated messages on immunization coverage during the first two years of life . DESIGN R and omized , controlled trial . SETTING County health department in the Denver metropolitan area . STUDY PARTICIPANTS Children ( n = 1227 ) 60 to 90 days of age who had received the first dose of diphtheria-tetanus-pertussis ( DTP ) and /or poliovirus vaccines . INTERVENTION Households of children were r and omized into four groups to receive : telephone messages followed by letters ( Group A ) ; telephone messages alone ( Group B ) ; letters only ( Group C ) ; or no notification ( Group D ) . Households in the intervention groups ( A , B , and C ) received up to five computer-generated telephone messages and /or up to four letters each time their children became due for immunization(s ) . MAIN OUTCOME MEASURE Immunization series completion at 24 months of age . RESULTS Children whose families were r and omized to receive any of the interventions were 21 % more likely to have completed the immunization series by 24 months of age than were children r and omized into the control group ( 49.2 % vs 40.9 % ; RR [ rate ratio ] = .21 ; CI [ confidence interval ] = 1.01 , 1.44 ) . While not statistically significant , children in Group A were 23 % more likely to complete their immunization series by 24 months of age than those in the control group ( 50.2 % vs 40.9 % ; RR = 1.23 ; CI = 1.00 , 1.52 ) . No differences were detected among the intervention groups . The costs per additional child completing the series by 24 months of age in Group A was $ 226 ( $ 79 after start-up costs were discounted ) . CONCLUSION Computer-generated contacts , either by phone or by mail ( or both combined ) , used each time vaccines become due , are efficacious in increasing immunization coverage of children under 2 years of age OBJECTIVE To evaluate effect of health promotion project of element school students in Beijing and Gansu . METHODS Evaluation field was conducted in 6 schools of hepatitis health promotion project . They were selected r and omly from Beijing and Gansu , question naires were given to students and teachers for evaluating the awareness to hepatitis transmission and prevention , telephone interview was given to student 's parents  for awareness to hepatitis knowledge . RESULTS Awareness to hepatitis was increased after health promotion , knowledge of hepatitis A and hepatitis B transmission among element school students were increased from 46.95 % , 32.26 % at baseline to 98.92 % , 96.42 % at middle-term respectively . Awareness rate of prevention of hepatitis A and hepatitis B were increased from 67.03%,67.38 % at baseline to 98.21 % , 99.64 % at middle-term respectively . Immunization coverage of hepatitis A and hepatitis B was 29.75 % at baseline , and reached 77.06 % at middle-term after health promotion . The parent 's awareness rate of hepatitis transmission and prevention also increased to 85 % and 99 % after intervention . CONCLUSION It was very effective of health promotion project in two provinces , the improvement of awareness of hepatitis was not only for students , but also for parents as well This study was conducted to determine whether implementing a program aim ed at providing a variety of incentives to physicians who provide immunizations to preschool-aged children would help to improve immunization rates and reduce fragmented care for patients . Twenty physicians from 14 private practice s that provide care to preschool-aged children from low income families in suburban Cook County , Illinois participated in the project . A r and omly selected subset of patient case records from the physicians ' offices were audited after the implementation of the project to determine the immunization status of children in the practice s and the nature of services provided . These 310 records of children under three years of age who were treated between 1991 - 1994 ( the intervention sample ) were compared to 310 charts from a 1988 - 1990 cohort of records ( baseline sample ) . The groups did not differ on race or gender ; however , significantly more families in the 1988 through 1990 cohort of children under 3 years of age were insured privately when compared to the 1991 through 1994 cohort . Seventy percent ( 218 ) of the records in the intervention sample were up to date for age on immunizations compared to 45 % ( 141 ) of the baseline records , reflecting a statistically significant difference ( p < .00001 ) . The intervention sample showed significantly more well child visits where immunizations were given and follow up visits where immunizations were given when compared to the baseline sample . Physicians completed surveys before and after implementation of the project . They were question ed about their knowledge and practice s regarding immunizations as well as their opinion of specific project components . All of the physicians viewed the project as an effective means to improve immunization services to low income children . The project demonstrates a potential means of enhancing immunization levels and continuity of care among preschool-aged children . It also highlights the workable nature of the partnership between public and private sectors The impact of medical documentaries on attendance to immunization sessions is not documented in developing countries . The impact of a video and TV medical documentary on  women 's vaccination  during a catch-up tetanus collective immunization was studied in Cambodia ( 2002 - 2004 ) . A medical video documentary produced locally was publicly shown in 10 villages chosen at r and om among 63 villages to be covered by collective tetanus immunization . In each village where the video was shown , 33 women , older than age 11 , were selected at r and om and question ed about their tetanus vaccination records , to assess if they attended the video and to evaluate their knowledge about tetanus . A second interview was conducted after the first collective vaccination to check their attendance and to record reasons for non-attendance . The same interview was conducted 10 months later , after the documentary was shown on a local TV channel and a second collective tetanus vaccination conducted . Data were collected from 323 ( 98 % ) women . Seventy-eight ( 24 % ) women saw the video documentary and only eight ( 2.4 % ) saw it on TV . Compared to farmers , shopkeepers saw significantly less the documentary ( χ² of Yates : 5.77,P = 0.016 ; 95 % CI : 0.10 < RR = 0.29 < 0.88 ) and no home keeper or civil servant attended it . Women of childbearing age with no school education were significantly more attracted by the video documentary ( χ² of Yates : 5.99,P = 0.01 ; 95 % CI : 1.10 < RR = 1.57 < 2.22 ) than other childbearing-aged women , although their final immunization coverage was not better . The documentary did not increase the knowledge that contamination for tetanus may come from earth and tools , but not from air and water , and that all ages are at-risk for tetanus , but it increased significantly the knowledge that vaccination can prevent the disease ( χ² of Yates : 13.98;P = 0.0001 ; 95 % CI : 1.28 < RR = 1.57 < 1.93 ) . Women who saw the video documentary  attended the first collective session more often than those who did not ( χ² of Yates : 11.00 ; P = 0.0006 ; 95 % CI : 1.23 < RR = 1.51 < 1.84)in spite of their better vaccination status before the immunization , and this was mostly significant for farmers and women more than 45 years of age . Women who saw the documentary either on video or on TV also attended more the second collective session , but not significantly ( χ² of Yates : 1.23;P = 0.266 ; 95 % CI : 0.91 < RR = 1.23 < 1.66 ) . Forty-nine percent of women had not attended school and the video documentary was re-run twice after the first performance . Women older than 45 years ( 55 % ) completely escaped immunization significantly more often than women of childbearing age ( 35 % ) ( χ² of Yates : 17.26;P = 0.00003 , 95 % CI : 1.53 < RR = 2.13 < 2.97 ) , who did it more often than schoolgirls ( 2 % ) ( χ² of Yates : 9.69;P = 0.002 ; 95 % CI : 0.01 < RR = 0.09 < 0.65 ) . The main reasons for not being vaccinated during catch-up collective tetanus vaccinations were a too short interval between doses according to the WHO schedule ( 25 % ) , agricultural task ( 18 % ) , leisure travel ( 8 % ) , fear of injections ( 7 % ) , and being completely vaccinated according to the WHO schedule ( 7 % ) . Only 2 % of women were not informed , showing that vaccination was well-publicized . This educational technique should be re-used in all villages during coming catch-up tetanus collective immunizations in Cambodia , mostly in urban context s where coverage during these sessions is lower . Video is still the best method in rural context if some education is also provided to the audience . According to the WHO schedule , the interval between two catch-up tetanus sessions should be extended to over a year to be able to give booster shots to women who already received three or more tetanus doses . Vaccination of schoolgirls is significantly easier to achieve with the help of the teachers . Vaccinating women aged over 45 should be encouraged as they are at risk of tetanus even in developed Asian countries BACKGROUND The Community Mothers Programme aims at using experienced volunteer mothers in disadvantaged areas to give support to first-time parents in rearing their children up to 1 year of age . The programme was evaluated by r and omized controlled trial in 1990 . METHODS Seven years later , trial participants were interviewed about child health , nutrition , cognitive stimulation , parenting skills , and maternal self-esteem . The aim of this study was to see whether the demonstrated benefits at 1 year of age of this programme could be sustained at age 8 . RESULTS One-third of the original group ( 38 intervention , 38 control ) , were contacted and interviewed . The risk for having an accident requiring a hospital visit was lower in the intervention group : relative risk ( RR ) 0.59 , 95 per cent confidence interval ( CI ) 0.31 - 1.11 . Intervention children were more likely to visit the library weekly : RR 1.58 , 95 per cent CI 1.10 - 2.26 . Intervention mothers were more likely to  check homework every night : RR 1.23 , 95 per cent CI 1.05 - 1.43 ( p=0.006 ) ; and to disagree with the statement ' children should be smacked for persistently bad behaviour ' : RR 2.11 , 95 per cent CI 1.10 - 4.06 . They were more likely to disagree with the statement ' I do not have much to be proud of ' : RR 1.24 , 95 per cent CI 1.04 - 1.40 ; and to make a positive statement about motherhood than controls : RR 1.53 , 95 per cent CI 1.06 - 2.20 . Subsequent children of intervention mothers were more likely to have completed Haemophilus influenzae b : RR 1.26 , 95 per cent CI 1.06 - 1.51 ; and polio immunization : RR 1.19 , 95 per cent CI 1.02 - 1.40 . CONCLUSIONS The Community Mothers programme had sustained beneficial effects on parenting skills and maternal self-esteem 7 years later with benefit extending to subsequent children
BACKGROUND A range of strategies are used to communicate with parents , caregivers and communities regarding child vaccination in order to inform decisions and improve vaccination uptake .
These strategies include interventions in which information is aim ed at larger groups in the community , for instance at public meetings , through radio or through leaflets .
This is one of two review s on communication interventions for childhood vaccination .
The companion review focuses on face-to-face interventions for informing or educating parents .
OBJECTIVES To assess the effects of interventions aim ed at communities to inform and /or educate people about vaccination in children six years and younger .