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{"sheet":"FULL MAP","index":2,"n_rows":941,"n_cols":5,"rows_kept":941,"cut":false,"hidden":false,"merged":[[420,2,447,2],[420,3,447,3],[420,4,447,4],[226,1,273,1],[226,2,273,2],[226,3,273,3],[226,4,273,4],[274,1,303,1],[274,2,303,2],[274,3,303,3],[274,4,303,4],[390,1,419,1],[390,2,419,2],[390,3,419,3],[390,4,419,4],[304,1,324,1],[304,2,324,2],[304,3,324,3],[304,4,324,4],[325,4,347,4],[22,1,22,4],[24,1,52,1],[24,2,52,2],[24,3,52,4],[113,1,145,1],[146,2,199,2],[146,1,199,1],[146,4,199,4],[53,1,62,1],[53,2,62,2],[53,3,62,4],[63,1,77,1],[63,2,77,2],[63,3,77,4],[113,3,145,3],[464,1,506,1],[464,2,506,2],[464,3,507,3],[464,4,507,4],[113,4,145,4],[146,3,199,3],[113,2,145,2],[80,1,80,4],[82,1,112,1],[82,4,112,4],[82,3,112,3],[82,2,112,2],[348,1,389,1],[348,2,389,2],[348,3,389,3],[348,4,389,4],[325,1,347,1],[325,2,347,2],[325,3,347,3],[200,1,225,1],[200,2,225,2],[200,4,225,4],[200,3,225,3],[420,1,447,1],[532,1,569,1],[532,2,569,2],[532,3,569,3],[532,4,569,4],[662,1,688,1],[662,2,688,2],[662,3,688,3],[662,4,688,4],[508,1,531,1],[508,2,531,2],[508,3,531,3],[508,4,531,4],[570,1,612,1],[570,2,612,2],[570,3,612,3],[570,4,612,4],[770,1,801,1],[770,2,801,2],[770,3,802,3],[770,4,801,4],[613,1,637,1],[613,2,637,2],[613,3,637,3],[613,4,637,4],[638,1,660,1],[638,2,660,2],[638,3,661,3],[638,4,660,4],[689,1,715,1],[689,2,715,2],[689,3,716,3],[689,4,715,4],[717,1,741,1],[717,2,741,2],[717,3,742,3],[717,4,742,4],[448,1,463,1],[448,2,463,2],[448,3,463,3],[448,4,463,4],[940,1,958,1],[940,2,958,2],[940,3,958,3],[940,4,958,4],[803,1,845,1],[803,2,845,2],[803,3,845,3],[803,4,845,4],[846,1,904,1],[846,2,904,2],[846,3,905,3],[846,4,904,4],[906,1,939,1],[906,2,939,2],[906,3,939,3],[906,4,939,4],[743,1,767,1],[743,2,767,2],[743,3,769,3],[743,4,769,4]]}
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[null,"GUIDANCE SECTION - FULL MAP"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Flu vaccination: increasing uptake. NG103. London: NICE; 2018.\nAvailable here.","This guideline is for: \n- Commissioners and providers of primary and secondary healthcare services, including maternity providers and community pharmacies\n- All employers of staff who provide NHS or social-care funded services (including maternity care, domiciliary care and care homes)\n- Local authorities, and community and voluntary sector organisations that employ health and social care workers\n- Occupational health services and infection prevention and control teams\n- NHS England teams and Health Education England teams\n- People using services, their families, carers and other members of the public, in particular those eligible for flu vaccination","This guideline covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.\n\nIt includes recommendations on:\n- Using a multicomponent approach\n- Raising awareness\n- Offering vaccination\n- Increasing uptake among eligible groups in primary and secondary care\n- Audit, monitoring and feedback\n- Vaccination in carers\n- Increasing uptake in health and social care staff"]
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[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEW SECTION - FULL MAP"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Jia  L et al. Payment methods for healthcare providers working in outpatient healthcare settings. Cochrane Database of Systematic Reviews 2021, Issue 1. Art. No.: CD011865. DOI: 10.1002/14651858.CD011865.pub2. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.\n\nThe reviewers included 27 studies in the review: 12 randomised trials, 13 controlled before‐and‐after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high‐income countries, with only one study from a low‐ or middle‐income country. The included studies were categorised into four groups based on comparisons of different payment methods. Of which only two groups fulfilled the outcome criteria for this evidence map. \n\n(1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings: P4P incentives probably improve child immunisation status [Risk ratio (RR) 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate‐certainty evidence].\n\n2)  Enhanced fee for service (FFS) compared with FFS for healthcare providers working in outpatient healthcare settings: Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate‐certainty evidence). The reviewers are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low‐certainty evidence). \n\n\n\n\n","For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate‐certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low‐certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low‐certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low‐certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects.\n\nThere is a need for further well‐conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low‐ and middle‐income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions."]
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[null,"Palmer  MJ et al. Targeted client communication via mobile devices for improving maternal, neonatal, and child health. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD013679. DOI: 10.1002/14651858.CD013679.\nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of targeted client communication via mobile devices (TCCMD) on health behaviour, service use, health, and well‐being for maternal, neonatal and child health (MNCH).  \n\nThe reviewers included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low‐, middle‐ or high‐income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle‐income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Only results relevant to this evidence map have been extracted below.\n\nPregnant and postpartum women\nTCCMD versus digital non‐targeted communication: No studies reported behavioural, health, or well‐being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low‐certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination [Risk ration (RR) 1.05, 95% confidence interval (CI) 0.71 to 1.58], though the CI encompasses both benefit and harm (low‐certainty evidence).\n\nParents of children aged less than five years\nTCCMD versus standard care: Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low‐certainty evidence); however, the effect estimates varied widely between studies.\n\nTCCMD versus non‐digital TCC: TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low‐certainty evidence), and may make little or no difference to oral hygiene practices (low‐certainty evidence).\n\nTCCMD versus digital non‐targeted communication: TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low‐certainty evidence).\n\nNo trials in any population reported data on unintended consequences.","The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High‐quality, adequately powered trials and cost‐effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality."]
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[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV;11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap [Odds ratio (OR) 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants], meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries (LMIC) where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Pantoja  T et al. Manually‐generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD001174. DOI: 10.1002/14651858.CD001174.pub4. \nAvailable here.","Age not specified","This Cochrane review aimed: 1. To determine the effectiveness of manually‐generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually‐generated reminders delivered on paper.\n\nThe reviewers identified 63 studies (41 cluster‐randomised trials, 18 individual randomised trials, and four non‐randomised trials) that met all inclusion criteria. Fifty‐seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty‐four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test‐ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention.\n\nForty‐eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process‐of‐care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Forty‐seven studies assessed the effect of reminders compared with control or usual care. In the studies assessing process adherence outcomes, only three of the effect estimates were related to recommended vaccination practices. \n\nManually‐generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% [Inter quartile range (IQR) 2.54% to 20.58%].","Manually‐generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single quality improvement (QI) intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually‐generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect."]
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[null,"Kaufman  J et al. Face‐to‐face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD010038. DOI: 10.1002/14651858.CD010038.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of face‐to‐face interventions for informing or educating parents about early childhood vaccination on vaccination status and parental knowledge, attitudes and intention to vaccinate.\n\nIn this update, the reviewers found four new studies, for a total of ten studies. They included seven randomised controlled trials (RCTs) and three cluster‐RCTs involving a total of 4527 participants, although we were unable to pool the data from one cluster‐RCT. Three of the ten studies were conducted in low‐ or middle‐ income countries.\n\nAll included studies compared face‐to‐face interventions with control. Most studies evaluated the effectiveness of a single intervention session delivered to individual parents. The interventions were an even mix of short (ten minutes or less) and longer sessions (15 minutes to several hours).\n\nOverall, elements of the study designs put them at moderate to high risk of bias. All studies but one were at low risk of bias for sequence generation (i.e. used a random number sequence). For allocation concealment (i.e. the person randomising participants was unaware of the study group to which participant would be allocated), three were at high risk and one was judged at unclear risk of bias. Due to the educational nature of the intervention, blinding of participants and personnel was not possible in any studies. The risk of bias due to blinding of outcome assessors was judged as low for four studies. Most studies were at unclear risk of bias for incomplete outcome data and selective reporting. Other potential sources of bias included failure to account for clustering in a cluster‐RCT and significant unexplained baseline differences between groups. One cluster‐RCT was at high risk for selective recruitment of participants.\n\nThe reviewers judged the certainty of the evidence to be low for the outcomes of children's vaccination status, parents' attitudes or beliefs, intention to vaccinate, adverse effects (e.g. anxiety), and immunisation cost, and moderate for parents' knowledge or understanding. All studies had limitations in design. They downgraded the certainty of the evidence where we judged that studies had problems with randomisation or allocation concealment, or when outcomes were self‐reported by participants who knew whether they'd received the intervention or not. They also downgraded the certainty for inconsistency (vaccination status), imprecision (intention to vaccinate and adverse effects), and indirectness (attitudes or beliefs, and cost).\n\nLow‐certainty evidence from seven studies (3004 participants) suggested that face‐to‐face interventions to inform or educate parents may improve vaccination status (RR 1.20, 95% CI 1.04 to 1.37). Moderate‐certainty evidence from four studies (657 participants) found that face‐to‐face interventions probably slightly improved parent knowledge (standardised mean difference (SMD) 0.19, 95% CI 0.00 to 0.38), and low‐certainty evidence from two studies (179 participants) suggested they may slightly improve intention to vaccinate (SMD 0.55, 95% CI 0.24 to 0.85). Low‐certainty evidence found the interventions may lead to little or no change in parent attitudes or beliefs about vaccination (SMD 0.03, 95% CI ‐0.20 to 0.27; three studies, 292 participants), or in parents’ anxiety (mean difference (MD) ‐1.93, 95% CI ‐7.27 to 3.41; one study, 90 participants). Only one study (365 participants) measured the intervention cost of a case management strategy, reporting that the estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care (low‐certainty evidence). No included studies reported outcomes associated with parents’ experience of the intervention (e.g. satisfaction).","There is low‐ to moderate‐certainty evidence suggesting that face‐to‐face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.\n\nFace‐to‐face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Posadzki  P et al. Automated telephone communication systems for preventive healthcare and management of long‐term conditions. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD009921. DOI: 10.1002/14651858.CD009921.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of automated telephone communication systems (ATCS) for preventing disease and managing long‐term conditions on behavioural change, clinical, process, cognitive, patient‐centred and adverse outcomes.\n\nThe reviewers included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty‐one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long‐term conditions, and seven studies for appointment reminders. They downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. They judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. They considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. Only results relevant to this evidence map have been extracted below.\n\nFor preventive healthcare, ATCS (ATCS Plus, interactive voice response , unidirectional) probably increase immunisation uptake in children (RR 1.25, 95% CI 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).","ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost‐effective."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Vaccination Programs: Home Visits to Increase Vaccination Rates. The Community Guide; 2016. \nAvailable here.","Age not specified","This report examines home visits to increase vaccination rates in children and adults, leading to a Community Preventive Services Task Force (CPSTF) recommendation on the subject. The CPSTF finding is based on evidence from a Community Guide systematic review completed in 2009 (19 studies, search period 1980-2009) combined with more recent evidence (4 studies, search period 2009-2012). \n\nThe Task Force considered evidence from 23 studies of home visits, with 20 studies and 21 study arms using a common measure of change in vaccination rates. The overall effect was a median increase of 11 percentage points (IQR: 5 to 15 percentage points). Meaningful improvements were observed as a result of home visits delivered to all clients (12 study arms) and to only those clients unresponsive to other interventions (9 study arms), home visits focused on vaccination alone (12 study arms) and in combination with other health concerns (9 study arms), and home visits providing on-site vaccinations (8 study arms) and referring clients to vaccination services outside the home (13 study arms). Home visits delivered as the sole intervention (8 study arms) and home visits delivered as part of a larger healthcare system or community-based program (13 study arms) also produced meaningful change in vaccination rates.\n\nEffectiveness studies were conducted primarily in urban settings (15 studies) and in lower income populations (10 studies). Increases in rates were comparable for home visits directed at children (15 studies) and adults (7 studies), as well as for influenza (7 studies) and childhood vaccinations (14 studies).\n","The CPSTF recommends home visits based on strong evidence of their effectiveness in increasing vaccination rates. Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. The Task Force notes that home visiting interventions are potentially effective in addressing a wide range of public health problems and that the focus of this review is the subset of interventions specifically addressing vaccination rates.\n\nThe report identified that more research is needed on the effectiveness and economic benefits of home visits to increase vaccination rates among adolescents and in rural settings. Additional economic research is needed to estimate the portion of home visits that can be attributed solely to improving vaccination rates when home visits include other activities and objectives."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Requirements for\nChild Care, School, and College Attendance. The Community Guide; 2016. \nAvailable here.","Under 5s\n5 to 18 years","This CPSTF report examines laws or policies requiring vaccinations or other documentation of immunity as a condition of child care, school, and college attendance. These findings are based on studies demonstrating effectiveness of vaccination requirements for attendance in a variety of settings, for an array of recommended vaccines, and in populations ranging in age from early childhood to late adolescence.\n\nThe Task Force finding is based on evidence from 32 studies (search period January 1980 – July 2015) that examined the effectiveness of vaccination requirements on vaccination coverage rates or changes in vaccine-preventable disease or illness.\n\nSeventeen studies with 24 study arms examined the effectiveness of state or local vaccination requirements on changes in vaccination rates. The median change was an increase of 18 percentage points (Interquartile interval [IQI]: 10 to 35 percentage points). Five additional studies examined changes in vaccination rates or series completion that could not be included in the summary effect estimate, although results were generally in the direction of increased coverage.\n\nTen studies examined the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements. Three U.S. studies found that the incidence of measles and mumps was lower in states with immunization requirements for school-aged children, and that low-incidence areas were more likely to enforce school entry laws by excluding non-compliant children from attendance.\n\nOne study from Italy found reductions in rates of hepatitis B disease attributable to the implementation of vaccination requirements and school and community-based vaccination programs. A study from Japan found increases in excess mortality rates among younger children due to influenza and pneumonia, after the removal of a national influenza vaccination mandate and school-based immunization program.\n\nFive studies evaluated other vaccination requirements and found: (1) lower incidence of mumps during an outbreak in children subject to a vaccination requirement; (2) greater declines in Haemophilus influenza type b disease incidence among child care attendees subject to vaccination requirements than for New York State as a whole; (3) lower risk for measles outbreaks in colleges with pre-matriculation immunization requirements; (4) decline in hepatitis A disease incidence following implementation of a child care entry requirement in response to an outbreak, and (5) reduction in influenza-associated hospitalizations among children following a child care entry requirement.\n\nIncluded studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies). Studies provided evidence of effectiveness for both primary school entry requirements (11 studies) and requirements for middle/high school students (13 studies). Six studies examined vaccinations for child care attendance and findings are applicable to these settings. Although only one study evaluated vaccination requirements for college (1\nstudies) findings are likely applicable to these settings.\n\nIncluded studies examined changes in coverage rates or disease incidence for vaccinations to protect against measles mumps-rubella (16 studies), tetanus (8 studies), pertussis (8 studies), varicella (8 studies), Haemophilus influenza type b disease (5 studies), hepatitis A (2 studies), hepatitis B (14 studies), meningococcal disease (3 studies), influenza (2 studies), and human papillomavirus (1 study). Task Force findings are applicable or likely applicable for the range of vaccines recommended for children and adolescents.","The CPSTF recommends vaccination requirements for child care, school, and college attendance based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine preventable disease (VPD) and associated morbidity and mortality. \n\nAlthough intervention studies overall provide strong evidence of effectiveness, three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease transmission: 1) geographic clustering of under immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions. \n\nMost included studies examined school vaccination requirements; additional evaluations of requirements for child care attendance and college residency would be useful. Additional research would be useful to clarify relationships between variations in school or child care documentation and enforcement and vaccination and exemption rates. Information on barriers to school and local enforcement and ways to overcome these barriers would also be useful. Likewise, studies examining factors that facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings would be helpful. Finally, more research is needed to assess the economic costs and benefits of vaccination requirements in each setting."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client-Held Paper\nImmunization Records. The Community Guide; 2016. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of client-held paper immunization records in increasing vaccination rates or reducing rates of vaccine preventable disease. Evidence was considered insufficient because of inconsistent findings and variability in the interventions evaluated.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (7 studies, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 8 studies with 11 study arms. Six studies (nine measurements) provided a common measure of vaccination rates and reported an overall median increase of 5.3 percentage points (IQI: -1.0 to 8.8 percentage points).\n\nResults were considered inconsistent because client-held paper immunization records were used as part of a multicomponent effort and comparison groups received one or more interventions.\n\nSeveral considerations for implementation were identified in the included studies and broader literature. These include clients'' declining interest over time and low card retention. Healthcare providers also have expressed concerns about time management when using a preventive services checklist.\n\nWith the expansion of population-based Immunization Information Systems and the development of on-line and electronic personal health care records, careful evaluation of client-held paper immunization records effectiveness is needed to achieve high levels of vaccination rates in the US population. However, until issues of privacy, security, and quality of electronic records have been resolved, and for clients on the other side of the \"digital divide,\" traditional client-held paper immunization records will continue to be useful. This may be particularly true for some populations, such as clients with limited computer access and adults whose change in employment status is accompanied by a change in providers.","This CPSTF report concludes that paper  immunization records maybe useful when they are used consistently—when providers update them and parents keep track of them. Children are more likely to receive recommended vaccinations and avoid being over-vaccinated. This is especially true when children are seen in non-traditional immunization settings, such as emergency departments.\n\nFurther research should therefore examine the effectiveness of additional activities to increase the retention and use of client-held paper immunization records for children by their parents or other caregivers."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Adams J, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study, and discrete choice experiment. Health Technology Assessment 2015;19(94). \nAvailable here","Parents and carers of preschool children, health and educational professionals. ","The review included studies exploring the effectiveness, acceptability or economic costs and consequences of interventions that offered contingent rewards or penalties with real material value for preschool vaccinations, or quasi-mandatory schemes that restricted access to ‘universal’ services, compared with usual care or no intervention.\nSystematic review – there was insufficient evidence to conclude that the interventions considered are effective. There was some evidence that the quasi-mandatory interventions were acceptable. There was insufficient evidence to draw conclusions on economic costs and consequences.\n","There is little current evidence on the effectiveness or economic costs and consequences of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. \nUniversal incentives are likely to be more acceptable than targeted ones. Preferences concerning incentives versus quasi-mandatory interventions may depend on the context in which these are elicited."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Standing Orders. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends standing orders for vaccinations on the basis of strong evidence of effectiveness in increasing vaccination rates among adults and children; when used alone or with additional interventions; and across a range of settings and populations. The Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (29 studies, search period 1997–2009) combined with more recent evidence (6 studies, search period 2009–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 35 studies. Of these, 27 studies provided a common measurement of change in vaccination rates with a median increase of 24 percentage points (IQI: 12 to 35 percentage points). Nine studies that examined the impact of standing orders alone documented a median increase of 16 percentage points (IQI: 9 to 29 percentage points). Nineteen studies that evaluated standing orders when combined with additional interventions documented a median increase of 27 percentage points (IQI: 13 to 40 percentage points). Seven studies that did not provide a common measure of change for vaccination rates all reported favorable results after implementation of standing orders.\n\nThe reviewed studies evaluated the effectiveness of standing orders across a wide range of clinical vaccination settings, health care personnel, and client populations. Standing orders were found to be effective in various settings including clinics, hospitals, and long-term care facilities. Interventions were effective when used with different vaccination providers including nurses and pharmacists. While most studies looked at adult populations, four examined intervention effectiveness among children and found a median absolute percent increase of 28 percentage points (range: 8 to 49). While no studies specifically evaluated the impact of standing orders for vaccination of adolescents, evidence from this review is likely applicable to this population. In addition, a subset of the included evidence suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings when compared to a provider reminder system.\n\nOne paper from the updated search period described the following barriers encountered during implementation of a pneumococcal vaccination standing orders program in three hospitals: gaps in staff education and training; personnel concerns about additional workload; staff reluctance to administer vaccines without a physician's order; attending physicians' resistance to having hospitalized patients vaccinated; and logistical difficulties. Some attending physicians expressed concern that vaccination would interfere with scheduled treatments or procedures. Other attending physicians did not consider inpatient stays to be an appropriate time for vaccinations (Middleton et al. 2005).\n\nAn additional study reported barriers to implementation of influenza and pneumococcal vaccination standing orders in various health care settings. Findings suggested that the adoption of these policies may have been too difficult to administer, staff were unclear or unconvinced of program benefits, and there was perceived physician discomfort with delegating responsibility for immunizations to nursing staff. A few of the respondents also indicated that resources, effectiveness of the vaccine, and time required to administer the vaccine were barriers for adoption. The majority of these barriers were specific to the administration of the influenza vaccine (Goldstein et al. 2005).","This CPSTF concludes that standing orders were shown to be effective in increasing vaccination rates for influenza and pneumococcal vaccines. Additional research is needed, however, to determine if these interventions are effective for different vaccines (e.g. hepatitis, tetanus and vaccines recommended for adolescents). More evidence is also needed on ways to address barriers to the implementation of standing orders in health systems.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Programs in the\nSpecial Supplemental Nutrition Program for Women, Infants and\nChildren (WIC) Settings. The Community Guide; 2015. \nAvailable here.","Under 5s","The CPSTF recommends coordinated vaccination interventions in women, infants and children (WIC) settings based on strong evidence of effectiveness in increasing vaccination rates in children. Evidence on effectiveness was considered strong based on studies in which assessment of client immunization status and referral to vaccination providers was combined with: 1) provision of vaccinations on-site or in a collocated healthcare facility, or 2) additional interventions such as monthly voucher pickup requirements, manual tracking and outreach, or client reminder and recall systems. Evidence was limited regarding the effectiveness of assessment and referral in WIC settings when implemented alone.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review.\nThe combined evidence included 15 studies of programs that coordinated assessment and referral in WIC settings with additional interventions. Only one study evaluated the use of assessment and referral programs when used alone and found no effect. Of the included studies, 8 (10 study arms) provided a common measurement of change in vaccination rates and observed a median increase of 10.5 percentage points (IQI: 4 to 19 percentage points).\nThe most common additional interventions were monthly voucher pickup (5 studies) and provision of vaccinations onsite or in collocated healthcare facilities (4 studies).\n\nAll of the included studies evaluated WIC programs in urban settings and populations. Despite the lack of evidence from suburban and rural settings, the Task Force considers the overall evidence on effectiveness to be applicable in most WIC settings and populations.","This CPSTF report concludes that WIC services provide opportunities for regular and ongoing contact with families who may have limited access or substantial barriers to immunization services. Although on-site or collocation of vaccination services can substantially enhance access, these approaches require ongoing communication and coordination between WIC programs and healthcare providers in order to minimize missed vaccination opportunities while maintaining continuity of care.\n\nOnly one study examined vaccination status assessment and referral when implemented alone. Additional studies are needed to determine the effectiveness of this basic approach. More research is needed on efforts to collocate WIC and health care services, on the adoption of monthly voucher pickup requirements, and on the impact of providing WIC interventions outside of the medical home."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Wide Education When Used Alone. The Community Guide; 2015. \nAvailable here.","Age not specified","This report aimed to determine the effectiveness of community-wide education interventions when implemented alone in increasing vaccination rates or reducing rates of vaccine preventable illness and found insufficient evidence. Evidence is considered insufficient due to inconsistent results and concerns about the applicability of evidence to more diverse communities in the United States where improvements in vaccination rates are needed.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (6 studies with 8 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009- February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 7 studies with 9 study arms. Among the studies providing a common measure of change in vaccination rates (4 studies with 6 arms) there was a median increase of 6 percentage points (range of values: 0.4 to 12.2 percentage points).\n\nThree studies evaluated mass media activities using different measures of change. In a targeted community in Australia, pneumococcal vaccines dispatched to service providers increased during the period of a mass media campaign. In Finland, a mass media campaign briefly increased MMR vaccine receipt for children 6 years of age, though changes were not reported for younger children. In the U.S., a mass media campaign addressing flu-related topics among a nationally representative population of older adults found a positive association between flu-related media reports and influenza vaccination rates in the weeks following the campaign (annual vaccination rates increased by 2.3-7.9 percentage points, p<0.001).\n\nOne U.S. study observed moderate increases in vaccination rates for hepatitis B vaccine following intensive communitywide educational efforts in two Vietnamese-American communities. Characteristics of the study communities that may have contributed to intervention effectiveness included: (1) popular Vietnamese-language media, (2) established Vietnamese service organizations, and (3) culturally appropriate strategies and materials.\n\nCommunity-wide education is commonly implemented in combination with additional interventions (such as efforts to expand and enhance access to vaccinations). In another review, the Task Force found strong evidence of effectiveness for community-based interventions implemented in combination to increase vaccination rates, and five of the included studies used community-wide education in the combination of interventions.","This CPSTF report states that although the evidence identified in this systematic review is insufficient to determine the effectiveness of community-wide education when implemented alone, two studies suggest that these interventions may be useful with certain communities. More research is needed to understand the potential applicability of these interventions to other populations, and for other vaccines.\n\nThe Task Force acknowledges an important role for mass media (and the potential role of social media) in disseminating\ninformation to large audiences and shaping public attitudes and behaviours.\n\nVaccine manufacturers have been increasing direct-to-consumer mass and small media advertising to promote new vaccines. While evidence from private sector marketing campaigns on vaccine uptake was not included in this review, the Task Force considered the applicability of these marketing experiences to public health efforts. They determined that community-wide educational efforts may have greater impact when used to inform members of the community about new vaccines (such as HPV), or new recommendations (such as the universal recommendation for seasonal influenza), and in situations of public health urgency (such as the H1N1 pandemic). The effectiveness of community-wide education to increase vaccination rates in these circumstances remains an important issue for further evaluation research.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Promoting Health Equity Through Education Programs and Policies:\nSchool-Based Health Centers. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.\n\nThe CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.\n\nMost evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.\n\nThe Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these \"whole school\" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen \"SBHC user\" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services. \n\nBecause most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.\n\nMost studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.\n\nMost of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.","This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. \n\nIn the implementation of SBHCs, the following issues should be considered:\n- Billing and financing is a major challenge to SBHC implementation and sustainability\n- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation\n- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings\n- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness\n\nThe report also identifies areas for further research.\n\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client or Family Incentive Rewards. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends client or family incentive rewards, used alone or in combination with additional interventions, based on sufficient evidence of effectiveness in increasing vaccination rates in children and adults.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (6 studies with 7 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on sufficient evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 8 percentage points (IQI: 4 to 16 percentage points). Two study arms that assessed the effectiveness of incentive rewards alone showed similar changes in vaccination rates (8.5 and 9.0 percentage points). In the six remaining study arms, incentive rewards were combined with additional interventions.\n\nAmong the studies included in this review, the type of incentive reward offered to clients included government payments (i.e., of $208 AUD and childcare assistance), lottery prizes (i.e., $50 grocery voucher or $175 in monetary prizes), gift cards (i.e., $10 for baby products), baby products, and food vouchers. \n\nOverall, the Task Force considers the evidence to be applicable to vaccinations for children and adults in a wide range of clinical and community settings, and for various types of incentive rewards.","This CPSTF concludes that client or family incentive rewards can also be one component of an effective combined approach to increase vaccination rates in both clinical and community settings. Based on updated, concurrent reviews the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based\ninterventions implemented in combination.\n\nAdditional research could focus on the independent effects of incentive rewards, examine the relationship between the value of the reward and effectiveness, and explore the duration of intervention impact. It also would be useful to have more information about the effectiveness of these interventions with adolescents and adults as most of the included studies examined the use of incentive rewards on vaccination rates for children."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Monetary Sanction Policies. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of monetary sanction policies to increase vaccination rates among children in families receiving government assistance. The Task Force finding is based on the small number of studies; differences in the type of sanction policies evaluated; inconsistent results on vaccination rates; and limited information on potential harms of these policies.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (2 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review. Both of the included studies were conducted in the United States and evaluated the implementation of state monetary sanction policies for families receiving assistance through the Aid to Families with Dependent Children (AFDC) program. The first study, a two-year randomized controlled trial of AFDC recipients in Maryland, evaluated outcomes in 1,324 children aged 3 to 24 months and observed no significant improvements in vaccination rates (decrease of -0.7 percentage points). The second study, a three-year randomized controlled trial of 2,500 families on AFDC assistance in Georgia, observed significant improvements in vaccination rates in children (increase of 11.8 percentage points).\n","This CPSTF report concludes that evidence on the broad range of potential outcomes of monetary sanction policies is insufficient to inform considerations on their use as an intervention option to increase vaccination rates. Programs that are considering the adoption of monetary sanctions should first determine the range of potential harms that may occur from these policies. Barriers to implementing monetary sanctions include: agencies might not adopt these policies because of concerns about harms to families or they may not enforce these policies with case workers unwilling to apply sanctions to families. The Georgia study examined the issuance of warnings and sanctions to families and found that both were infrequently applied.\n\nAdditional evidence is needed to determine if monetary sanction policies are effective and beneficial to the communities they address. If so, research is needed to identify common elements of successful policies and programs and explore the health and financial effects of these policies on families requiring assistance.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Assessment and Feedback. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends assessment and feedback for vaccination providers on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults and children; (2) when used alone or with additional interventions; and (3) across a range of settings and populations. While there was not enough evidence to determine which characteristics of assessment and feedback contributed most to its effectiveness, various strategies have been consistently effective in a wide range of contexts.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997–2007) combined with more recent evidence (1 study, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 20 studies. Of these, 16 studies with 20 study arms provided common measurements of change in vaccination rates. The median increase of 9 percentage points (IQI: 3 to 14 percentage points). Fifteen study arms provided sufficient information to calculate the change in vaccination rates and showed a median increase of 18.0% (IQI: 9.5% to 24.0%). Seven study arms evaluated the impact of assessment and feedback for providers when implemented alone and found a median increase of 11 percentage points (IQI: 7 to 12 percentage points). Thirteen study arms evaluated provider assessment and feedback with additional interventions and observed a median increase of 6 percentage points (IQI: 3 to 18 percentage points). One additional study did not provide a common measurement of change in vaccination rates, and reported no change after implementation of intervention.\n\nThe reviewed studies evaluated the impact of assessment and feedback for vaccination providers in a wide range of target populations and settings, and for most vaccines appropriate for adults or children. While no studies specifically evaluated the impact of assessment and feedback for vaccination of adolescents, evidence from this review is likely applicable to this population.","This CPSTF concludes that none of the studies identified in this review evaluated the impact of provider assessment and feedback interventions on the delivery of vaccines to adolescents. Future studies should examine the effectiveness of these interventions in increasing vaccination rates among adolescents."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Education When Used Alone. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of provider education interventions when implemented alone in improving vaccination rates or reducing vaccine-preventable illness. Evidence is considered insufficient because the six identified studies observed changes in vaccination rates that were both small in magnitude and inconsistent.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (5 studies with 6 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient effectiveness.\n\nThe Task Force review included six studies that provided seven measurements of change in vaccination rates. The overall median absolute increase in vaccination rates was 4 percentage points (interquartile interval: 2 to 4 percentage points), however none of the study effect estimates were statistically significant, and results were inconsistent across the small body of evidence.\n\nThe Task Force identified, but did not consider in this review, an emerging body of evidence on the education of vaccination providers on the process of quality improvement. Education about quality improvement with the goal of reducing missed opportunities for vaccination and increasing vaccination rates was considered as a distinct intervention from provider education focused on vaccines and vaccinations.\n\nProvider education can be one component of an effective, combined approach to increase vaccination rates. Based on strong evidence of effectiveness identified in updated reviews, the Task Force recommends health care system-based interventions implemented in combination and community-based interventions implemented in combination.\n","This CPSTF report concludes that despite the common and continued use of provider education interventions alone, there are few published studies on their effectiveness.\n\nOne potential area for continued intervention research is provider education regarding new vaccines and expanded recommendations for specific vaccinations. As vaccine recommendations and schedules from the Advisory Committee on Immunization Practices continue to evolve, the potential effectiveness of provider education in increasing or improving the implementation of new recommendations warrants continued research.\n\nNone of the included studies assessed the effectiveness of provider education through distance-based training. Newer educational approaches might increase opportunities for vaccination providers to both share and learn from the experiences of peers and experts in the field."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client Reminder and Recall Systems. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends client reminder and recall interventions based on strong evidence of effectiveness in improving vaccination rates: (1) in children, adolescents and adults; (2) in a range of settings and populations; (3) when applied at different levels of scale—from individual practice settings to entire communities; (4) across a range of intervention characteristics (e.g., reminder or recall, content, theoretical basis and method of delivery); and (5) whether used alone or with additional components.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997-2007) combined with more recent evidence (10 studies, search period 2007-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 11 percentage points (IQI: 4 to 17 percentage points). Client reminder and recall interventions used alone resulted in a median increase of 6 percentage points (IQI: 3 to 13 percentage points; 14 studies), and interventions implemented with additional components led to a median increase of 12 percentage points (IQI: 10 to 30 percentage points; 15 studies).\n\nThe included studies evaluated the effectiveness of client reminder and recall interventions for a wide range of client and provider populations, settings, vaccinations and delivery methods. Based on the evidence, the Task Force finding should be broadly applicable to all patient populations, in both clinical and community settings, and for the range of vaccines and delivery methods.\n","This CPSTF concludes that client reminder and recall systems can also be important, effective components of combined approaches to increase vaccination rates. Based on updated, concurrent reviews, the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based interventions implemented in combination. Immunization information systems, which can also generate client reminder or recall notices provide an additional implementation option.\n\nMore research is needed on effective implementation, sustainability, and expansion of reminder and recall interventions. Future research should also examine the effectiveness of reminder and recall notices using emerging communication technologies (i.e. text message, email). Additional studies should also examine the effectiveness of client reminder and recall interventions on adolescent vaccines such as the HPV.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Reducing Client Out-of-Pocket Costs for Vaccinations. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends interventions that reduce client out-of-pocket costs based on strong evidence of effectiveness in improving vaccination rates. The effectiveness of these interventions has been demonstrated among children, adolescents, and adults, in a range of settings and populations, when applied in varying levels of scale from individual clinical settings to statewide programs to national efforts, and whether used alone or as part of a multi-component intervention.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies; search period 1997 - 2009) combined with more recent evidence (5 studies, search period 2009 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nEleven studies provided a common measurement of change in vaccination rates and showed a median increase of 22 percentage points (IQI: 6 to 33 percentage points). Six studies examined the impact of reducing client out-of-pocket costs alone (median increase of 28 percentage points; IQI: 2 to 47 percentage points) and 5 studies examined reducing client out-of-pocket costs as part of a multi-component strategy (median increase of 20 percentage points; IQI: 6 to 20 percentage points). The nine qualifying studies that did not provide a common measurement of change also reported overall increases in vaccinations received or administered.\n\nIncluded studies evaluated intervention effects on childhood vaccination series (3 studies), influenza (9 studies), pneumococcal (6 studies), hepatitis B (2 studies), and human papilloma virus (1 study). The reviewed studies evaluated the effectiveness of interventions that reduced client out-of-pocket costs in a range of client and provider populations and settings.\n\nPolicies adopted in the United States, including the Federal Vaccines for Children Program and the Affordable Care Act, have expanded access to many vaccines at reduced out-of-pocket cost. Barriers to expanded implementation of efforts include the adequacy and timeliness of reimbursement for the costs of vaccines, storage, and administration. In the United States, the ability of health care systems and providers to implement these interventions may depend on the adequacy and timeliness of reimbursement for the costs of the vaccines, storage, and administration.","This CPSTF concludes that additional research is needed to determine the effectiveness of reducing client out-of-pocket cost interventions to increase rates of recommended vaccinations for adolescents (e.g., HPV, meningococcal, influenza). In addition, the Task Force suggests additional research to determine if these interventions are effective options to increase receipt of annual influenza vaccinations. Future research should also examine whether reducing client out-of-pocket cost interventions are essential components of school-based vaccination programs and on-site vaccination programs in general."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends community-based interventions implemented in combination to increase vaccinations in targeted populations, on the basis of strong evidence of effectiveness in increasing vaccination rates.\n\nThe conclusion of strong evidence was based on findings from 18 studies that evaluated coordinated interventions to:\n- Increase community demand\n- Enhance access to vaccination services, and\n- Reduce missed opportunities by vaccination providers\nIn 13 of the 18 studies, the community-based effort combined one or more interventions to increase community demand for vaccinations with one or more interventions to enhance access to vaccination services.\n\nThe Task Force notes that implementing manual outreach and tracking or home visits can be resource-intensive and costly, relative to other options for increasing vaccination rates. Such interventions should be used only when there is demonstrated need, and resources are available.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (17 studies; search period 1980 - 2010) combined with more recent evidence (1 study, search period 2010 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nAll of the included studies provided a common measure of change and showed a median increase in vacation rates of 14 percentage points (IQI: 7 to 24 percentage points).\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches.\nFourteen studies implemented an effective combination of one or more interventions to increase community demand with one or more interventions to enhance access to vaccination services and showed a median increase in vaccination rates of 16 percentage points (IQI: 12 to 26 percentage points).\n\nClient reminder and recall systems were used in most of the evaluated programs (15 study arms). Systems were implemented by vaccination providers, established as one part of a community manual outreach and tracking program, or generated from a regional immunization information system (IIS).","This CPSTF concludes that coordinated interventions may be especially important in communities that have wide disparities in vaccination coverage. Program planners should consider community characteristics, such as mobility and fragmentation of health care, in the selection and combination of interventions to increase vaccination rates and reduce disparities.\n\nPartnerships between community organizations and vaccination providers are likely to be an essential component of effective, sustained community-based efforts. Most studies involved partnerships with existing vaccination providers in\nthe community to increase access to vaccinations, rather than creating new vaccination services. Coalitions represent one way to establish effective partnerships, with the size of the coalition varying based on the community, targeted population, and scope of the problem. Four studies involved community coalitions that used the principles of community-based participatory research.\n\nMore evidence is needed on the effectiveness of these programs in adolescents, and when implemented in rural settings. More economic information on these interventions is needed, specifically, evaluations on the efficiencies of the resource-intensive components of manual outreach and tracking and home visits. Future research could compare program effectiveness based on differences in the component interventions and strategic combinations. Additional research also should examine ways to sustain these programs, especially when provided by existing community-based organizations."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Health Care System-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n","The CPSTF recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.\n\nBased on findings from 37 of the 64 included studies, the Task Force further recommends a combination that includes the following:\nAt least one intervention to increase client demand for vaccinations, such as:\n- Client reminder and recall systems\n- Clinic-based client education\n- Manual outreach and tracking\nAnd one or more interventions that address either, or both, of the following strategies:\n- Interventions to enhance access to vaccinations: Expanded access in health care settings, reduced client out-of-pocket costs, home visits\n- Interventions directed at vaccination providers or systems: Provider reminders, standing orders, provider assessment and feedback\n\nInterventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. \n\nOf the combined 64 included studies (76 study arms), 58 of them (70 study arms) provided a common measure of change in vaccination rates and showed a median increase of 9 percentage points (IQI: 4 to 21 percentage points). In general, changes in vaccination rates were greater when interventions were implemented in settings with low baseline rates.\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches. These strategic approaches included the following:\n- Interventions to increase client demand (client reminder and recall systems, clinic-based client education, client\nor family incentives, client-held paper immunization records, case management, and manual outreach and\ntracking)\n- Interventions to enhance access to vaccination services (expanded access in health care settings, reduced client\nout-of-pocket costs, and home visits)\n- Interventions directed at vaccination providers (provider reminder systems, standing orders, provider\nassessment and feedback, provider education, and provider incentives)\n\nThe most common individual interventions implemented in a combined approach were client reminder and recall\nsystems (34 study arms) and provider reminders (31 study arms).\n\nThirty-seven studies (44 study arms) evaluated a combination of interventions across two or three of the strategic approaches and showed a median increase in vaccination rates of 17 percentage points (IQI: 6 to 27 percentage points). In 26 study arms, interventions were combined within only one strategic approach and found a median increase in vaccination rates of 4 percentage points (IQI: 2 to 9 percentage points).\n\nNine studies evaluated combinations of interventions implemented as a part of a health care system quality improvement effort. The most commonly implemented interventions were those directed at vaccination providers (provider education, provider reminders, and provider assessment and feedback). The studies included in this evaluation were typically short in duration and reported mixed results.\n\nEvidence did not show a direct relationship between the number of interventions implemented and changes in vaccination rates. Included studies evaluated combinations of between two and nine interventions. The majority of studies implemented two (31 study arms) or three (18 study arms) interventions.","This CPSTF concludes that overall, included studies provided evidence of effectiveness for intervention combinations implemented in a range of clinical settings and communities, although evidence from rural settings was limited. Studies also demonstrated effectiveness across a range of client populations and vaccinations, including young children (childhood series, influenza) and older adults (influenza, pneumococcal, and tetanus vaccines). Two of the included studies evaluated interventions targeted at increasing vaccination rates among adolescents. Finally, the included studies demonstrated increases in vaccination rates for populations of low socioeconomic status (22 study arms) and across a range of racial and ethnic groups. Most of the included evidence evaluated client populations with low to moderate baseline vaccination rates,\nand findings are most applicable to these situations.\n\nMore evidence is needed on the effectiveness of these interventions in rural settings and when applied to increase vaccinations recommended for adolescents. Future research on quality improvement activities in these settings should incorporate study periods sufficient to evaluate continuous quality improvement efforts."]
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[null,"Saeterdal  I et al. Interventions aimed at communities to inform and/or educate about early childhood vaccination. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010232. DOI: 10.1002/14651858.CD010232.pub2.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.\n\nThe reviewers included two cluster‐randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.\n\nThe trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine‐preventable diseases among intervention participants (adjusted mean difference (MD) 0.121, 95% CI 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (RR 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted MD 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision‐making regarding childhood vaccination (adjusted MD 0.043, 95% CI ‐0.009 to 0.097).\n\nThe studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.","This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.’"]
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[null,"Turnbull C & Osborn  DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD004456. DOI: 10.1002/14651858.CD004456.pub3.\nAvailable here.","Under 5s","This Cochrane review aimed to determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.\n\nSeven studies (reporting 803 mother‐infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African‐American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; RR 1.05, 95% CI 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six‐month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI ‐1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI ‐0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non‐accidental injury and non‐voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).","There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high‐quality trials are needed."]

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[null,"UNDER 5s"]
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[null,"GUIDANCE - UNDER 5s"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Flu vaccination: increasing uptake. NG103. London: NICE; 2018.\nAvailable here.","This guideline is for: \n- Commissioners and providers of primary and secondary healthcare services, including maternity providers and community pharmacies\n- All employers of staff who provide NHS or social-care funded services (including maternity care, domiciliary care and care homes)\n- Local authorities, and community and voluntary sector organisations that employ health and social care workers\n- Occupational health services and infection prevention and control teams\n- NHS England teams and Health Education England teams\n- People using services, their families, carers and other members of the public, in particular those eligible for flu vaccination","This guideline covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.\n\nIt includes recommendations on:\n- Using a multicomponent approach\n- Raising awareness\n- Offering vaccination\n- Increasing uptake among eligible groups in primary and secondary care\n- Audit, monitoring and feedback\n- Vaccination in carers\n- Increasing uptake in health and social care staff"]
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[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - UNDER 5s"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Jia  L et al. Payment methods for healthcare providers working in outpatient healthcare settings. Cochrane Database of Systematic Reviews 2021, Issue 1. Art. No.: CD011865. DOI: 10.1002/14651858.CD011865.pub2. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.\n\nThe reviewers included 27 studies in the review: 12 randomised trials, 13 controlled before‐and‐after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high‐income countries, with only one study from a low‐ or middle‐income country. The included studies were categorised into four groups based on comparisons of different payment methods. Of which only two groups fulfilled the outcome criteria for this map. \n\n(1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings: P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate‐certainty evidence).\n\n2)  Enhanced fee for service (FFS) compared with FFS for healthcare providers working in outpatient healthcare settings: Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate‐certainty evidence). The reviewers are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low‐certainty evidence). \n\n\n\n\n","For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate‐certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low‐certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low‐certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low‐certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects.\n\nThere is a need for further well‐conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low‐ and middle‐income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions."]
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[null,"Palmer  MJ et al. Targeted client communication via mobile devices for improving maternal, neonatal, and child health. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD013679. DOI: 10.1002/14651858.CD013679.\nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of targeted client communication via mobile devices (TCCMD) on health behaviour, service use, health, and well‐being for maternal, neonatal and child health (MNCH).  \n\nThe reviewers included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low‐, middle‐ or high‐income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle‐income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Only results relevant to this evidence map have been extracted below.\n\nPregnant and postpartum women\nTCCMD versus digital non‐targeted communication: No studies reported behavioural, health, or well‐being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low‐certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low‐certainty evidence).\n\nParents of children aged less than five years\nTCCMD versus standard care: Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low‐certainty evidence); however, the effect estimates varied widely between studies.\n\nTCCMD versus non‐digital TCC: TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low‐certainty evidence), and may make little or no difference to oral hygiene practices (low‐certainty evidence).\n\nTCCMD versus digital non‐targeted communication: TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low‐certainty evidence).\n\nNo trials in any population reported data on unintended consequences.","The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High‐quality, adequately powered trials and cost‐effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality."]
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[null,"Kaufman  J et al. Face‐to‐face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD010038. DOI: 10.1002/14651858.CD010038.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of face‐to‐face interventions for informing or educating parents about early childhood vaccination on vaccination status and parental knowledge, attitudes and intention to vaccinate.\n\nIn this update, the reviewers found four new studies, for a total of ten studies. They included seven randomised controlled trials (RCTs) and three cluster‐RCTs involving a total of 4527 participants, although we were unable to pool the data from one cluster‐RCT. Three of the ten studies were conducted in low‐ or middle‐ income countries.\n\nAll included studies compared face‐to‐face interventions with control. Most studies evaluated the effectiveness of a single intervention session delivered to individual parents. The interventions were an even mix of short (ten minutes or less) and longer sessions (15 minutes to several hours).\n\nOverall, elements of the study designs put them at moderate to high risk of bias. All studies but one were at low risk of bias for sequence generation (i.e. used a random number sequence). For allocation concealment (i.e. the person randomising participants was unaware of the study group to which participant would be allocated), three were at high risk and one was judged at unclear risk of bias. Due to the educational nature of the intervention, blinding of participants and personnel was not possible in any studies. The risk of bias due to blinding of outcome assessors was judged as low for four studies. Most studies were at unclear risk of bias for incomplete outcome data and selective reporting. Other potential sources of bias included failure to account for clustering in a cluster‐RCT and significant unexplained baseline differences between groups. One cluster‐RCT was at high risk for selective recruitment of participants.\n\nThe reviewers judged the certainty of the evidence to be low for the outcomes of children's vaccination status, parents' attitudes or beliefs, intention to vaccinate, adverse effects (e.g. anxiety), and immunisation cost, and moderate for parents' knowledge or understanding. All studies had limitations in design. They downgraded the certainty of the evidence where we judged that studies had problems with randomisation or allocation concealment, or when outcomes were self‐reported by participants who knew whether they'd received the intervention or not. They also downgraded the certainty for inconsistency (vaccination status), imprecision (intention to vaccinate and adverse effects), and indirectness (attitudes or beliefs, and cost).\n\nLow‐certainty evidence from seven studies (3004 participants) suggested that face‐to‐face interventions to inform or educate parents may improve vaccination status (RR) 1.20, 95% CI 1.04 to 1.37). Moderate‐certainty evidence from four studies (657 participants) found that face‐to‐face interventions probably slightly improved parent knowledge (standardised mean difference (SMD) 0.19, 95% CI 0.00 to 0.38), and low‐certainty evidence from two studies (179 participants) suggested they may slightly improve intention to vaccinate (SMD 0.55, 95% CI 0.24 to 0.85). Low‐certainty evidence found the interventions may lead to little or no change in parent attitudes or beliefs about vaccination (SMD 0.03, 95% CI ‐0.20 to 0.27; three studies, 292 participants), or in parents’ anxiety (mean difference (MD) ‐1.93, 95% CI ‐7.27 to 3.41; one study, 90 participants). Only one study (365 participants) measured the intervention cost of a case management strategy, reporting that the estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care (low‐certainty evidence). No included studies reported outcomes associated with parents’ experience of the intervention (e.g. satisfaction).","There is low‐ to moderate‐certainty evidence suggesting that face‐to‐face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.\n\nFace‐to‐face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Posadzki  P et al. Automated telephone communication systems for preventive healthcare and management of long‐term conditions. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD009921. DOI: 10.1002/14651858.CD009921.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of automated telephone communication systems (ATCS) for preventing disease and managing long‐term conditions on behavioural change, clinical, process, cognitive, patient‐centred and adverse outcomes.\n\nThe reviewers included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty‐one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long‐term conditions, and seven studies for appointment reminders. They downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. They judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. They considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. Only results relevant to this evidence map have been extracted below.\n\nFor preventive healthcare, ATCS (ATCS Plus, interactive voice response , unidirectional) probably increase immunisation uptake in children (RR 1.25, 95% CI 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).","ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost‐effective."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Requirements for\nChild Care, School, and College Attendance. The Community Guide; 2016. \nAvailable here.","Under 5s\n5 to 18 years","This CPSTF report examines laws or policies requiring vaccinations or other documentation of immunity as a condition of child care, school, and college attendance. These findings are based on studies demonstrating effectiveness of vaccination requirements for attendance in a variety of settings, for an array of recommended vaccines, and in populations ranging in age from early childhood to late adolescence.\n\nThe Task Force finding is based on evidence from 32 studies (search period January 1980 – July 2015) that examined the effectiveness of vaccination requirements on vaccination coverage rates or changes in vaccine-preventable disease or illness.\n\nSeventeen studies with 24 study arms examined the effectiveness of state or local vaccination requirements on changes in vaccination rates. The median change was an increase of 18 percentage points (Interquartile interval [IQI]: 10 to 35 percentage points). Five additional studies examined changes in vaccination rates or series completion that could not be included in the summary effect estimate, although results were generally in the direction of increased coverage.\n\nTen studies examined the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements. Three U.S. studies found that the incidence of measles and mumps was lower in states with immunization requirements for school-aged children, and that low-incidence areas were more likely to enforce school entry laws by excluding non-compliant children from attendance.\n\nOne study from Italy found reductions in rates of hepatitis B disease attributable to the implementation of vaccination requirements and school and community-based vaccination programs. A study from Japan found increases in excess mortality rates among younger children due to influenza and pneumonia, after the removal of a national influenza vaccination mandate and school-based immunization program.\n\nFive studies evaluated other vaccination requirements and found: (1) lower incidence of mumps during an outbreak in children subject to a vaccination requirement; (2) greater declines in Haemophilus influenza type b disease incidence among child care attendees subject to vaccination requirements than for New York State as a whole; (3) lower risk for measles outbreaks in colleges with pre-matriculation immunization requirements; (4) decline in hepatitis A disease incidence following implementation of a child care entry requirement in response to an outbreak, and (5) reduction in influenza-associated hospitalizations among children following a child care entry requirement.\n\nIncluded studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies). Studies provided evidence of effectiveness for both primary school entry requirements (11 studies) and requirements for middle/high school students (13 studies). Six studies examined vaccinations for child care attendance and findings are applicable to these settings. Although only one study evaluated vaccination requirements for college (1\nstudies) findings are likely applicable to these settings.\n\nIncluded studies examined changes in coverage rates or disease incidence for vaccinations to protect against measles mumps-rubella (16 studies), tetanus (8 studies), pertussis (8 studies), varicella (8 studies), Haemophilus influenza type b disease (5 studies), hepatitis A (2 studies), hepatitis B (14 studies), meningococcal disease (3 studies), influenza (2 studies), and human papillomavirus (1 study). Task Force findings are applicable or likely applicable for the range of vaccines recommended for children and adolescents.","The CPSTF recommends vaccination requirements for child care, school, and college attendance based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine preventable disease (VPD) and associated morbidity and mortality. \n\nAlthough intervention studies overall provide strong evidence of effectiveness, three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease transmission: 1) geographic clustering of under immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions. \n\nMost included studies examined school vaccination requirements; additional evaluations of requirements for child care attendance and college residency would be useful. Additional research would be useful to clarify relationships between variations in school or child care documentation and enforcement and vaccination and exemption rates. Information on barriers to school and local enforcement and ways to overcome these barriers would also be useful. Likewise, studies examining factors that facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings would be helpful. Finally, more research is needed to assess the economic costs and benefits of vaccination requirements in each setting."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Adams J, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study, and discrete choice experiment. Health Technology Assessment 2015;19(94). \nAvailable here","Parents and carers of preschool children, health and educational professionals. ","The review included studies exploring the effectiveness, acceptability or economic costs and consequences of interventions that offered contingent rewards or penalties with real material value for preschool vaccinations, or quasi-mandatory schemes that restricted access to ‘universal’ services, compared with usual care or no intervention.\nSystematic review – there was insufficient evidence to conclude that the interventions considered are effective. There was some evidence that the quasi-mandatory interventions were acceptable. There was insufficient evidence to draw conclusions on economic costs and consequences.","There is little current evidence on the effectiveness or economic costs and consequences of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. \nUniversal incentives are likely to be more acceptable than targeted ones. Preferences concerning incentives versus quasi-mandatory interventions may depend on the context in which these are elicited."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Programs in the\nSpecial Supplemental Nutrition Program for Women, Infants and\nChildren (WIC) Settings. The Community Guide; 2015. \nAvailable here.","Under 5s","The CPSTF recommends coordinated vaccination interventions in women, infants and children (WIC) settings based on strong evidence of effectiveness in increasing vaccination rates in children. Evidence on effectiveness was considered strong based on studies in which assessment of client immunization status and referral to vaccination providers was combined with: 1) provision of vaccinations on-site or in a collocated healthcare facility, or 2) additional interventions such as monthly voucher pickup requirements, manual tracking and outreach, or client reminder and recall systems. Evidence was limited regarding the effectiveness of assessment and referral in WIC settings when implemented alone.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review.\nThe combined evidence included 15 studies of programs that coordinated assessment and referral in WIC settings with additional interventions. Only one study evaluated the use of assessment and referral programs when used alone and found no effect. Of the included studies, 8 (10 study arms) provided a common measurement of change in vaccination rates and observed a median increase of 10.5 percentage points (IQI: 4 to 19 percentage points).\nThe most common additional interventions were monthly voucher pickup (5 studies) and provision of vaccinations onsite or in collocated healthcare facilities (4 studies).\n\nAll of the included studies evaluated WIC programs in urban settings and populations. Despite the lack of evidence from suburban and rural settings, the Task Force considers the overall evidence on effectiveness to be applicable in most WIC settings and populations.","This CPSTF report concludes that WIC services provide opportunities for regular and ongoing contact with families who may have limited access or substantial barriers to immunization services. Although on-site or collocation of vaccination services can substantially enhance access, these approaches require ongoing communication and coordination between WIC programs and healthcare providers in order to minimize missed vaccination opportunities while maintaining continuity of care.\n\nOnly one study examined vaccination status assessment and referral when implemented alone. Additional studies are needed to determine the effectiveness of this basic approach. More research is needed on efforts to collocate WIC and health care services, on the adoption of monthly voucher pickup requirements, and on the impact of providing WIC interventions outside of the medical home."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Promoting Health Equity Through Education Programs and Policies:\nSchool-Based Health Centers. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.\n\nThe CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.\n\nMost evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.\n\nThe Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these \"whole school\" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen \"SBHC user\" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services. \n\nBecause most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.\n\nMost studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.\n\nMost of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.","This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. \n\nIn the implementation of SBHCs, the following issues should be considered:\n- Billing and financing is a major challenge to SBHC implementation and sustainability\n- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation\n- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings\n- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness\n\nThe report also identifies areas for further research.\n\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Assessment and Feedback. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends assessment and feedback for vaccination providers on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults and children; (2) when used alone or with additional interventions; and (3) across a range of settings and populations. While there was not enough evidence to determine which characteristics of assessment and feedback contributed most to its effectiveness, various strategies have been consistently effective in a wide range of contexts.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997–2007) combined with more recent evidence (1 study, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 20 studies. Of these, 16 studies with 20 study arms provided common measurements of change in vaccination rates. The median increase of 9 percentage points (IQI: 3 to 14 percentage points). Fifteen study arms provided sufficient information to calculate the change in vaccination rates and showed a median increase of 18.0% (IQI: 9.5% to 24.0%). Seven study arms evaluated the impact of assessment and feedback for providers when implemented alone and found a median increase of 11 percentage points (IQI: 7 to 12 percentage points). Thirteen study arms evaluated provider assessment and feedback with additional interventions and observed a median increase of 6 percentage points (IQI: 3 to 18 percentage points). One additional study did not provide a common measurement of change in vaccination rates, and reported no change after implementation of intervention.\n\nThe reviewed studies evaluated the impact of assessment and feedback for vaccination providers in a wide range of target populations and settings, and for most vaccines appropriate for adults or children. While no studies specifically evaluated the impact of assessment and feedback for vaccination of adolescents, evidence from this review is likely applicable to this population.","This CPSTF concludes that none of the studies identified in this review evaluated the impact of provider assessment and feedback interventions on the delivery of vaccines to adolescents. Future studies should examine the effectiveness of these interventions in increasing vaccination rates among adolescents."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client Reminder and Recall Systems. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends client reminder and recall interventions based on strong evidence of effectiveness in improving vaccination rates: (1) in children, adolescents and adults; (2) in a range of settings and populations; (3) when applied at different levels of scale—from individual practice settings to entire communities; (4) across a range of intervention characteristics (e.g., reminder or recall, content, theoretical basis and method of delivery); and (5) whether used alone or with additional components.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997-2007) combined with more recent evidence (10 studies, search period 2007-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 11 percentage points (IQI: 4 to 17 percentage points). Client reminder and recall interventions used alone resulted in a median increase of 6 percentage points (IQI: 3 to 13 percentage points; 14 studies), and interventions implemented with additional components led to a median increase of 12 percentage points (IQI: 10 to 30 percentage points; 15 studies).\n\nThe included studies evaluated the effectiveness of client reminder and recall interventions for a wide range of client and provider populations, settings, vaccinations and delivery methods. Based on the evidence, the Task Force finding should be broadly applicable to all patient populations, in both clinical and community settings, and for the range of vaccines and delivery methods.\n","This CPSTF concludes that client reminder and recall systems can also be important, effective components of combined approaches to increase vaccination rates. Based on updated, concurrent reviews, the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based interventions implemented in combination. Immunization information systems, which can also generate client reminder or recall notices provide an additional implementation option.\n\nMore research is needed on effective implementation, sustainability, and expansion of reminder and recall interventions. Future research should also examine the effectiveness of reminder and recall notices using emerging communication technologies (i.e. text message, email). Additional studies should also examine the effectiveness of client reminder and recall interventions on adolescent vaccines such as the HPV.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Reducing Client Out-of-Pocket Costs for Vaccinations. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends interventions that reduce client out-of-pocket costs based on strong evidence of effectiveness in improving vaccination rates. The effectiveness of these interventions has been demonstrated among children, adolescents, and adults, in a range of settings and populations, when applied in varying levels of scale from individual clinical settings to statewide programs to national efforts, and whether used alone or as part of a multi-component intervention.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies; search period 1997 - 2009) combined with more recent evidence (5 studies, search period 2009 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nEleven studies provided a common measurement of change in vaccination rates and showed a median increase of 22 percentage points (IQI: 6 to 33 percentage points). Six studies examined the impact of reducing client out-of-pocket costs alone (median increase of 28 percentage points; IQI: 2 to 47 percentage points) and 5 studies examined reducing client out-of-pocket costs as part of a multi-component strategy (median increase of 20 percentage points; IQI: 6 to 20 percentage points). The nine qualifying studies that did not provide a common measurement of change also reported overall increases in vaccinations received or administered.\n\nIncluded studies evaluated intervention effects on childhood vaccination series (3 studies), influenza (9 studies), pneumococcal (6 studies), hepatitis B (2 studies), and human papilloma virus (1 study). The reviewed studies evaluated the effectiveness of interventions that reduced client out-of-pocket costs in a range of client and provider populations and settings.\n\nPolicies adopted in the United States, including the Federal Vaccines for Children Program and the Affordable Care Act, have expanded access to many vaccines at reduced out-of-pocket cost. Barriers to expanded implementation of efforts include the adequacy and timeliness of reimbursement for the costs of vaccines, storage, and administration. In the United States, the ability of health care systems and providers to implement these interventions may depend on the adequacy and timeliness of reimbursement for the costs of the vaccines, storage, and administration.","This CPSTF concludes that additional research is needed to determine the effectiveness of reducing client out-of-pocket cost interventions to increase rates of recommended vaccinations for adolescents (e.g., HPV, meningococcal, influenza). In addition, the Task Force suggests additional research to determine if these interventions are effective options to increase receipt of annual influenza vaccinations. Future research should also examine whether reducing client out-of-pocket cost interventions are essential components of school-based vaccination programs and on-site vaccination programs in general."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends community-based interventions implemented in combination to increase vaccinations in targeted populations, on the basis of strong evidence of effectiveness in increasing vaccination rates.\n\nThe conclusion of strong evidence was based on findings from 18 studies that evaluated coordinated interventions to:\n- Increase community demand\n- Enhance access to vaccination services, and\n- Reduce missed opportunities by vaccination providers\nIn 13 of the 18 studies, the community-based effort combined one or more interventions to increase community demand for vaccinations with one or more interventions to enhance access to vaccination services.\n\nThe Task Force notes that implementing manual outreach and tracking or home visits can be resource-intensive and costly, relative to other options for increasing vaccination rates. Such interventions should be used only when there is demonstrated need, and resources are available.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (17 studies; search period 1980 - 2010) combined with more recent evidence (1 study, search period 2010 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nAll of the included studies provided a common measure of change and showed a median increase in vacation rates of 14 percentage points (IQI: 7 to 24 percentage points).\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches.\nFourteen studies implemented an effective combination of one or more interventions to increase community demand with one or more interventions to enhance access to vaccination services and showed a median increase in vaccination rates of 16 percentage points (IQI: 12 to 26 percentage points).\n\nClient reminder and recall systems were used in most of the evaluated programs (15 study arms). Systems were implemented by vaccination providers, established as one part of a community manual outreach and tracking program, or generated from a regional immunization information system (IIS).","This CPSTF concludes that coordinated interventions may be especially important in communities that have wide disparities in vaccination coverage. Program planners should consider community characteristics, such as mobility and fragmentation of health care, in the selection and combination of interventions to increase vaccination rates and reduce disparities.\n\nPartnerships between community organizations and vaccination providers are likely to be an essential component of effective, sustained community-based efforts. Most studies involved partnerships with existing vaccination providers in\nthe community to increase access to vaccinations, rather than creating new vaccination services. Coalitions represent one way to establish effective partnerships, with the size of the coalition varying based on the community, targeted population, and scope of the problem. Four studies involved community coalitions that used the principles of community-based participatory research.\n\nMore evidence is needed on the effectiveness of these programs in adolescents, and when implemented in rural settings. More economic information on these interventions is needed, specifically, evaluations on the efficiencies of the resource-intensive components of manual outreach and tracking and home visits. Future research could compare program effectiveness based on differences in the component interventions and strategic combinations. Additional research also should examine ways to sustain these programs, especially when provided by existing community-based organizations."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Health Care System-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n","The CPSTF recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.\n\nBased on findings from 37 of the 64 included studies, the Task Force further recommends a combination that includes the following:\nAt least one intervention to increase client demand for vaccinations, such as:\n- Client reminder and recall systems\n- Clinic-based client education\n- Manual outreach and tracking\nAnd one or more interventions that address either, or both, of the following strategies:\n- Interventions to enhance access to vaccinations: Expanded access in health care settings, reduced client out-of-pocket costs, home visits\n- Interventions directed at vaccination providers or systems: Provider reminders, standing orders, provider assessment and feedback\n\nInterventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. \n\nOf the combined 64 included studies (76 study arms), 58 of them (70 study arms) provided a common measure of change in vaccination rates and showed a median increase of 9 percentage points (IQI: 4 to 21 percentage points). In general, changes in vaccination rates were greater when interventions were implemented in settings with low baseline rates.\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches. These strategic approaches included the following:\n- Interventions to increase client demand (client reminder and recall systems, clinic-based client education, client\nor family incentives, client-held paper immunization records, case management, and manual outreach and\ntracking)\n- Interventions to enhance access to vaccination services (expanded access in health care settings, reduced client\nout-of-pocket costs, and home visits)\n- Interventions directed at vaccination providers (provider reminder systems, standing orders, provider\nassessment and feedback, provider education, and provider incentives)\n\nThe most common individual interventions implemented in a combined approach were client reminder and recall\nsystems (34 study arms) and provider reminders (31 study arms).\n\nThirty-seven studies (44 study arms) evaluated a combination of interventions across two or three of the strategic approaches and showed a median increase in vaccination rates of 17 percentage points (IQI: 6 to 27 percentage points). In 26 study arms, interventions were combined within only one strategic approach and found a median increase in vaccination rates of 4 percentage points (IQI: 2 to 9 percentage points).\n\nNine studies evaluated combinations of interventions implemented as a part of a health care system quality improvement effort. The most commonly implemented interventions were those directed at vaccination providers (provider education, provider reminders, and provider assessment and feedback). The studies included in this evaluation were typically short in duration and reported mixed results.\n\nEvidence did not show a direct relationship between the number of interventions implemented and changes in vaccination rates. Included studies evaluated combinations of between two and nine interventions. The majority of studies implemented two (31 study arms) or three (18 study arms) interventions.","This CPSTF concludes that overall, included studies provided evidence of effectiveness for intervention combinations implemented in a range of clinical settings and communities, although evidence from rural settings was limited. Studies also demonstrated effectiveness across a range of client populations and vaccinations, including young children (childhood series, influenza) and older adults (influenza, pneumococcal, and tetanus vaccines). Two of the included studies evaluated interventions targeted at increasing vaccination rates among adolescents. Finally, the included studies demonstrated increases in vaccination rates for populations of low socioeconomic status (22 study arms) and across a range of racial and ethnic groups. Most of the included evidence evaluated client populations with low to moderate baseline vaccination rates,\nand findings are most applicable to these situations.\n\nMore evidence is needed on the effectiveness of these interventions in rural settings and when applied to increase vaccinations recommended for adolescents. Future research on quality improvement activities in these settings should incorporate study periods sufficient to evaluate continuous quality improvement efforts."]
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[null,"Saeterdal I et al. Interventions aimed at communities to inform and/or educate about early childhood vaccination. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010232. DOI: 10.1002/14651858.CD010232.pub2.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.\n\nThe reviewers included two cluster‐randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.\n\nThe trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine‐preventable diseases among intervention participants (adjusted mean difference (MD) 0.121, 95% CI 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (RR 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted MD 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision‐making regarding childhood vaccination (adjusted MD 0.043, 95% CI ‐0.009 to 0.097).\n\nThe studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.","This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.’"]
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[null,"Turnbull C & Osborn  DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD004456. DOI: 10.1002/14651858.CD004456.pub3.\nAvailable here.","Under 5s","This Cochrane review aimed to determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.\n\nSeven studies (reporting 803 mother‐infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African‐American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; RR 1.05, 95% CI 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six‐month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI ‐1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI ‐0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non‐accidental injury and non‐voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).","There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high‐quality trials are needed."]

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[null,"5 TO 18 YEAR OLDS"]
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[null,"GUIDANCE - 5 TO 18 YEAR OLDS"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - 5 TO 18 YEAR OLDS"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers' included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Posadzki  P et al. Automated telephone communication systems for preventive healthcare and management of long‐term conditions. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD009921. DOI: 10.1002/14651858.CD009921.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of automated telephone communication systems (ATCS) for preventing disease and managing long‐term conditions on behavioural change, clinical, process, cognitive, patient‐centred and adverse outcomes.\n\nThe reviewers included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty‐one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long‐term conditions, and seven studies for appointment reminders. They downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. They judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. They considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. Only results relevant to this evidence map have been extracted below.\n\nFor preventive healthcare, ATCS (ATCS Plus, interactive voice response , unidirectional) probably increase immunisation uptake in children (RR 1.25, 95% CI 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).","ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost‐effective."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Requirements for\nChild Care, School, and College Attendance. The Community Guide; 2016. \nAvailable here.","Under 5s\n5 to 18 years","This CPSTF report examines laws or policies requiring vaccinations or other documentation of immunity as a condition of child care, school, and college attendance. These findings are based on studies demonstrating effectiveness of vaccination requirements for attendance in a variety of settings, for an array of recommended vaccines, and in populations ranging in age from early childhood to late adolescence.\n\nThe Task Force finding is based on evidence from 32 studies (search period January 1980 – July 2015) that examined the effectiveness of vaccination requirements on vaccination coverage rates or changes in vaccine-preventable disease or illness.\n\nSeventeen studies with 24 study arms examined the effectiveness of state or local vaccination requirements on changes in vaccination rates. The median change was an increase of 18 percentage points (Interquartile interval [IQI]: 10 to 35 percentage points). Five additional studies examined changes in vaccination rates or series completion that could not be included in the summary effect estimate, although results were generally in the direction of increased coverage.\n\nTen studies examined the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements. Three U.S. studies found that the incidence of measles and mumps was lower in states with immunization requirements for school-aged children, and that low-incidence areas were more likely to enforce school entry laws by excluding non-compliant children from attendance.\n\nOne study from Italy found reductions in rates of hepatitis B disease attributable to the implementation of vaccination requirements and school and community-based vaccination programs. A study from Japan found increases in excess mortality rates among younger children due to influenza and pneumonia, after the removal of a national influenza vaccination mandate and school-based immunization program.\n\nFive studies evaluated other vaccination requirements and found: (1) lower incidence of mumps during an outbreak in children subject to a vaccination requirement; (2) greater declines in Haemophilus influenza type b disease incidence among child care attendees subject to vaccination requirements than for New York State as a whole; (3) lower risk for measles outbreaks in colleges with pre-matriculation immunization requirements; (4) decline in hepatitis A disease incidence following implementation of a child care entry requirement in response to an outbreak, and (5) reduction in influenza-associated hospitalizations among children following a child care entry requirement.\n\nIncluded studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies). Studies provided evidence of effectiveness for both primary school entry requirements (11 studies) and requirements for middle/high school students (13 studies). Six studies examined vaccinations for child care attendance and findings are applicable to these settings. Although only one study evaluated vaccination requirements for college (1\nstudies) findings are likely applicable to these settings.\n\nIncluded studies examined changes in coverage rates or disease incidence for vaccinations to protect against measles mumps-rubella (16 studies), tetanus (8 studies), pertussis (8 studies), varicella (8 studies), Haemophilus influenza type b disease (5 studies), hepatitis A (2 studies), hepatitis B (14 studies), meningococcal disease (3 studies), influenza (2 studies), and human papillomavirus (1 study). Task Force findings are applicable or likely applicable for the range of vaccines recommended for children and adolescents.","The CPSTF recommends vaccination requirements for child care, school, and college attendance based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine preventable disease (VPD) and associated morbidity and mortality. \n\nAlthough intervention studies overall provide strong evidence of effectiveness, three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease transmission: 1) geographic clustering of under immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions. \n\nMost included studies examined school vaccination requirements; additional evaluations of requirements for child care attendance and college residency would be useful. Additional research would be useful to clarify relationships between variations in school or child care documentation and enforcement and vaccination and exemption rates. Information on barriers to school and local enforcement and ways to overcome these barriers would also be useful. Likewise, studies examining factors that facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings would be helpful. Finally, more research is needed to assess the economic costs and benefits of vaccination requirements in each setting."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Promoting Health Equity Through Education Programs and Policies:\nSchool-Based Health Centers. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.\n\nThe CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.\n\nMost evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.\n\nThe Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these \"whole school\" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen \"SBHC user\" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services. \n\nBecause most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.\n\nMost studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.\n\nMost of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.","This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. \n\nIn the implementation of SBHCs, the following issues should be considered:\n- Billing and financing is a major challenge to SBHC implementation and sustainability\n- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation\n- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings\n- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness\n\nThe report also identifies areas for further research.\n\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Assessment and Feedback. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends assessment and feedback for vaccination providers on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults and children; (2) when used alone or with additional interventions; and (3) across a range of settings and populations. While there was not enough evidence to determine which characteristics of assessment and feedback contributed most to its effectiveness, various strategies have been consistently effective in a wide range of contexts.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997–2007) combined with more recent evidence (1 study, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 20 studies. Of these, 16 studies with 20 study arms provided common measurements of change in vaccination rates. The median increase of 9 percentage points (IQI: 3 to 14 percentage points). Fifteen study arms provided sufficient information to calculate the change in vaccination rates and showed a median increase of 18.0% (IQI: 9.5% to 24.0%). Seven study arms evaluated the impact of assessment and feedback for providers when implemented alone and found a median increase of 11 percentage points (IQI: 7 to 12 percentage points). Thirteen study arms evaluated provider assessment and feedback with additional interventions and observed a median increase of 6 percentage points (IQI: 3 to 18 percentage points). One additional study did not provide a common measurement of change in vaccination rates, and reported no change after implementation of intervention.\n\nThe reviewed studies evaluated the impact of assessment and feedback for vaccination providers in a wide range of target populations and settings, and for most vaccines appropriate for adults or children. While no studies specifically evaluated the impact of assessment and feedback for vaccination of adolescents, evidence from this review is likely applicable to this population.","This CPSTF concludes that none of the studies identified in this review evaluated the impact of provider assessment and feedback interventions on the delivery of vaccines to adolescents. Future studies should examine the effectiveness of these interventions in increasing vaccination rates among adolescents."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client Reminder and Recall Systems. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends client reminder and recall interventions based on strong evidence of effectiveness in improving vaccination rates: (1) in children, adolescents and adults; (2) in a range of settings and populations; (3) when applied at different levels of scale—from individual practice settings to entire communities; (4) across a range of intervention characteristics (e.g., reminder or recall, content, theoretical basis and method of delivery); and (5) whether used alone or with additional components.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997-2007) combined with more recent evidence (10 studies, search period 2007-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 11 percentage points (IQI: 4 to 17 percentage points). Client reminder and recall interventions used alone resulted in a median increase of 6 percentage points (IQI: 3 to 13 percentage points; 14 studies), and interventions implemented with additional components led to a median increase of 12 percentage points (IQI: 10 to 30 percentage points; 15 studies).\n\nThe included studies evaluated the effectiveness of client reminder and recall interventions for a wide range of client and provider populations, settings, vaccinations and delivery methods. Based on the evidence, the Task Force finding should be broadly applicable to all patient populations, in both clinical and community settings, and for the range of vaccines and delivery methods.\n","This CPSTF concludes that client reminder and recall systems can also be important, effective components of combined approaches to increase vaccination rates. Based on updated, concurrent reviews, the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based interventions implemented in combination. Immunization information systems, which can also generate client reminder or recall notices provide an additional implementation option.\n\nMore research is needed on effective implementation, sustainability, and expansion of reminder and recall interventions. Future research should also examine the effectiveness of reminder and recall notices using emerging communication technologies (i.e. text message, email). Additional studies should also examine the effectiveness of client reminder and recall interventions on adolescent vaccines such as the HPV.\n"]
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[null,"Saeterdal I et al. Interventions aimed at communities to inform and/or educate about early childhood vaccination. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010232. DOI: 10.1002/14651858.CD010232.pub2.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.\n\nThe reviewers included two cluster‐randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.\n\nThe trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine‐preventable diseases among intervention participants (adjusted mean difference (MD) 0.121, 95% CI 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (RR 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted MD 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision‐making regarding childhood vaccination (adjusted MD 0.043, 95% CI ‐0.009 to 0.097).\n\nThe studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.","This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.’"]

{"sheet":"HighRisk","index":5,"n_rows":64,"n_cols":4,"rows_kept":64,"cut":false,"hidden":false,"merged":[[53,1,62,1],[53,2,62,2],[53,3,62,4],[63,1,77,1],[63,2,77,2],[63,3,77,4],[24,1,52,1],[24,2,52,2],[24,3,52,4],[19,1,20,4],[22,1,22,4]]}
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[null,"HIGH RISK GROUPS"]
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[null,"GUIDANCE - HIGH RISK GROUPS"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Flu vaccination: increasing uptake. NG103. London: NICE; 2018.\nAvailable here.","This guideline is for: \n- Commissioners and providers of primary and secondary healthcare services, including maternity providers and community pharmacies\n- All employers of staff who provide NHS or social-care funded services (including maternity care, domiciliary care and care homes)\n- Local authorities, and community and voluntary sector organisations that employ health and social care workers\n- Occupational health services and infection prevention and control teams\n- NHS England teams and Health Education England teams\n- People using services, their families, carers and other members of the public, in particular those eligible for flu vaccination","This guideline covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.\n\nIt includes recommendations on:\n- Using a multicomponent approach\n- Raising awareness\n- Offering vaccination\n- Increasing uptake among eligible groups in primary and secondary care\n- Audit, monitoring and feedback\n- Vaccination in carers\n- Increasing uptake in health and social care staff"]
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[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]

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[null,"GUIDANCE - REMINDER/ RECALL SERVICES"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Flu vaccination: increasing uptake. NG103. London: NICE; 2018.\nAvailable here.","This guideline is for: \n- Commissioners and providers of primary and secondary healthcare services, including maternity providers and community pharmacies\n- All employers of staff who provide NHS or social-care funded services (including maternity care, domiciliary care and care homes)\n- Local authorities, and community and voluntary sector organisations that employ health and social care workers\n- Occupational health services and infection prevention and control teams\n- NHS England teams and Health Education England teams\n- People using services, their families, carers and other members of the public, in particular those eligible for flu vaccination","This guideline covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.\n\nIt includes recommendations on:\n- Using a multicomponent approach\n- Raising awareness\n- Offering vaccination\n- Increasing uptake among eligible groups in primary and secondary care\n- Audit, monitoring and feedback\n- Vaccination in carers\n- Increasing uptake in health and social care staff"]
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[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - REMINDERS/ RECALL SERVICES"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Palmer  MJ et al. Targeted client communication via mobile devices for improving maternal, neonatal, and child health. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD013679. DOI: 10.1002/14651858.CD013679.\nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of targeted client communication via mobile devices (TCCMD) on health behaviour, service use, health, and well‐being for maternal, neonatal and child health (MNCH).  \n\nThe reviewers included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low‐, middle‐ or high‐income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle‐income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Only results relevant to this evidence map have been extracted below.\n\nPregnant and postpartum women\nTCCMD versus digital non‐targeted communication: No studies reported behavioural, health, or well‐being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low‐certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low‐certainty evidence).\n\nParents of children aged less than five years\nTCCMD versus standard care: Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low‐certainty evidence); however, the effect estimates varied widely between studies.\n\nTCCMD versus non‐digital TCC: TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low‐certainty evidence), and may make little or no difference to oral hygiene practices (low‐certainty evidence).\n\nTCCMD versus digital non‐targeted communication: TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low‐certainty evidence).\n\nNo trials in any population reported data on unintended consequences.","The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High‐quality, adequately powered trials and cost‐effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality."]
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[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Pantoja  T et al. Manually‐generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD001174. DOI: 10.1002/14651858.CD001174.pub4. \nAvailable here.","Age not specified","This Cochrane review aimed: 1. To determine the effectiveness of manually‐generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually‐generated reminders delivered on paper.\n\nThe reviewers identified 63 studies (41 cluster‐randomised trials, 18 individual randomised trials, and four non‐randomised trials) that met all inclusion criteria. Fifty‐seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty‐four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test‐ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention.\n\nForty‐eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process‐of‐care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Forty‐seven studies assessed the effect of reminders compared with control or usual care. In the studies assessing process adherence outcomes, only three of the effect estimates were related to recommended vaccination practices. \n\nManually‐generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% [Inter quartile range (QR) 2.54% to 20.58%].","Manually‐generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single quality improvement (QI) intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually‐generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Posadzki  P et al. Automated telephone communication systems for preventive healthcare and management of long‐term conditions. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD009921. DOI: 10.1002/14651858.CD009921.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of automated telephone communication systems (ATCS) for preventing disease and managing long‐term conditions on behavioural change, clinical, process, cognitive, patient‐centred and adverse outcomes.\n\nThe reviewers included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty‐one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long‐term conditions, and seven studies for appointment reminders. They downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. They judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. They considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. Only results relevant to this evidence map have been extracted below.\n\nFor preventive healthcare, ATCS (ATCS Plus, interactive voice response , unidirectional) probably increase immunisation uptake in children (RR 1.25, 95% CI 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).","ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost‐effective."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client-Held Paper\nImmunization Records. The Community Guide; 2016. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of client-held paper immunization records in increasing vaccination rates or reducing rates of vaccine preventable disease. Evidence was considered insufficient because of inconsistent findings and variability in the interventions evaluated.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (7 studies, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 8 studies with 11 study arms. Six studies (nine measurements) provided a common measure of vaccination rates and reported an overall median increase of 5.3 percentage points (IQI: -1.0 to 8.8 percentage points).\n\nResults were considered inconsistent because client-held paper immunization records were used as part of a multicomponent effort and comparison groups received one or more interventions.\n\nSeveral considerations for implementation were identified in the included studies and broader literature. These include clients'' declining interest over time and low card retention. Healthcare providers also have expressed concerns about time management when using a preventive services checklist.\n\nWith the expansion of population-based Immunization Information Systems and the development of on-line and electronic personal health care records, careful evaluation of client-held paper immunization records effectiveness is needed to achieve high levels of vaccination rates in the US population. However, until issues of privacy, security, and quality of electronic records have been resolved, and for clients on the other side of the \"digital divide,\" traditional client-held paper immunization records will continue to be useful. This may be particularly true for some populations, such as clients with limited computer access and adults whose change in employment status is accompanied by a change in providers.","This CPSTF report concludes that paper  immunization records maybe useful when they are used consistently—when providers update them and parents keep track of them. Children are more likely to receive recommended vaccinations and avoid being over-vaccinated. This is especially true when children are seen in non-traditional immunization settings, such as emergency departments.\n\nFurther research should therefore examine the effectiveness of additional activities to increase the retention and use of client-held paper immunization records for children by their parents or other caregivers."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Programs in the\nSpecial Supplemental Nutrition Program for Women, Infants and\nChildren (WIC) Settings. The Community Guide; 2015. \nAvailable here.","Under 5s","The CPSTF recommends coordinated vaccination interventions in women, infants and children (WIC) settings based on strong evidence of effectiveness in increasing vaccination rates in children. Evidence on effectiveness was considered strong based on studies in which assessment of client immunization status and referral to vaccination providers was combined with: 1) provision of vaccinations on-site or in a collocated healthcare facility, or 2) additional interventions such as monthly voucher pickup requirements, manual tracking and outreach, or client reminder and recall systems. Evidence was limited regarding the effectiveness of assessment and referral in WIC settings when implemented alone.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review.\nThe combined evidence included 15 studies of programs that coordinated assessment and referral in WIC settings with additional interventions. Only one study evaluated the use of assessment and referral programs when used alone and found no effect. Of the included studies, 8 (10 study arms) provided a common measurement of change in vaccination rates and observed a median increase of 10.5 percentage points (IQI: 4 to 19 percentage points).\nThe most common additional interventions were monthly voucher pickup (5 studies) and provision of vaccinations onsite or in collocated healthcare facilities (4 studies).\n\nAll of the included studies evaluated WIC programs in urban settings and populations. Despite the lack of evidence from suburban and rural settings, the Task Force considers the overall evidence on effectiveness to be applicable in most WIC settings and populations.","This CPSTF report concludes that WIC services provide opportunities for regular and ongoing contact with families who may have limited access or substantial barriers to immunization services. Although on-site or collocation of vaccination services can substantially enhance access, these approaches require ongoing communication and coordination between WIC programs and healthcare providers in order to minimize missed vaccination opportunities while maintaining continuity of care.\n\nOnly one study examined vaccination status assessment and referral when implemented alone. Additional studies are needed to determine the effectiveness of this basic approach. More research is needed on efforts to collocate WIC and health care services, on the adoption of monthly voucher pickup requirements, and on the impact of providing WIC interventions outside of the medical home."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client Reminder and Recall Systems. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends client reminder and recall interventions based on strong evidence of effectiveness in improving vaccination rates: (1) in children, adolescents and adults; (2) in a range of settings and populations; (3) when applied at different levels of scale—from individual practice settings to entire communities; (4) across a range of intervention characteristics (e.g., reminder or recall, content, theoretical basis and method of delivery); and (5) whether used alone or with additional components.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997-2007) combined with more recent evidence (10 studies, search period 2007-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 11 percentage points (IQI: 4 to 17 percentage points). Client reminder and recall interventions used alone resulted in a median increase of 6 percentage points (IQI: 3 to 13 percentage points; 14 studies), and interventions implemented with additional components led to a median increase of 12 percentage points (IQI: 10 to 30 percentage points; 15 studies).\n\nThe included studies evaluated the effectiveness of client reminder and recall interventions for a wide range of client and provider populations, settings, vaccinations and delivery methods. Based on the evidence, the Task Force finding should be broadly applicable to all patient populations, in both clinical and community settings, and for the range of vaccines and delivery methods.\n","This CPSTF concludes that client reminder and recall systems can also be important, effective components of combined approaches to increase vaccination rates. Based on updated, concurrent reviews, the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based interventions implemented in combination. Immunization information systems, which can also generate client reminder or recall notices provide an additional implementation option.\n\nMore research is needed on effective implementation, sustainability, and expansion of reminder and recall interventions. Future research should also examine the effectiveness of reminder and recall notices using emerging communication technologies (i.e. text message, email). Additional studies should also examine the effectiveness of client reminder and recall interventions on adolescent vaccines such as the HPV.\n"]

{"sheet":"Incentives","index":7,"n_rows":199,"n_cols":5,"rows_kept":199,"cut":false,"hidden":false,"merged":[[75,1,128,1],[75,2,128,2],[75,3,128,3],[75,4,128,4],[24,1,24,4],[26,1,40,1],[26,2,40,2],[26,3,40,4],[42,1,42,4],[44,1,74,1],[44,2,74,2],[44,3,74,3],[44,4,74,4],[129,1,144,1],[129,2,144,2],[129,3,144,3],[129,4,144,4],[198,1,229,1],[198,2,229,2],[198,3,230,3],[198,4,229,4],[145,1,167,1],[145,2,167,2],[145,3,168,3],[145,4,167,4],[169,1,197,1],[169,2,197,2],[169,3,197,3],[169,4,197,4]]}
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[null,"GUIDANCE - INCENTIVES"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - INCENTIVES"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Jia  L et al. Payment methods for healthcare providers working in outpatient healthcare settings. Cochrane Database of Systematic Reviews 2021, Issue 1. Art. No.: CD011865. DOI: 10.1002/14651858.CD011865.pub2. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.\n\nThe reviewers included 27 studies in the review: 12 randomised trials, 13 controlled before‐and‐after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high‐income countries, with only one study from a low‐ or middle‐income country. The included studies were categorised into four groups based on comparisons of different payment methods. Of which only two groups fulfilled the outcome criteria for this map. \n\n(1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings: P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate‐certainty evidence).\n\n2)  Enhanced fee for service (FFS) compared with FFS for healthcare providers working in outpatient healthcare settings: Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate‐certainty evidence). The reviewers are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low‐certainty evidence). \n\n\n\n\n","For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate‐certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low‐certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low‐certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low‐certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects.\n\nThere is a need for further well‐conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low‐ and middle‐income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions."]
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[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Adams J, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study, and discrete choice experiment. Health Technology Assessment 2015;19(94). \nAvailable here","Parents and carers of preschool children, health and educational professionals. ","The review included studies exploring the effectiveness, acceptability or economic costs and consequences of interventions that offered contingent rewards or penalties with real material value for preschool vaccinations, or quasi-mandatory schemes that restricted access to ‘universal’ services, compared with usual care or no intervention.\nSystematic review – there was insufficient evidence to conclude that the interventions considered are effective. There was some evidence that the quasi-mandatory interventions were acceptable. There was insufficient evidence to draw conclusions on economic costs and consequences.\n","There is little current evidence on the effectiveness or economic costs and consequences of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. \nUniversal incentives are likely to be more acceptable than targeted ones. Preferences concerning incentives versus quasi-mandatory interventions may depend on the context in which these are elicited."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client or Family Incentive Rewards. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends client or family incentive rewards, used alone or in combination with additional interventions, based on sufficient evidence of effectiveness in increasing vaccination rates in children and adults.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (6 studies with 7 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on sufficient evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 8 percentage points (IQI: 4 to 16 percentage points). Two study arms that assessed the effectiveness of incentive rewards alone showed similar changes in vaccination rates (8.5 and 9.0 percentage points). In the six remaining study arms, incentive rewards were combined with additional interventions.\n\nAmong the studies included in this review, the type of incentive reward offered to clients included government payments (i.e., of $208 AUD and childcare assistance), lottery prizes (i.e., $50 grocery voucher or $175 in monetary prizes), gift cards (i.e., $10 for baby products), baby products, and food vouchers. \n\nOverall, the Task Force considers the evidence to be applicable to vaccinations for children and adults in a wide range of clinical and community settings, and for various types of incentive rewards.","This CPSTF concludes that client or family incentive rewards can also be one component of an effective combined approach to increase vaccination rates in both clinical and community settings. Based on updated, concurrent reviews the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based\ninterventions implemented in combination.\n\nAdditional research could focus on the independent effects of incentive rewards, examine the relationship between the value of the reward and effectiveness, and explore the duration of intervention impact. It also would be useful to have more information about the effectiveness of these interventions with adolescents and adults as most of the included studies examined the use of incentive rewards on vaccination rates for children."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Monetary Sanction Policies. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of monetary sanction policies to increase vaccination rates among children in families receiving government assistance. The Task Force finding is based on the small number of studies; differences in the type of sanction policies evaluated; inconsistent results on vaccination rates; and limited information on potential harms of these policies.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (2 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review. Both of the included studies were conducted in the United States and evaluated the implementation of state monetary sanction policies for families receiving assistance through the Aid to Families with Dependent Children (AFDC) program. The first study, a two-year randomized controlled trial of AFDC recipients in Maryland, evaluated outcomes in 1,324 children aged 3 to 24 months and observed no significant improvements in vaccination rates (decrease of -0.7 percentage points). The second study, a three-year randomized controlled trial of 2,500 families on AFDC assistance in Georgia, observed significant improvements in vaccination rates in children (increase of 11.8 percentage points).\n","This CPSTF report concludes that evidence on the broad range of potential outcomes of monetary sanction policies is insufficient to inform considerations on their use as an intervention option to increase vaccination rates. Programs that are considering the adoption of monetary sanctions should first determine the range of potential harms that may occur from these policies. Barriers to implementing monetary sanctions include: agencies might not adopt these policies because of concerns about harms to families or they may not enforce these policies with case workers unwilling to apply sanctions to families. The Georgia study examined the issuance of warnings and sanctions to families and found that both were infrequently applied.\n\nAdditional evidence is needed to determine if monetary sanction policies are effective and beneficial to the communities they address. If so, research is needed to identify common elements of successful policies and programs and explore the health and financial effects of these policies on families requiring assistance.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Reducing Client Out-of-Pocket Costs for Vaccinations. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends interventions that reduce client out-of-pocket costs based on strong evidence of effectiveness in improving vaccination rates. The effectiveness of these interventions has been demonstrated among children, adolescents, and adults, in a range of settings and populations, when applied in varying levels of scale from individual clinical settings to statewide programs to national efforts, and whether used alone or as part of a multi-component intervention.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies; search period 1997 - 2009) combined with more recent evidence (5 studies, search period 2009 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nEleven studies provided a common measurement of change in vaccination rates and showed a median increase of 22 percentage points (IQI: 6 to 33 percentage points). Six studies examined the impact of reducing client out-of-pocket costs alone (median increase of 28 percentage points; IQI: 2 to 47 percentage points) and 5 studies examined reducing client out-of-pocket costs as part of a multi-component strategy (median increase of 20 percentage points; IQI: 6 to 20 percentage points). The nine qualifying studies that did not provide a common measurement of change also reported overall increases in vaccinations received or administered.\n\nIncluded studies evaluated intervention effects on childhood vaccination series (3 studies), influenza (9 studies), pneumococcal (6 studies), hepatitis B (2 studies), and human papilloma virus (1 study). The reviewed studies evaluated the effectiveness of interventions that reduced client out-of-pocket costs in a range of client and provider populations and settings.\n\nPolicies adopted in the United States, including the Federal Vaccines for Children Program and the Affordable Care Act, have expanded access to many vaccines at reduced out-of-pocket cost. Barriers to expanded implementation of efforts include the adequacy and timeliness of reimbursement for the costs of vaccines, storage, and administration. In the United States, the ability of health care systems and providers to implement these interventions may depend on the adequacy and timeliness of reimbursement for the costs of the vaccines, storage, and administration.","This CPSTF concludes that additional research is needed to determine the effectiveness of reducing client out-of-pocket cost interventions to increase rates of recommended vaccinations for adolescents (e.g., HPV, meningococcal, influenza). In addition, the Task Force suggests additional research to determine if these interventions are effective options to increase receipt of annual influenza vaccinations. Future research should also examine whether reducing client out-of-pocket cost interventions are essential components of school-based vaccination programs and on-site vaccination programs in general."]

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[null,"GUIDANCE - HEALTH LITERACY"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - HEALTH LITERACY"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Kaufman  J et al. Face‐to‐face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD010038. DOI: 10.1002/14651858.CD010038.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of face‐to‐face interventions for informing or educating parents about early childhood vaccination on vaccination status and parental knowledge, attitudes and intention to vaccinate.\n\nIn this update, the reviewers found four new studies, for a total of ten studies. They included seven randomised controlled trials (RCTs) and three cluster‐RCTs involving a total of 4527 participants, although we were unable to pool the data from one cluster‐RCT. Three of the ten studies were conducted in low‐ or middle‐ income countries.\n\nAll included studies compared face‐to‐face interventions with control. Most studies evaluated the effectiveness of a single intervention session delivered to individual parents. The interventions were an even mix of short (ten minutes or less) and longer sessions (15 minutes to several hours).\n\nOverall, elements of the study designs put them at moderate to high risk of bias. All studies but one were at low risk of bias for sequence generation (i.e. used a random number sequence). For allocation concealment (i.e. the person randomising participants was unaware of the study group to which participant would be allocated), three were at high risk and one was judged at unclear risk of bias. Due to the educational nature of the intervention, blinding of participants and personnel was not possible in any studies. The risk of bias due to blinding of outcome assessors was judged as low for four studies. Most studies were at unclear risk of bias for incomplete outcome data and selective reporting. Other potential sources of bias included failure to account for clustering in a cluster‐RCT and significant unexplained baseline differences between groups. One cluster‐RCT was at high risk for selective recruitment of participants.\n\nThe reviewers judged the certainty of the evidence to be low for the outcomes of children's vaccination status, parents' attitudes or beliefs, intention to vaccinate, adverse effects (e.g. anxiety), and immunisation cost, and moderate for parents' knowledge or understanding. All studies had limitations in design. They downgraded the certainty of the evidence where we judged that studies had problems with randomisation or allocation concealment, or when outcomes were self‐reported by participants who knew whether they'd received the intervention or not. They also downgraded the certainty for inconsistency (vaccination status), imprecision (intention to vaccinate and adverse effects), and indirectness (attitudes or beliefs, and cost).\n\nLow‐certainty evidence from seven studies (3004 participants) suggested that face‐to‐face interventions to inform or educate parents may improve vaccination status (RR) 1.20, 95% CI 1.04 to 1.37). Moderate‐certainty evidence from four studies (657 participants) found that face‐to‐face interventions probably slightly improved parent knowledge (standardised mean difference (SMD) 0.19, 95% CI 0.00 to 0.38), and low‐certainty evidence from two studies (179 participants) suggested they may slightly improve intention to vaccinate (SMD 0.55, 95% CI 0.24 to 0.85). Low‐certainty evidence found the interventions may lead to little or no change in parent attitudes or beliefs about vaccination (SMD 0.03, 95% CI ‐0.20 to 0.27; three studies, 292 participants), or in parents’ anxiety (mean difference (MD) ‐1.93, 95% CI ‐7.27 to 3.41; one study, 90 participants). Only one study (365 participants) measured the intervention cost of a case management strategy, reporting that the estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care (low‐certainty evidence). No included studies reported outcomes associated with parents’ experience of the intervention (e.g. satisfaction).","There is low‐ to moderate‐certainty evidence suggesting that face‐to‐face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.\n\nFace‐to‐face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Wide Education When Used Alone. The Community Guide; 2015. \nAvailable here.","Age not specified","This report aimed to determine the effectiveness of community-wide education interventions when implemented alone in increasing vaccination rates or reducing rates of vaccine preventable illness and found insufficient evidence. Evidence is considered insufficient due to inconsistent results and concerns about the applicability of evidence to more diverse communities in the United States where improvements in vaccination rates are needed.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (6 studies with 8 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009- February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 7 studies with 9 study arms. Among the studies providing a common measure of change in vaccination rates (4 studies with 6 arms) there was a median increase of 6 percentage points (range of values: 0.4 to 12.2 percentage points).\n\nThree studies evaluated mass media activities using different measures of change. In a targeted community in Australia, pneumococcal vaccines dispatched to service providers increased during the period of a mass media campaign. In Finland, a mass media campaign briefly increased MMR vaccine receipt for children 6 years of age, though changes were not reported for younger children. In the U.S., a mass media campaign addressing flu-related topics among a nationally representative population of older adults found a positive association between flu-related media reports and influenza vaccination rates in the weeks following the campaign (annual vaccination rates increased by 2.3-7.9 percentage points, p<0.001).\n\nOne U.S. study observed moderate increases in vaccination rates for hepatitis B vaccine following intensive communitywide educational efforts in two Vietnamese-American communities. Characteristics of the study communities that may have contributed to intervention effectiveness included: (1) popular Vietnamese-language media, (2) established Vietnamese service organizations, and (3) culturally appropriate strategies and materials.\n\nCommunity-wide education is commonly implemented in combination with additional interventions (such as efforts to expand and enhance access to vaccinations). In another review, the Task Force found strong evidence of effectiveness for community-based interventions implemented in combination to increase vaccination rates, and five of the included studies used community-wide education in the combination of interventions.","This CPSTF report states that although the evidence identified in this systematic review is insufficient to determine the effectiveness of community-wide education when implemented alone, two studies suggest that these interventions may be useful with certain communities. More research is needed to understand the potential applicability of these interventions to other populations, and for other vaccines.\n\nThe Task Force acknowledges an important role for mass media (and the potential role of social media) in disseminating\ninformation to large audiences and shaping public attitudes and behaviours.\n\nVaccine manufacturers have been increasing direct-to-consumer mass and small media advertising to promote new vaccines. While evidence from private sector marketing campaigns on vaccine uptake was not included in this review, the Task Force considered the applicability of these marketing experiences to public health efforts. They determined that community-wide educational efforts may have greater impact when used to inform members of the community about new vaccines (such as HPV), or new recommendations (such as the universal recommendation for seasonal influenza), and in situations of public health urgency (such as the H1N1 pandemic). The effectiveness of community-wide education to increase vaccination rates in these circumstances remains an important issue for further evaluation research.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Assessment and Feedback. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends assessment and feedback for vaccination providers on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults and children; (2) when used alone or with additional interventions; and (3) across a range of settings and populations. While there was not enough evidence to determine which characteristics of assessment and feedback contributed most to its effectiveness, various strategies have been consistently effective in a wide range of contexts.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (19 studies, search period 1997–2007) combined with more recent evidence (1 study, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 20 studies. Of these, 16 studies with 20 study arms provided common measurements of change in vaccination rates. The median increase of 9 percentage points (IQI: 3 to 14 percentage points). Fifteen study arms provided sufficient information to calculate the change in vaccination rates and showed a median increase of 18.0% (IQI: 9.5% to 24.0%). Seven study arms evaluated the impact of assessment and feedback for providers when implemented alone and found a median increase of 11 percentage points (IQI: 7 to 12 percentage points). Thirteen study arms evaluated provider assessment and feedback with additional interventions and observed a median increase of 6 percentage points (IQI: 3 to 18 percentage points). One additional study did not provide a common measurement of change in vaccination rates, and reported no change after implementation of intervention.\n\nThe reviewed studies evaluated the impact of assessment and feedback for vaccination providers in a wide range of target populations and settings, and for most vaccines appropriate for adults or children. While no studies specifically evaluated the impact of assessment and feedback for vaccination of adolescents, evidence from this review is likely applicable to this population.","This CPSTF concludes that none of the studies identified in this review evaluated the impact of provider assessment and feedback interventions on the delivery of vaccines to adolescents. Future studies should examine the effectiveness of these interventions in increasing vaccination rates among adolescents."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Education When Used Alone. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of provider education interventions when implemented alone in improving vaccination rates or reducing vaccine-preventable illness. Evidence is considered insufficient because the six identified studies observed changes in vaccination rates that were both small in magnitude and inconsistent.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (5 studies with 6 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient effectiveness.\n\nThe Task Force review included six studies that provided seven measurements of change in vaccination rates. The overall median absolute increase in vaccination rates was 4 percentage points (interquartile interval: 2 to 4 percentage points), however none of the study effect estimates were statistically significant, and results were inconsistent across the small body of evidence.\n\nThe Task Force identified, but did not consider in this review, an emerging body of evidence on the education of vaccination providers on the process of quality improvement. Education about quality improvement with the goal of reducing missed opportunities for vaccination and increasing vaccination rates was considered as a distinct intervention from provider education focused on vaccines and vaccinations.\n\nProvider education can be one component of an effective, combined approach to increase vaccination rates. Based on strong evidence of effectiveness identified in updated reviews, the Task Force recommends health care system-based interventions implemented in combination and community-based interventions implemented in combination.\n","This CPSTF report concludes that despite the common and continued use of provider education interventions alone, there are few published studies on their effectiveness.\n\nOne potential area for continued intervention research is provider education regarding new vaccines and expanded recommendations for specific vaccinations. As vaccine recommendations and schedules from the Advisory Committee on Immunization Practices continue to evolve, the potential effectiveness of provider education in increasing or improving the implementation of new recommendations warrants continued research.\n\nNone of the included studies assessed the effectiveness of provider education through distance-based training. Newer educational approaches might increase opportunities for vaccination providers to both share and learn from the experiences of peers and experts in the field."]
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[null,"Saeterdal I et al. Interventions aimed at communities to inform and/or educate about early childhood vaccination. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010232. DOI: 10.1002/14651858.CD010232.pub2.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.\n\nThe reviewers included two cluster‐randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.\n\nThe trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine‐preventable diseases among intervention participants (adjusted mean difference (MD) 0.121, 95% CI 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (RR 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted MD 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision‐making regarding childhood vaccination (adjusted MD 0.043, 95% CI ‐0.009 to 0.097).\n\nThe studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.","This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.’"]

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[null,"SYSTEMATIC REVIEWS - IMPROVING ACCESS"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Vaccination Programs: Home Visits to Increase Vaccination Rates. The Community Guide; 2016. \nAvailable here.","Age not specified","This report examines home visits to increase vaccination rates in children and adults, leading to a Community Preventative Task Force (CPSTF) recommendation on the subject. The CPSTF finding is based on evidence from a Community Guide systematic review completed in 2009 (19 studies, search period 1980-2009) combined with more recent evidence (4 studies, search period 2009-2012). \n\nThe Task Force considered evidence from 23 studies of home visits, with 20 studies and 21 study arms using a common measure of change in vaccination rates. The overall effect was a median increase of 11 percentage points (IQR: 5 to 15 percentage points). Meaningful improvements were observed as a result of home visits delivered to all clients (12 study arms) and to only those clients unresponsive to other interventions (9 study arms), home visits focused on vaccination alone (12 study arms) and in combination with other health concerns (9 study arms), and home visits providing on-site vaccinations (8 study arms) and referring clients to vaccination services outside the home (13 study arms). Home visits delivered as the sole intervention (8 study arms) and home visits delivered as part of a larger healthcare system or community-based program (13 study arms) also produced meaningful change in vaccination rates.\n\nEffectiveness studies were conducted primarily in urban settings (15 studies) and in lower income populations (10 studies). Increases in rates were comparable for home visits directed at children (15 studies) and adults (7 studies), as well as for influenza (7 studies) and childhood vaccinations (14 studies).\n","The CPSTF recommends home visits based on strong evidence of their effectiveness in increasing vaccination rates. Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. The Task Force notes that home visiting interventions are potentially effective in addressing a wide range of public health problems and that the focus of this review is the subset of interventions specifically addressing vaccination rates.\n\nThe report identified that more research is needed on the effectiveness and economic benefits of home visits to increase vaccination rates among adolescents and in rural settings. Additional economic research is needed to estimate the portion of home visits that can be attributed solely to improving vaccination rates when home visits include other activities and objectives."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Promoting Health Equity Through Education Programs and Policies:\nSchool-Based Health Centers. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.\n\nThe CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.\n\nMost evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.\n\nThe Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these \"whole school\" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen \"SBHC user\" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services. \n\nBecause most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.\n\nMost studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.\n\nMost of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.","This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. \n\nIn the implementation of SBHCs, the following issues should be considered:\n- Billing and financing is a major challenge to SBHC implementation and sustainability\n- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation\n- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings\n- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness\n\nThe report also identifies areas for further research.\n\n"]
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[null,"Turnbull C & Osborn  DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD004456. DOI: 10.1002/14651858.CD004456.pub3.\nAvailable here.","Under 5s","This Cochrane review aimed to determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.\n\nSeven studies (reporting 803 mother‐infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African‐American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; RR 1.05, 95% CI 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six‐month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI ‐1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI ‐0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non‐accidental injury and non‐voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).","There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high‐quality trials are needed."]

{"sheet":"Multi-comp","index":10,"n_rows":199,"n_cols":5,"rows_kept":199,"cut":false,"hidden":false,"merged":[[23,1,23,4],[25,1,78,1],[25,2,78,2],[25,3,78,3],[25,4,78,4],[79,1,105,1],[79,2,105,2],[79,3,105,3],[79,4,105,4],[106,1,129,1],[106,2,129,2],[106,3,129,3],[106,4,129,4],[198,1,256,1],[198,2,256,2],[198,3,257,3],[198,4,256,4],[130,1,154,1],[130,2,154,2],[130,3,154,3],[130,4,154,4],[155,1,197,1],[155,2,197,2],[155,3,197,3],[155,4,197,4]]}
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[null,"SYSTEMATIC REVIEWS - MULTI-COMPONENT APPROACHES"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Programs in the\nSpecial Supplemental Nutrition Program for Women, Infants and\nChildren (WIC) Settings. The Community Guide; 2015. \nAvailable here.","Under 5s","The CPSTF recommends coordinated vaccination interventions in women, infants and children (WIC) settings based on strong evidence of effectiveness in increasing vaccination rates in children. Evidence on effectiveness was considered strong based on studies in which assessment of client immunization status and referral to vaccination providers was combined with: 1) provision of vaccinations on-site or in a collocated healthcare facility, or 2) additional interventions such as monthly voucher pickup requirements, manual tracking and outreach, or client reminder and recall systems. Evidence was limited regarding the effectiveness of assessment and referral in WIC settings when implemented alone.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review.\nThe combined evidence included 15 studies of programs that coordinated assessment and referral in WIC settings with additional interventions. Only one study evaluated the use of assessment and referral programs when used alone and found no effect. Of the included studies, 8 (10 study arms) provided a common measurement of change in vaccination rates and observed a median increase of 10.5 percentage points (IQI: 4 to 19 percentage points).\nThe most common additional interventions were monthly voucher pickup (5 studies) and provision of vaccinations onsite or in collocated healthcare facilities (4 studies).\n\nAll of the included studies evaluated WIC programs in urban settings and populations. Despite the lack of evidence from suburban and rural settings, the Task Force considers the overall evidence on effectiveness to be applicable in most WIC settings and populations.","This CPSTF report concludes that WIC services provide opportunities for regular and ongoing contact with families who may have limited access or substantial barriers to immunization services. Although on-site or collocation of vaccination services can substantially enhance access, these approaches require ongoing communication and coordination between WIC programs and healthcare providers in order to minimize missed vaccination opportunities while maintaining continuity of care.\n\nOnly one study examined vaccination status assessment and referral when implemented alone. Additional studies are needed to determine the effectiveness of this basic approach. More research is needed on efforts to collocate WIC and health care services, on the adoption of monthly voucher pickup requirements, and on the impact of providing WIC interventions outside of the medical home."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends community-based interventions implemented in combination to increase vaccinations in targeted populations, on the basis of strong evidence of effectiveness in increasing vaccination rates.\n\nThe conclusion of strong evidence was based on findings from 18 studies that evaluated coordinated interventions to:\n- Increase community demand\n- Enhance access to vaccination services, and\n- Reduce missed opportunities by vaccination providers\nIn 13 of the 18 studies, the community-based effort combined one or more interventions to increase community demand for vaccinations with one or more interventions to enhance access to vaccination services.\n\nThe Task Force notes that implementing manual outreach and tracking or home visits can be resource-intensive and costly, relative to other options for increasing vaccination rates. Such interventions should be used only when there is demonstrated need, and resources are available.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (17 studies; search period 1980 - 2010) combined with more recent evidence (1 study, search period 2010 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nAll of the included studies provided a common measure of change and showed a median increase in vacation rates of 14 percentage points (IQI: 7 to 24 percentage points).\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches.\nFourteen studies implemented an effective combination of one or more interventions to increase community demand with one or more interventions to enhance access to vaccination services and showed a median increase in vaccination rates of 16 percentage points (IQI: 12 to 26 percentage points).\n\nClient reminder and recall systems were used in most of the evaluated programs (15 study arms). Systems were implemented by vaccination providers, established as one part of a community manual outreach and tracking program, or generated from a regional immunization information system (IIS).","This CPSTF concludes that coordinated interventions may be especially important in communities that have wide disparities in vaccination coverage. Program planners should consider community characteristics, such as mobility and fragmentation of health care, in the selection and combination of interventions to increase vaccination rates and reduce disparities.\n\nPartnerships between community organizations and vaccination providers are likely to be an essential component of effective, sustained community-based efforts. Most studies involved partnerships with existing vaccination providers in\nthe community to increase access to vaccinations, rather than creating new vaccination services. Coalitions represent one way to establish effective partnerships, with the size of the coalition varying based on the community, targeted population, and scope of the problem. Four studies involved community coalitions that used the principles of community-based participatory research.\n\nMore evidence is needed on the effectiveness of these programs in adolescents, and when implemented in rural settings. More economic information on these interventions is needed, specifically, evaluations on the efficiencies of the resource-intensive components of manual outreach and tracking and home visits. Future research could compare program effectiveness based on differences in the component interventions and strategic combinations. Additional research also should examine ways to sustain these programs, especially when provided by existing community-based organizations."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Health Care System-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n","The CPSTF recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.\n\nBased on findings from 37 of the 64 included studies, the Task Force further recommends a combination that includes the following:\nAt least one intervention to increase client demand for vaccinations, such as:\n- Client reminder and recall systems\n- Clinic-based client education\n- Manual outreach and tracking\nAnd one or more interventions that address either, or both, of the following strategies:\n- Interventions to enhance access to vaccinations: Expanded access in health care settings, reduced client out-of-pocket costs, home visits\n- Interventions directed at vaccination providers or systems: Provider reminders, standing orders, provider assessment and feedback\n\nInterventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. \n\nOf the combined 64 included studies (76 study arms), 58 of them (70 study arms) provided a common measure of change in vaccination rates and showed a median increase of 9 percentage points (IQI: 4 to 21 percentage points). In general, changes in vaccination rates were greater when interventions were implemented in settings with low baseline rates.\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches. These strategic approaches included the following:\n- Interventions to increase client demand (client reminder and recall systems, clinic-based client education, client\nor family incentives, client-held paper immunization records, case management, and manual outreach and\ntracking)\n- Interventions to enhance access to vaccination services (expanded access in health care settings, reduced client\nout-of-pocket costs, and home visits)\n- Interventions directed at vaccination providers (provider reminder systems, standing orders, provider\nassessment and feedback, provider education, and provider incentives)\n\nThe most common individual interventions implemented in a combined approach were client reminder and recall\nsystems (34 study arms) and provider reminders (31 study arms).\n\nThirty-seven studies (44 study arms) evaluated a combination of interventions across two or three of the strategic approaches and showed a median increase in vaccination rates of 17 percentage points (IQI: 6 to 27 percentage points). In 26 study arms, interventions were combined within only one strategic approach and found a median increase in vaccination rates of 4 percentage points (IQI: 2 to 9 percentage points).\n\nNine studies evaluated combinations of interventions implemented as a part of a health care system quality improvement effort. The most commonly implemented interventions were those directed at vaccination providers (provider education, provider reminders, and provider assessment and feedback). The studies included in this evaluation were typically short in duration and reported mixed results.\n\nEvidence did not show a direct relationship between the number of interventions implemented and changes in vaccination rates. Included studies evaluated combinations of between two and nine interventions. The majority of studies implemented two (31 study arms) or three (18 study arms) interventions.","This CPSTF concludes that overall, included studies provided evidence of effectiveness for intervention combinations implemented in a range of clinical settings and communities, although evidence from rural settings was limited. Studies also demonstrated effectiveness across a range of client populations and vaccinations, including young children (childhood series, influenza) and older adults (influenza, pneumococcal, and tetanus vaccines). Two of the included studies evaluated interventions targeted at increasing vaccination rates among adolescents. Finally, the included studies demonstrated increases in vaccination rates for populations of low socioeconomic status (22 study arms) and across a range of racial and ethnic groups. Most of the included evidence evaluated client populations with low to moderate baseline vaccination rates,\nand findings are most applicable to these situations.\n\nMore evidence is needed on the effectiveness of these interventions in rural settings and when applied to increase vaccinations recommended for adolescents. Future research on quality improvement activities in these settings should incorporate study periods sufficient to evaluate continuous quality improvement efforts."]

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[null,"SYSTEMATIC REVIEWS - OTHER INTERVENTIONS"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Requirements for\nChild Care, School, and College Attendance. The Community Guide; 2016. \nAvailable here.","Under 5s\n5 to 18 years","This CPSTF report examines laws or policies requiring vaccinations or other documentation of immunity as a condition of child care, school, and college attendance. These findings are based on studies demonstrating effectiveness of vaccination requirements for attendance in a variety of settings, for an array of recommended vaccines, and in populations ranging in age from early childhood to late adolescence.\n\nThe Task Force finding is based on evidence from 32 studies (search period January 1980 – July 2015) that examined the effectiveness of vaccination requirements on vaccination coverage rates or changes in vaccine-preventable disease or illness.\n\nSeventeen studies with 24 study arms examined the effectiveness of state or local vaccination requirements on changes in vaccination rates. The median change was an increase of 18 percentage points (Interquartile interval [IQI]: 10 to 35 percentage points). Five additional studies examined changes in vaccination rates or series completion that could not be included in the summary effect estimate, although results were generally in the direction of increased coverage.\n\nTen studies examined the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements. Three U.S. studies found that the incidence of measles and mumps was lower in states with immunization requirements for school-aged children, and that low-incidence areas were more likely to enforce school entry laws by excluding non-compliant children from attendance.\n\nOne study from Italy found reductions in rates of hepatitis B disease attributable to the implementation of vaccination requirements and school and community-based vaccination programs. A study from Japan found increases in excess mortality rates among younger children due to influenza and pneumonia, after the removal of a national influenza vaccination mandate and school-based immunization program.\n\nFive studies evaluated other vaccination requirements and found: (1) lower incidence of mumps during an outbreak in children subject to a vaccination requirement; (2) greater declines in Haemophilus influenza type b disease incidence among child care attendees subject to vaccination requirements than for New York State as a whole; (3) lower risk for measles outbreaks in colleges with pre-matriculation immunization requirements; (4) decline in hepatitis A disease incidence following implementation of a child care entry requirement in response to an outbreak, and (5) reduction in influenza-associated hospitalizations among children following a child care entry requirement.\n\nIncluded studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies). Studies provided evidence of effectiveness for both primary school entry requirements (11 studies) and requirements for middle/high school students (13 studies). Six studies examined vaccinations for child care attendance and findings are applicable to these settings. Although only one study evaluated vaccination requirements for college (1\nstudies) findings are likely applicable to these settings.\n\nIncluded studies examined changes in coverage rates or disease incidence for vaccinations to protect against measles mumps-rubella (16 studies), tetanus (8 studies), pertussis (8 studies), varicella (8 studies), Haemophilus influenza type b disease (5 studies), hepatitis A (2 studies), hepatitis B (14 studies), meningococcal disease (3 studies), influenza (2 studies), and human papillomavirus (1 study). Task Force findings are applicable or likely applicable for the range of vaccines recommended for children and adolescents.","The CPSTF recommends vaccination requirements for child care, school, and college attendance based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine preventable disease (VPD) and associated morbidity and mortality. \n\nAlthough intervention studies overall provide strong evidence of effectiveness, three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease transmission: 1) geographic clustering of under immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions. \n\nMost included studies examined school vaccination requirements; additional evaluations of requirements for child care attendance and college residency would be useful. Additional research would be useful to clarify relationships between variations in school or child care documentation and enforcement and vaccination and exemption rates. Information on barriers to school and local enforcement and ways to overcome these barriers would also be useful. Likewise, studies examining factors that facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings would be helpful. Finally, more research is needed to assess the economic costs and benefits of vaccination requirements in each setting."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Standing Orders. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends standing orders for vaccinations on the basis of strong evidence of effectiveness in increasing vaccination rates among adults and children; when used alone or with additional interventions; and across a range of settings and populations. The Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (29 studies, search period 1997–2009) combined with more recent evidence (6 studies, search period 2009–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 35 studies. Of these, 27 studies provided a common measurement of change in vaccination rates with a median increase of 24 percentage points (IQI: 12 to 35 percentage points). Nine studies that examined the impact of standing orders alone documented a median increase of 16 percentage points (IQI: 9 to 29 percentage points). Nineteen studies that evaluated standing orders when combined with additional interventions documented a median increase of 27 percentage points (IQI: 13 to 40 percentage points). Seven studies that did not provide a common measure of change for vaccination rates all reported favorable results after implementation of standing orders.\n\nThe reviewed studies evaluated the effectiveness of standing orders across a wide range of clinical vaccination settings, health care personnel, and client populations. Standing orders were found to be effective in various settings including clinics, hospitals, and long-term care facilities. Interventions were effective when used with different vaccination providers including nurses and pharmacists. While most studies looked at adult populations, four examined intervention effectiveness among children and found a median absolute percent increase of 28 percentage points (range: 8 to 49). While no studies specifically evaluated the impact of standing orders for vaccination of adolescents, evidence from this review is likely applicable to this population. In addition, a subset of the included evidence suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings when compared to a provider reminder system.\n\nOne paper from the updated search period described the following barriers encountered during implementation of a pneumococcal vaccination standing orders program in three hospitals: gaps in staff education and training; personnel concerns about additional workload; staff reluctance to administer vaccines without a physician's order; attending physicians' resistance to having hospitalized patients vaccinated; and logistical difficulties. Some attending physicians expressed concern that vaccination would interfere with scheduled treatments or procedures. Other attending physicians did not consider inpatient stays to be an appropriate time for vaccinations (Middleton et al. 2005).\n\nAn additional study reported barriers to implementation of influenza and pneumococcal vaccination standing orders in various health care settings. Findings suggested that the adoption of these policies may have been too difficult to administer, staff were unclear or unconvinced of program benefits, and there was perceived physician discomfort with delegating responsibility for immunizations to nursing staff. A few of the respondents also indicated that resources, effectiveness of the vaccine, and time required to administer the vaccine were barriers for adoption. The majority of these barriers were specific to the administration of the influenza vaccine (Goldstein et al. 2005).","This CPSTF concludes that standing orders were shown to be effective in increasing vaccination rates for influenza and pneumococcal vaccines. Additional research is needed, however, to determine if these interventions are effective for different vaccines (e.g. hepatitis, tetanus and vaccines recommended for adolescents). More evidence is also needed on ways to address barriers to the implementation of standing orders in health systems.\n"]

{"sheet":"Primary care","index":12,"n_rows":679,"n_cols":5,"rows_kept":679,"cut":false,"hidden":false,"merged":[[255,1,284,1],[255,2,284,2],[255,3,284,3],[255,4,284,4],[285,1,305,1],[285,2,305,2],[285,3,305,3],[285,4,305,4],[181,1,206,1],[181,2,206,2],[181,3,206,3],[181,4,206,4],[207,1,254,1],[207,2,254,2],[207,3,254,3],[207,4,254,4],[19,1,19,4],[50,1,59,1],[50,2,59,2],[50,3,59,4],[21,1,49,1],[21,2,49,2],[21,3,49,4],[61,1,61,4],[63,1,93,1],[63,2,93,2],[63,3,93,3],[63,4,93,4],[94,1,126,1],[94,2,126,2],[94,3,126,3],[94,4,126,4],[127,1,180,1],[127,2,180,2],[127,3,180,3],[127,4,180,4],[359,1,385,1],[359,2,385,2],[359,3,385,3],[359,4,385,4],[306,1,328,1],[306,2,328,2],[306,3,328,3],[306,4,328,4],[329,1,358,1],[329,2,358,2],[329,3,358,3],[329,4,358,4],[386,1,428,1],[386,2,428,2],[386,3,429,3],[386,4,429,4],[430,1,453,1],[430,2,453,2],[430,3,453,3],[430,4,453,4],[454,1,496,1],[454,2,496,2],[454,3,496,3],[454,4,496,4],[497,1,521,1],[497,2,521,2],[497,3,521,3],[497,4,521,4],[522,1,544,1],[522,2,544,2],[522,3,545,3],[522,4,544,4],[546,1,574,1],[546,2,574,2],[546,3,574,3],[546,4,574,4],[678,1,696,1],[678,2,696,2],[678,3,696,3],[678,4,696,4],[575,1,617,1],[575,2,617,2],[575,3,617,3],[575,4,617,4],[618,1,676,1],[618,2,676,2],[618,3,677,3],[618,4,676,4]]}
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[null,"GUIDANCE - PRIMARY CARE"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Flu vaccination: increasing uptake. NG103. London: NICE; 2018.\nAvailable here.","This guideline is for: \n- Commissioners and providers of primary and secondary healthcare services, including maternity providers and community pharmacies\n- All employers of staff who provide NHS or social-care funded services (including maternity care, domiciliary care and care homes)\n- Local authorities, and community and voluntary sector organisations that employ health and social care workers\n- Occupational health services and infection prevention and control teams\n- NHS England teams and Health Education England teams\n- People using services, their families, carers and other members of the public, in particular those eligible for flu vaccination","This guideline covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.\n\nIt includes recommendations on:\n- Using a multicomponent approach\n- Raising awareness\n- Offering vaccination\n- Increasing uptake among eligible groups in primary and secondary care\n- Audit, monitoring and feedback\n- Vaccination in carers\n- Increasing uptake in health and social care staff"]
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[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"SYSTEMATIC REVIEWS - PRIMARY CARE"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Jia  L et al. Payment methods for healthcare providers working in outpatient healthcare settings. Cochrane Database of Systematic Reviews 2021, Issue 1. Art. No.: CD011865. DOI: 10.1002/14651858.CD011865.pub2. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.\n\nThe reviewers included 27 studies in the review: 12 randomised trials, 13 controlled before‐and‐after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high‐income countries, with only one study from a low‐ or middle‐income country. The included studies were categorised into four groups based on comparisons of different payment methods. Of which only two groups fulfilled the outcome criteria for this map. \n\n(1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings: P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate‐certainty evidence).\n\n2)  Enhanced fee for service (FFS) compared with FFS for healthcare providers working in outpatient healthcare settings: Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate‐certainty evidence). The reviewers are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low‐certainty evidence). \n\n\n\n\n","For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate‐certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low‐certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low‐certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low‐certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects.\n\nThere is a need for further well‐conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low‐ and middle‐income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions."]
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[null,"Palmer  MJ et al. Targeted client communication via mobile devices for improving maternal, neonatal, and child health. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD013679. DOI: 10.1002/14651858.CD013679.\nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of targeted client communication via mobile devices (TCCMD) on health behaviour, service use, health, and well‐being for maternal, neonatal and child health (MNCH).  \n\nThe reviewers included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low‐, middle‐ or high‐income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle‐income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Only results relevant to this evidence map have been extracted below.\n\nPregnant and postpartum women\nTCCMD versus digital non‐targeted communication: No studies reported behavioural, health, or well‐being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low‐certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low‐certainty evidence).\n\nParents of children aged less than five years\nTCCMD versus standard care: Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low‐certainty evidence); however, the effect estimates varied widely between studies.\n\nTCCMD versus non‐digital TCC: TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low‐certainty evidence), and may make little or no difference to oral hygiene practices (low‐certainty evidence).\n\nTCCMD versus digital non‐targeted communication: TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low‐certainty evidence).\n\nNo trials in any population reported data on unintended consequences.","The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High‐quality, adequately powered trials and cost‐effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality."]
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[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Pantoja  T et al. Manually‐generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD001174. DOI: 10.1002/14651858.CD001174.pub4. \nAvailable here.","Age not specified","This Cochrane review aimed: 1. To determine the effectiveness of manually‐generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually‐generated reminders delivered on paper.\n\nThe reviewers identified 63 studies (41 cluster‐randomised trials, 18 individual randomised trials, and four non‐randomised trials) that met all inclusion criteria. Fifty‐seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty‐four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test‐ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention.\n\nForty‐eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process‐of‐care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Forty‐seven studies assessed the effect of reminders compared with control or usual care. In the studies assessing process adherence outcomes, only three of the effect estimates were related to recommended vaccination practices. \n\nManually‐generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% [Inter quartile range (QR) 2.54% to 20.58%].","Manually‐generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single quality improvement (QI) intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually‐generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect."]
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[null,"Kaufman  J et al. Face‐to‐face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD010038. DOI: 10.1002/14651858.CD010038.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of face‐to‐face interventions for informing or educating parents about early childhood vaccination on vaccination status and parental knowledge, attitudes and intention to vaccinate.\n\nIn this update, the reviewers found four new studies, for a total of ten studies. They included seven randomised controlled trials (RCTs) and three cluster‐RCTs involving a total of 4527 participants, although we were unable to pool the data from one cluster‐RCT. Three of the ten studies were conducted in low‐ or middle‐ income countries.\n\nAll included studies compared face‐to‐face interventions with control. Most studies evaluated the effectiveness of a single intervention session delivered to individual parents. The interventions were an even mix of short (ten minutes or less) and longer sessions (15 minutes to several hours).\n\nOverall, elements of the study designs put them at moderate to high risk of bias. All studies but one were at low risk of bias for sequence generation (i.e. used a random number sequence). For allocation concealment (i.e. the person randomising participants was unaware of the study group to which participant would be allocated), three were at high risk and one was judged at unclear risk of bias. Due to the educational nature of the intervention, blinding of participants and personnel was not possible in any studies. The risk of bias due to blinding of outcome assessors was judged as low for four studies. Most studies were at unclear risk of bias for incomplete outcome data and selective reporting. Other potential sources of bias included failure to account for clustering in a cluster‐RCT and significant unexplained baseline differences between groups. One cluster‐RCT was at high risk for selective recruitment of participants.\n\nThe reviewers judged the certainty of the evidence to be low for the outcomes of children's vaccination status, parents' attitudes or beliefs, intention to vaccinate, adverse effects (e.g. anxiety), and immunisation cost, and moderate for parents' knowledge or understanding. All studies had limitations in design. They downgraded the certainty of the evidence where we judged that studies had problems with randomisation or allocation concealment, or when outcomes were self‐reported by participants who knew whether they'd received the intervention or not. They also downgraded the certainty for inconsistency (vaccination status), imprecision (intention to vaccinate and adverse effects), and indirectness (attitudes or beliefs, and cost).\n\nLow‐certainty evidence from seven studies (3004 participants) suggested that face‐to‐face interventions to inform or educate parents may improve vaccination status (RR) 1.20, 95% CI 1.04 to 1.37). Moderate‐certainty evidence from four studies (657 participants) found that face‐to‐face interventions probably slightly improved parent knowledge (standardised mean difference (SMD) 0.19, 95% CI 0.00 to 0.38), and low‐certainty evidence from two studies (179 participants) suggested they may slightly improve intention to vaccinate (SMD 0.55, 95% CI 0.24 to 0.85). Low‐certainty evidence found the interventions may lead to little or no change in parent attitudes or beliefs about vaccination (SMD 0.03, 95% CI ‐0.20 to 0.27; three studies, 292 participants), or in parents’ anxiety (mean difference (MD) ‐1.93, 95% CI ‐7.27 to 3.41; one study, 90 participants). Only one study (365 participants) measured the intervention cost of a case management strategy, reporting that the estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care (low‐certainty evidence). No included studies reported outcomes associated with parents’ experience of the intervention (e.g. satisfaction).","There is low‐ to moderate‐certainty evidence suggesting that face‐to‐face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.\n\nFace‐to‐face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Posadzki  P et al. Automated telephone communication systems for preventive healthcare and management of long‐term conditions. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD009921. DOI: 10.1002/14651858.CD009921.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of automated telephone communication systems (ATCS) for preventing disease and managing long‐term conditions on behavioural change, clinical, process, cognitive, patient‐centred and adverse outcomes.\n\nThe reviewers included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty‐one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long‐term conditions, and seven studies for appointment reminders. They downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. They judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. They considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear. Only results relevant to this evidence map have been extracted below.\n\nFor preventive healthcare, ATCS (ATCS Plus, interactive voice response , unidirectional) probably increase immunisation uptake in children (RR 1.25, 95% CI 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).","ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost‐effective."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Vaccination Programs: Home Visits to Increase Vaccination Rates. The Community Guide; 2016. \nAvailable here.","Age not specified","This report examines home visits to increase vaccination rates in children and adults, leading to a Community Preventative Task Force (CPSTF) recommendation on the subject. The CPSTF finding is based on evidence from a Community Guide systematic review completed in 2009 (19 studies, search period 1980-2009) combined with more recent evidence (4 studies, search period 2009-2012). \n\nThe Task Force considered evidence from 23 studies of home visits, with 20 studies and 21 study arms using a common measure of change in vaccination rates. The overall effect was a median increase of 11 percentage points (IQR: 5 to 15 percentage points). Meaningful improvements were observed as a result of home visits delivered to all clients (12 study arms) and to only those clients unresponsive to other interventions (9 study arms), home visits focused on vaccination alone (12 study arms) and in combination with other health concerns (9 study arms), and home visits providing on-site vaccinations (8 study arms) and referring clients to vaccination services outside the home (13 study arms). Home visits delivered as the sole intervention (8 study arms) and home visits delivered as part of a larger healthcare system or community-based program (13 study arms) also produced meaningful change in vaccination rates.\n\nEffectiveness studies were conducted primarily in urban settings (15 studies) and in lower income populations (10 studies). Increases in rates were comparable for home visits directed at children (15 studies) and adults (7 studies), as well as for influenza (7 studies) and childhood vaccinations (14 studies).\n","The CPSTF recommends home visits based on strong evidence of their effectiveness in increasing vaccination rates. Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. The Task Force notes that home visiting interventions are potentially effective in addressing a wide range of public health problems and that the focus of this review is the subset of interventions specifically addressing vaccination rates.\n\nThe report identified that more research is needed on the effectiveness and economic benefits of home visits to increase vaccination rates among adolescents and in rural settings. Additional economic research is needed to estimate the portion of home visits that can be attributed solely to improving vaccination rates when home visits include other activities and objectives."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client-Held Paper\nImmunization Records. The Community Guide; 2016. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of client-held paper immunization records in increasing vaccination rates or reducing rates of vaccine preventable disease. Evidence was considered insufficient because of inconsistent findings and variability in the interventions evaluated.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (7 studies, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 8 studies with 11 study arms. Six studies (nine measurements) provided a common measure of vaccination rates and reported an overall median increase of 5.3 percentage points (IQI: -1.0 to 8.8 percentage points).\n\nResults were considered inconsistent because client-held paper immunization records were used as part of a multicomponent effort and comparison groups received one or more interventions.\n\nSeveral considerations for implementation were identified in the included studies and broader literature. These include clients'' declining interest over time and low card retention. Healthcare providers also have expressed concerns about time management when using a preventive services checklist.\n\nWith the expansion of population-based Immunization Information Systems and the development of on-line and electronic personal health care records, careful evaluation of client-held paper immunization records effectiveness is needed to achieve high levels of vaccination rates in the US population. However, until issues of privacy, security, and quality of electronic records have been resolved, and for clients on the other side of the \"digital divide,\" traditional client-held paper immunization records will continue to be useful. This may be particularly true for some populations, such as clients with limited computer access and adults whose change in employment status is accompanied by a change in providers.","This CPSTF report concludes that paper  immunization records maybe useful when they are used consistently—when providers update them and parents keep track of them. Children are more likely to receive recommended vaccinations and avoid being over-vaccinated. This is especially true when children are seen in non-traditional immunization settings, such as emergency departments.\n\nFurther research should therefore examine the effectiveness of additional activities to increase the retention and use of client-held paper immunization records for children by their parents or other caregivers."]
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[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Standing Orders. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends standing orders for vaccinations on the basis of strong evidence of effectiveness in increasing vaccination rates among adults and children; when used alone or with additional interventions; and across a range of settings and populations. The Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (29 studies, search period 1997–2009) combined with more recent evidence (6 studies, search period 2009–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 35 studies. Of these, 27 studies provided a common measurement of change in vaccination rates with a median increase of 24 percentage points (IQI: 12 to 35 percentage points). Nine studies that examined the impact of standing orders alone documented a median increase of 16 percentage points (IQI: 9 to 29 percentage points). Nineteen studies that evaluated standing orders when combined with additional interventions documented a median increase of 27 percentage points (IQI: 13 to 40 percentage points). Seven studies that did not provide a common measure of change for vaccination rates all reported favorable results after implementation of standing orders.\n\nThe reviewed studies evaluated the effectiveness of standing orders across a wide range of clinical vaccination settings, health care personnel, and client populations. Standing orders were found to be effective in various settings including clinics, hospitals, and long-term care facilities. Interventions were effective when used with different vaccination providers including nurses and pharmacists. While most studies looked at adult populations, four examined intervention effectiveness among children and found a median absolute percent increase of 28 percentage points (range: 8 to 49). While no studies specifically evaluated the impact of standing orders for vaccination of adolescents, evidence from this review is likely applicable to this population. In addition, a subset of the included evidence suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings when compared to a provider reminder system.\n\nOne paper from the updated search period described the following barriers encountered during implementation of a pneumococcal vaccination standing orders program in three hospitals: gaps in staff education and training; personnel concerns about additional workload; staff reluctance to administer vaccines without a physician's order; attending physicians' resistance to having hospitalized patients vaccinated; and logistical difficulties. Some attending physicians expressed concern that vaccination would interfere with scheduled treatments or procedures. Other attending physicians did not consider inpatient stays to be an appropriate time for vaccinations (Middleton et al. 2005).\n\nAn additional study reported barriers to implementation of influenza and pneumococcal vaccination standing orders in various health care settings. Findings suggested that the adoption of these policies may have been too difficult to administer, staff were unclear or unconvinced of program benefits, and there was perceived physician discomfort with delegating responsibility for immunizations to nursing staff. A few of the respondents also indicated that resources, effectiveness of the vaccine, and time required to administer the vaccine were barriers for adoption. The majority of these barriers were specific to the administration of the influenza vaccine (Goldstein et al. 2005).","This CPSTF concludes that standing orders were shown to be effective in increasing vaccination rates for influenza and pneumococcal vaccines. Additional research is needed, however, to determine if these interventions are effective for different vaccines (e.g. hepatitis, tetanus and vaccines recommended for adolescents). More evidence is also needed on ways to address barriers to the implementation of standing orders in health systems.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Programs in the\nSpecial Supplemental Nutrition Program for Women, Infants and\nChildren (WIC) Settings. The Community Guide; 2015. \nAvailable here.","Under 5s","The CPSTF recommends coordinated vaccination interventions in women, infants and children (WIC) settings based on strong evidence of effectiveness in increasing vaccination rates in children. Evidence on effectiveness was considered strong based on studies in which assessment of client immunization status and referral to vaccination providers was combined with: 1) provision of vaccinations on-site or in a collocated healthcare facility, or 2) additional interventions such as monthly voucher pickup requirements, manual tracking and outreach, or client reminder and recall systems. Evidence was limited regarding the effectiveness of assessment and referral in WIC settings when implemented alone.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review.\nThe combined evidence included 15 studies of programs that coordinated assessment and referral in WIC settings with additional interventions. Only one study evaluated the use of assessment and referral programs when used alone and found no effect. Of the included studies, 8 (10 study arms) provided a common measurement of change in vaccination rates and observed a median increase of 10.5 percentage points (IQI: 4 to 19 percentage points).\nThe most common additional interventions were monthly voucher pickup (5 studies) and provision of vaccinations onsite or in collocated healthcare facilities (4 studies).\n\nAll of the included studies evaluated WIC programs in urban settings and populations. Despite the lack of evidence from suburban and rural settings, the Task Force considers the overall evidence on effectiveness to be applicable in most WIC settings and populations.","This CPSTF report concludes that WIC services provide opportunities for regular and ongoing contact with families who may have limited access or substantial barriers to immunization services. Although on-site or collocation of vaccination services can substantially enhance access, these approaches require ongoing communication and coordination between WIC programs and healthcare providers in order to minimize missed vaccination opportunities while maintaining continuity of care.\n\nOnly one study examined vaccination status assessment and referral when implemented alone. Additional studies are needed to determine the effectiveness of this basic approach. More research is needed on efforts to collocate WIC and health care services, on the adoption of monthly voucher pickup requirements, and on the impact of providing WIC interventions outside of the medical home."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Promoting Health Equity Through Education Programs and Policies:\nSchool-Based Health Centers. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.\n\nThe CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.\n\nMost evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.\n\nThe Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these \"whole school\" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen \"SBHC user\" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services. \n\nBecause most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.\n\nMost studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.\n\nMost of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.","This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. \n\nIn the implementation of SBHCs, the following issues should be considered:\n- Billing and financing is a major challenge to SBHC implementation and sustainability\n- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation\n- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings\n- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness\n\nThe report also identifies areas for further research.\n\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client or Family Incentive Rewards. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends client or family incentive rewards, used alone or in combination with additional interventions, based on sufficient evidence of effectiveness in increasing vaccination rates in children and adults.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (6 studies with 7 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on sufficient evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 8 percentage points (IQI: 4 to 16 percentage points). Two study arms that assessed the effectiveness of incentive rewards alone showed similar changes in vaccination rates (8.5 and 9.0 percentage points). In the six remaining study arms, incentive rewards were combined with additional interventions.\n\nAmong the studies included in this review, the type of incentive reward offered to clients included government payments (i.e., of $208 AUD and childcare assistance), lottery prizes (i.e., $50 grocery voucher or $175 in monetary prizes), gift cards (i.e., $10 for baby products), baby products, and food vouchers. \n\nOverall, the Task Force considers the evidence to be applicable to vaccinations for children and adults in a wide range of clinical and community settings, and for various types of incentive rewards.","This CPSTF concludes that client or family incentive rewards can also be one component of an effective combined approach to increase vaccination rates in both clinical and community settings. Based on updated, concurrent reviews the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based\ninterventions implemented in combination.\n\nAdditional research could focus on the independent effects of incentive rewards, examine the relationship between the value of the reward and effectiveness, and explore the duration of intervention impact. It also would be useful to have more information about the effectiveness of these interventions with adolescents and adults as most of the included studies examined the use of incentive rewards on vaccination rates for children."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Monetary Sanction Policies. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of monetary sanction policies to increase vaccination rates among children in families receiving government assistance. The Task Force finding is based on the small number of studies; differences in the type of sanction policies evaluated; inconsistent results on vaccination rates; and limited information on potential harms of these policies.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (2 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review. Both of the included studies were conducted in the United States and evaluated the implementation of state monetary sanction policies for families receiving assistance through the Aid to Families with Dependent Children (AFDC) program. The first study, a two-year randomized controlled trial of AFDC recipients in Maryland, evaluated outcomes in 1,324 children aged 3 to 24 months and observed no significant improvements in vaccination rates (decrease of -0.7 percentage points). The second study, a three-year randomized controlled trial of 2,500 families on AFDC assistance in Georgia, observed significant improvements in vaccination rates in children (increase of 11.8 percentage points).\n","This CPSTF report concludes that evidence on the broad range of potential outcomes of monetary sanction policies is insufficient to inform considerations on their use as an intervention option to increase vaccination rates. Programs that are considering the adoption of monetary sanctions should first determine the range of potential harms that may occur from these policies. Barriers to implementing monetary sanctions include: agencies might not adopt these policies because of concerns about harms to families or they may not enforce these policies with case workers unwilling to apply sanctions to families. The Georgia study examined the issuance of warnings and sanctions to families and found that both were infrequently applied.\n\nAdditional evidence is needed to determine if monetary sanction policies are effective and beneficial to the communities they address. If so, research is needed to identify common elements of successful policies and programs and explore the health and financial effects of these policies on families requiring assistance.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends community-based interventions implemented in combination to increase vaccinations in targeted populations, on the basis of strong evidence of effectiveness in increasing vaccination rates.\n\nThe conclusion of strong evidence was based on findings from 18 studies that evaluated coordinated interventions to:\n- Increase community demand\n- Enhance access to vaccination services, and\n- Reduce missed opportunities by vaccination providers\nIn 13 of the 18 studies, the community-based effort combined one or more interventions to increase community demand for vaccinations with one or more interventions to enhance access to vaccination services.\n\nThe Task Force notes that implementing manual outreach and tracking or home visits can be resource-intensive and costly, relative to other options for increasing vaccination rates. Such interventions should be used only when there is demonstrated need, and resources are available.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (17 studies; search period 1980 - 2010) combined with more recent evidence (1 study, search period 2010 - 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nAll of the included studies provided a common measure of change and showed a median increase in vacation rates of 14 percentage points (IQI: 7 to 24 percentage points).\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches.\nFourteen studies implemented an effective combination of one or more interventions to increase community demand with one or more interventions to enhance access to vaccination services and showed a median increase in vaccination rates of 16 percentage points (IQI: 12 to 26 percentage points).\n\nClient reminder and recall systems were used in most of the evaluated programs (15 study arms). Systems were implemented by vaccination providers, established as one part of a community manual outreach and tracking program, or generated from a regional immunization information system (IIS).","This CPSTF concludes that coordinated interventions may be especially important in communities that have wide disparities in vaccination coverage. Program planners should consider community characteristics, such as mobility and fragmentation of health care, in the selection and combination of interventions to increase vaccination rates and reduce disparities.\n\nPartnerships between community organizations and vaccination providers are likely to be an essential component of effective, sustained community-based efforts. Most studies involved partnerships with existing vaccination providers in\nthe community to increase access to vaccinations, rather than creating new vaccination services. Coalitions represent one way to establish effective partnerships, with the size of the coalition varying based on the community, targeted population, and scope of the problem. Four studies involved community coalitions that used the principles of community-based participatory research.\n\nMore evidence is needed on the effectiveness of these programs in adolescents, and when implemented in rural settings. More economic information on these interventions is needed, specifically, evaluations on the efficiencies of the resource-intensive components of manual outreach and tracking and home visits. Future research could compare program effectiveness based on differences in the component interventions and strategic combinations. Additional research also should examine ways to sustain these programs, especially when provided by existing community-based organizations."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Health Care System-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n","The CPSTF recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.\n\nBased on findings from 37 of the 64 included studies, the Task Force further recommends a combination that includes the following:\nAt least one intervention to increase client demand for vaccinations, such as:\n- Client reminder and recall systems\n- Clinic-based client education\n- Manual outreach and tracking\nAnd one or more interventions that address either, or both, of the following strategies:\n- Interventions to enhance access to vaccinations: Expanded access in health care settings, reduced client out-of-pocket costs, home visits\n- Interventions directed at vaccination providers or systems: Provider reminders, standing orders, provider assessment and feedback\n\nInterventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. \n\nOf the combined 64 included studies (76 study arms), 58 of them (70 study arms) provided a common measure of change in vaccination rates and showed a median increase of 9 percentage points (IQI: 4 to 21 percentage points). In general, changes in vaccination rates were greater when interventions were implemented in settings with low baseline rates.\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches. These strategic approaches included the following:\n- Interventions to increase client demand (client reminder and recall systems, clinic-based client education, client\nor family incentives, client-held paper immunization records, case management, and manual outreach and\ntracking)\n- Interventions to enhance access to vaccination services (expanded access in health care settings, reduced client\nout-of-pocket costs, and home visits)\n- Interventions directed at vaccination providers (provider reminder systems, standing orders, provider\nassessment and feedback, provider education, and provider incentives)\n\nThe most common individual interventions implemented in a combined approach were client reminder and recall\nsystems (34 study arms) and provider reminders (31 study arms).\n\nThirty-seven studies (44 study arms) evaluated a combination of interventions across two or three of the strategic approaches and showed a median increase in vaccination rates of 17 percentage points (IQI: 6 to 27 percentage points). In 26 study arms, interventions were combined within only one strategic approach and found a median increase in vaccination rates of 4 percentage points (IQI: 2 to 9 percentage points).\n\nNine studies evaluated combinations of interventions implemented as a part of a health care system quality improvement effort. The most commonly implemented interventions were those directed at vaccination providers (provider education, provider reminders, and provider assessment and feedback). The studies included in this evaluation were typically short in duration and reported mixed results.\n\nEvidence did not show a direct relationship between the number of interventions implemented and changes in vaccination rates. Included studies evaluated combinations of between two and nine interventions. The majority of studies implemented two (31 study arms) or three (18 study arms) interventions.","This CPSTF concludes that overall, included studies provided evidence of effectiveness for intervention combinations implemented in a range of clinical settings and communities, although evidence from rural settings was limited. Studies also demonstrated effectiveness across a range of client populations and vaccinations, including young children (childhood series, influenza) and older adults (influenza, pneumococcal, and tetanus vaccines). Two of the included studies evaluated interventions targeted at increasing vaccination rates among adolescents. Finally, the included studies demonstrated increases in vaccination rates for populations of low socioeconomic status (22 study arms) and across a range of racial and ethnic groups. Most of the included evidence evaluated client populations with low to moderate baseline vaccination rates,\nand findings are most applicable to these situations.\n\nMore evidence is needed on the effectiveness of these interventions in rural settings and when applied to increase vaccinations recommended for adolescents. Future research on quality improvement activities in these settings should incorporate study periods sufficient to evaluate continuous quality improvement efforts."]
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[null,"Turnbull C & Osborn  DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD004456. DOI: 10.1002/14651858.CD004456.pub3.\nAvailable here.","Under 5s","This Cochrane review aimed to determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.\n\nSeven studies (reporting 803 mother‐infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African‐American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; RR 1.05, 95% CI 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six‐month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI ‐1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI ‐0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non‐accidental injury and non‐voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).","There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high‐quality trials are needed."]

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[null,"GUIDANCE - SECONDARY CARE"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Flu vaccination: increasing uptake. NG103. London: NICE; 2018.\nAvailable here.","This guideline is for: \n- Commissioners and providers of primary and secondary healthcare services, including maternity providers and community pharmacies\n- All employers of staff who provide NHS or social-care funded services (including maternity care, domiciliary care and care homes)\n- Local authorities, and community and voluntary sector organisations that employ health and social care workers\n- Occupational health services and infection prevention and control teams\n- NHS England teams and Health Education England teams\n- People using services, their families, carers and other members of the public, in particular those eligible for flu vaccination","This guideline covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.\n\nIt includes recommendations on:\n- Using a multicomponent approach\n- Raising awareness\n- Offering vaccination\n- Increasing uptake among eligible groups in primary and secondary care\n- Audit, monitoring and feedback\n- Vaccination in carers\n- Increasing uptake in health and social care staff"]
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[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"SYSTEMATIC REVIEWS -SECONDARY CARE"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Pantoja  T et al. Manually‐generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD001174. DOI: 10.1002/14651858.CD001174.pub4. \nAvailable here.","Age not specified","This Cochrane review aimed: 1. To determine the effectiveness of manually‐generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually‐generated reminders delivered on paper.\n\nThe reviewers identified 63 studies (41 cluster‐randomised trials, 18 individual randomised trials, and four non‐randomised trials) that met all inclusion criteria. Fifty‐seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty‐four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test‐ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention.\n\nForty‐eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process‐of‐care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Forty‐seven studies assessed the effect of reminders compared with control or usual care. In the studies assessing process adherence outcomes, only three of the effect estimates were related to recommended vaccination practices. \n\nManually‐generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% [Inter quartile range (QR) 2.54% to 20.58%].","Manually‐generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single quality improvement (QI) intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually‐generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect."]
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[null,"Kaufman  J et al. Face‐to‐face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD010038. DOI: 10.1002/14651858.CD010038.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to assess the effects of face‐to‐face interventions for informing or educating parents about early childhood vaccination on vaccination status and parental knowledge, attitudes and intention to vaccinate.\n\nIn this update, the reviewers found four new studies, for a total of ten studies. They included seven randomised controlled trials (RCTs) and three cluster‐RCTs involving a total of 4527 participants, although we were unable to pool the data from one cluster‐RCT. Three of the ten studies were conducted in low‐ or middle‐ income countries.\n\nAll included studies compared face‐to‐face interventions with control. Most studies evaluated the effectiveness of a single intervention session delivered to individual parents. The interventions were an even mix of short (ten minutes or less) and longer sessions (15 minutes to several hours).\n\nOverall, elements of the study designs put them at moderate to high risk of bias. All studies but one were at low risk of bias for sequence generation (i.e. used a random number sequence). For allocation concealment (i.e. the person randomising participants was unaware of the study group to which participant would be allocated), three were at high risk and one was judged at unclear risk of bias. Due to the educational nature of the intervention, blinding of participants and personnel was not possible in any studies. The risk of bias due to blinding of outcome assessors was judged as low for four studies. Most studies were at unclear risk of bias for incomplete outcome data and selective reporting. Other potential sources of bias included failure to account for clustering in a cluster‐RCT and significant unexplained baseline differences between groups. One cluster‐RCT was at high risk for selective recruitment of participants.\n\nThe reviewers judged the certainty of the evidence to be low for the outcomes of children's vaccination status, parents' attitudes or beliefs, intention to vaccinate, adverse effects (e.g. anxiety), and immunisation cost, and moderate for parents' knowledge or understanding. All studies had limitations in design. They downgraded the certainty of the evidence where we judged that studies had problems with randomisation or allocation concealment, or when outcomes were self‐reported by participants who knew whether they'd received the intervention or not. They also downgraded the certainty for inconsistency (vaccination status), imprecision (intention to vaccinate and adverse effects), and indirectness (attitudes or beliefs, and cost).\n\nLow‐certainty evidence from seven studies (3004 participants) suggested that face‐to‐face interventions to inform or educate parents may improve vaccination status (RR) 1.20, 95% CI 1.04 to 1.37). Moderate‐certainty evidence from four studies (657 participants) found that face‐to‐face interventions probably slightly improved parent knowledge (standardised mean difference (SMD) 0.19, 95% CI 0.00 to 0.38), and low‐certainty evidence from two studies (179 participants) suggested they may slightly improve intention to vaccinate (SMD 0.55, 95% CI 0.24 to 0.85). Low‐certainty evidence found the interventions may lead to little or no change in parent attitudes or beliefs about vaccination (SMD 0.03, 95% CI ‐0.20 to 0.27; three studies, 292 participants), or in parents’ anxiety (mean difference (MD) ‐1.93, 95% CI ‐7.27 to 3.41; one study, 90 participants). Only one study (365 participants) measured the intervention cost of a case management strategy, reporting that the estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care (low‐certainty evidence). No included studies reported outcomes associated with parents’ experience of the intervention (e.g. satisfaction).","There is low‐ to moderate‐certainty evidence suggesting that face‐to‐face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.\n\nFace‐to‐face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies."]
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[null,"Jacobson Vann  JC et al. Patient reminder and recall interventions to improve immunization rates. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub3.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.\n\nThe 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.\n\nPatient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (RR 1.28, 95% CI 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.\n\nThree types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).\n\nBased on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).","Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client-Held Paper\nImmunization Records. The Community Guide; 2016. \nAvailable here.","Age not specified","The CPSTF finds insufficient evidence to determine the effectiveness of client-held paper immunization records in increasing vaccination rates or reducing rates of vaccine preventable disease. Evidence was considered insufficient because of inconsistent findings and variability in the interventions evaluated.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (7 studies, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 8 studies with 11 study arms. Six studies (nine measurements) provided a common measure of vaccination rates and reported an overall median increase of 5.3 percentage points (IQI: -1.0 to 8.8 percentage points).\n\nResults were considered inconsistent because client-held paper immunization records were used as part of a multicomponent effort and comparison groups received one or more interventions.\n\nSeveral considerations for implementation were identified in the included studies and broader literature. These include clients'' declining interest over time and low card retention. Healthcare providers also have expressed concerns about time management when using a preventive services checklist.\n\nWith the expansion of population-based Immunization Information Systems and the development of on-line and electronic personal health care records, careful evaluation of client-held paper immunization records effectiveness is needed to achieve high levels of vaccination rates in the US population. However, until issues of privacy, security, and quality of electronic records have been resolved, and for clients on the other side of the \"digital divide,\" traditional client-held paper immunization records will continue to be useful. This may be particularly true for some populations, such as clients with limited computer access and adults whose change in employment status is accompanied by a change in providers.","This CPSTF report concludes that paper  immunization records maybe useful when they are used consistently—when providers update them and parents keep track of them. Children are more likely to receive recommended vaccinations and avoid being over-vaccinated. This is especially true when children are seen in non-traditional immunization settings, such as emergency departments.\n\nFurther research should therefore examine the effectiveness of additional activities to increase the retention and use of client-held paper immunization records for children by their parents or other caregivers."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Standing Orders. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends standing orders for vaccinations on the basis of strong evidence of effectiveness in increasing vaccination rates among adults and children; when used alone or with additional interventions; and across a range of settings and populations. The Task Force finding is based on evidence from a Community Guide systematic review completed in 2009 (29 studies, search period 1997–2009) combined with more recent evidence (6 studies, search period 2009–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\n\nThe Task Force considered evidence from 35 studies. Of these, 27 studies provided a common measurement of change in vaccination rates with a median increase of 24 percentage points (IQI: 12 to 35 percentage points). Nine studies that examined the impact of standing orders alone documented a median increase of 16 percentage points (IQI: 9 to 29 percentage points). Nineteen studies that evaluated standing orders when combined with additional interventions documented a median increase of 27 percentage points (IQI: 13 to 40 percentage points). Seven studies that did not provide a common measure of change for vaccination rates all reported favorable results after implementation of standing orders.\n\nThe reviewed studies evaluated the effectiveness of standing orders across a wide range of clinical vaccination settings, health care personnel, and client populations. Standing orders were found to be effective in various settings including clinics, hospitals, and long-term care facilities. Interventions were effective when used with different vaccination providers including nurses and pharmacists. While most studies looked at adult populations, four examined intervention effectiveness among children and found a median absolute percent increase of 28 percentage points (range: 8 to 49). While no studies specifically evaluated the impact of standing orders for vaccination of adolescents, evidence from this review is likely applicable to this population. In addition, a subset of the included evidence suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings when compared to a provider reminder system.\n\nOne paper from the updated search period described the following barriers encountered during implementation of a pneumococcal vaccination standing orders program in three hospitals: gaps in staff education and training; personnel concerns about additional workload; staff reluctance to administer vaccines without a physician's order; attending physicians' resistance to having hospitalized patients vaccinated; and logistical difficulties. Some attending physicians expressed concern that vaccination would interfere with scheduled treatments or procedures. Other attending physicians did not consider inpatient stays to be an appropriate time for vaccinations (Middleton et al. 2005).\n\nAn additional study reported barriers to implementation of influenza and pneumococcal vaccination standing orders in various health care settings. Findings suggested that the adoption of these policies may have been too difficult to administer, staff were unclear or unconvinced of program benefits, and there was perceived physician discomfort with delegating responsibility for immunizations to nursing staff. A few of the respondents also indicated that resources, effectiveness of the vaccine, and time required to administer the vaccine were barriers for adoption. The majority of these barriers were specific to the administration of the influenza vaccine (Goldstein et al. 2005).","This CPSTF concludes that standing orders were shown to be effective in increasing vaccination rates for influenza and pneumococcal vaccines. Additional research is needed, however, to determine if these interventions are effective for different vaccines (e.g. hepatitis, tetanus and vaccines recommended for adolescents). More evidence is also needed on ways to address barriers to the implementation of standing orders in health systems.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Provider Reminders. The Community Guide; 2015. \nAvailable here.","Under 5s \n5 to 18 years","The CPSTF recommends provider reminders on the basis of strong evidence of effectiveness in increasing vaccination rates: (1) among adults, adolescents and children; (2) when used alone or with additional interventions; (3) across a range of intervention characteristics (e.g., computerized or simple reminders, checklists, flowcharts); and (4) in a range of settings and populations.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2008 (23 studies, search period 1997–2007) combined with more recent evidence (5 studies, search period 2007–February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.\nThe Task Force considered evidence from 28 studies. Twenty-two studies provided a measurement of change in vaccination rates, with an overall median increase of 10 percentage points (IQI: 6 to 25 percentage points). Of these, seven studies examined provider reminders alone with a median increase of 12 percentage points (IQI: 6 percentage point to 25 percentage points). Fifteen studies examined the impact of provider reminders with additional interventions and observed a median increase of 9 percentage points (IQI: 5 to 25 percentage points). Six additional studies did not provide a common measurement of change in vaccination rates; however, five of the studies provided additional support for the use of provider reminders.\n\nEvidence indicates that provider reminders remain an effective option for consideration in a wide range of clinical settings and populations. A subset of the included evidence, however, suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings than provider reminder systems.","Evidence in this CPSTF report indicates that provider reminders are effective in a wide range of contexts. Additional research should focus on system-level implementation of reminder systems, and identify strategies to encourage regular and sustained use. In addition, future research could examine or compare the effectiveness of specific reminder prompts provided as a capability of regional or state-level immunization information systems."]

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[null,"GUIDANCE - EDUCATIONAL INSTITUTES"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - EDUCATIONAL INSTITUTES"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Abdullahi  LH et al. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD011895. DOI: 10.1002/14651858.CD011895.pub2.\nAvailable here.","5 to 18 years","This Cochrane review aimed to evaluate the effects of interventions to improve vaccine uptake among adolescents.\n\nThe reviewers included 16 studies (eight individually randomised trials, four cluster randomised trials, three non‐randomised trials, and one controlled before‐after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. They categorised interventions as recipient‐oriented, provider‐oriented, or health systems‐oriented.\n\nThe interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus–diphtheria–acellular–pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents.\n\nHealth education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high‐certainty evidence). In addition, one large study provided evidence that a complex multi‐component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate‐certainty evidence).\n\nFinancial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low‐certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence).\n\nMandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate‐certainty evidence).\n\nProvider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate‐certainty evidence).\n\nProvider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non‐participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low‐certainty evidence).\n\nA class‐based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age‐based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate‐certainty evidence).\n\nA multi‐component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate‐certainty evidence). A multi‐component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low‐certainty evidence.","Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class‐based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low‐ and middle‐income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Vaccination Requirements for\nChild Care, School, and College Attendance. The Community Guide; 2016. \nAvailable here.","Under 5s\n5 to 18 years","This CPSTF report examines laws or policies requiring vaccinations or other documentation of immunity as a condition of child care, school, and college attendance. These findings are based on studies demonstrating effectiveness of vaccination requirements for attendance in a variety of settings, for an array of recommended vaccines, and in populations ranging in age from early childhood to late adolescence.\n\nThe Task Force finding is based on evidence from 32 studies (search period January 1980 – July 2015) that examined the effectiveness of vaccination requirements on vaccination coverage rates or changes in vaccine-preventable disease or illness.\n\nSeventeen studies with 24 study arms examined the effectiveness of state or local vaccination requirements on changes in vaccination rates. The median change was an increase of 18 percentage points (Interquartile interval [IQI]: 10 to 35 percentage points). Five additional studies examined changes in vaccination rates or series completion that could not be included in the summary effect estimate, although results were generally in the direction of increased coverage.\n\nTen studies examined the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements. Three U.S. studies found that the incidence of measles and mumps was lower in states with immunization requirements for school-aged children, and that low-incidence areas were more likely to enforce school entry laws by excluding non-compliant children from attendance.\n\nOne study from Italy found reductions in rates of hepatitis B disease attributable to the implementation of vaccination requirements and school and community-based vaccination programs. A study from Japan found increases in excess mortality rates among younger children due to influenza and pneumonia, after the removal of a national influenza vaccination mandate and school-based immunization program.\n\nFive studies evaluated other vaccination requirements and found: (1) lower incidence of mumps during an outbreak in children subject to a vaccination requirement; (2) greater declines in Haemophilus influenza type b disease incidence among child care attendees subject to vaccination requirements than for New York State as a whole; (3) lower risk for measles outbreaks in colleges with pre-matriculation immunization requirements; (4) decline in hepatitis A disease incidence following implementation of a child care entry requirement in response to an outbreak, and (5) reduction in influenza-associated hospitalizations among children following a child care entry requirement.\n\nIncluded studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies). Studies provided evidence of effectiveness for both primary school entry requirements (11 studies) and requirements for middle/high school students (13 studies). Six studies examined vaccinations for child care attendance and findings are applicable to these settings. Although only one study evaluated vaccination requirements for college (1\nstudies) findings are likely applicable to these settings.\n\nIncluded studies examined changes in coverage rates or disease incidence for vaccinations to protect against measles mumps-rubella (16 studies), tetanus (8 studies), pertussis (8 studies), varicella (8 studies), Haemophilus influenza type b disease (5 studies), hepatitis A (2 studies), hepatitis B (14 studies), meningococcal disease (3 studies), influenza (2 studies), and human papillomavirus (1 study). Task Force findings are applicable or likely applicable for the range of vaccines recommended for children and adolescents.","The CPSTF recommends vaccination requirements for child care, school, and college attendance based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine preventable disease (VPD) and associated morbidity and mortality. \n\nAlthough intervention studies overall provide strong evidence of effectiveness, three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease transmission: 1) geographic clustering of under immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions. \n\nMost included studies examined school vaccination requirements; additional evaluations of requirements for child care attendance and college residency would be useful. Additional research would be useful to clarify relationships between variations in school or child care documentation and enforcement and vaccination and exemption rates. Information on barriers to school and local enforcement and ways to overcome these barriers would also be useful. Likewise, studies examining factors that facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings would be helpful. Finally, more research is needed to assess the economic costs and benefits of vaccination requirements in each setting."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Promoting Health Equity Through Education Programs and Policies:\nSchool-Based Health Centers. The Community Guide; 2015. \nAvailable here.","Under 5s\n5 to 18 years","The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.\n\nThe CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.\n\nMost evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.\n\nThe Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these \"whole school\" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen \"SBHC user\" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services. \n\nBecause most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.\n\nMost studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.\n\nMost of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.","This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. \n\nIn the implementation of SBHCs, the following issues should be considered:\n- Billing and financing is a major challenge to SBHC implementation and sustainability\n- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation\n- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings\n- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness\n\nThe report also identifies areas for further research.\n\n"]

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[null,"GUIDANCE - OTHER SETTINGS"]
[null,"Source:","Audience:","Recommendations:"]
[null,"National Institute for Health and Care Excellence. Hepatitis B and C testing: people at risk of infection. PH43. London: NICE; 2012.\nAvailable here.\nLast updated in March 2013.","This public health guidance is relevant to:\n- Commissioners and providers\n- People at increased risk of viral hepatitis\n- Members of the public","This guideline covers raising awareness of and testing for hepatitis B and C infection. It aims to ensure that people at increased risk of hepatitis B and C infection are tested.\n\nIt  includes recommendations on:\n- Raising awareness about hepatitis B and C among the general population and people at increased risk of infection\n- Education and training for professionals who provide services for people at increased risk of infection\n- Testing for hepatitis B and C in primary care, prisons and immigration removal centres, drugs services, and sexual health and genitourinary medicine clinics\n- Tracing close contacts of people with hepatitis B infection\n- Neonatal hepatitis B vaccination\n- Commissioning integrated services for testing and treatment and laboratory services for testing"]
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[null,"National Institute for Health and Care Excellence. Immunisations: reducing differences in uptake in under 19s. PH21. London: NICE; 2009.\nAvailable here.\nLast updated in September 2017.","This public health guidance is relevant to:\n- Healthcare professionals\n- Commissioners and providers\n- People who work in children’s services and local authorities\n- People who work in schools, colleges and workplaces\n- People who work in the private, voluntary and community sectors\n- Parents, carers and young people","This guideline covers increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low. It aims to improve access to immunisation services and increase timely immunisation of children and young people. It also aims to ensure babies born to mothers infected with hepatitis B are immunised.\n\nIt includes recommendations on:\n- Immunisation programmes\n- Information systems for recording immunisation status\n- Training for staff involved in immunisation services\n- Contribution of nurseries, schools and further education colleges\n- Targeting groups at risk of not being fully immunised\n- Hepatitis B immunisation for infants"]
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[null,"SYSTEMATIC REVIEWS - OTHER SETTINGS"]
[null,"Source:","Population:","Findings:","Authors' Conclusions:"]
[null,"Oyo‐Ita  A et al. Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.pub3. \nAvailable here.","Under 5s","This Cochrane review aimed to evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in low‐ and middle‐income countries (LMICs).\n\nFourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community‐based health education (three studies), facility‐based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).\n\nThe reviewers found moderate‐certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria‐tetanus‐pertussis vaccines (DTP3: RR 1.68, 95% CI 1.09 to 2.59). We also found low‐certainty evidence that facility‐based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low‐certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low‐certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low‐certainty evidence). Home visits to identify non‐vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low‐certainty evidence). There was low‐certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).","Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well‐conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Community-Wide Education When Used Alone. The Community Guide; 2015. \nAvailable here.","Age not specified","This report aimed to determine the effectiveness of community-wide education interventions when implemented alone in increasing vaccination rates or reducing rates of vaccine preventable illness and found insufficient evidence. Evidence is considered insufficient due to inconsistent results and concerns about the applicability of evidence to more diverse communities in the United States where improvements in vaccination rates are needed.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (6 studies with 8 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009- February 2012). Based on the combined evidence, the Task Force reaffirms its finding of insufficient evidence.\n\nThe Task Force considered evidence from 7 studies with 9 study arms. Among the studies providing a common measure of change in vaccination rates (4 studies with 6 arms) there was a median increase of 6 percentage points (range of values: 0.4 to 12.2 percentage points).\n\nThree studies evaluated mass media activities using different measures of change. In a targeted community in Australia, pneumococcal vaccines dispatched to service providers increased during the period of a mass media campaign. In Finland, a mass media campaign briefly increased MMR vaccine receipt for children 6 years of age, though changes were not reported for younger children. In the U.S., a mass media campaign addressing flu-related topics among a nationally representative population of older adults found a positive association between flu-related media reports and influenza vaccination rates in the weeks following the campaign (annual vaccination rates increased by 2.3-7.9 percentage points, p<0.001).\n\nOne U.S. study observed moderate increases in vaccination rates for hepatitis B vaccine following intensive communitywide educational efforts in two Vietnamese-American communities. Characteristics of the study communities that may have contributed to intervention effectiveness included: (1) popular Vietnamese-language media, (2) established Vietnamese service organizations, and (3) culturally appropriate strategies and materials.\n\nCommunity-wide education is commonly implemented in combination with additional interventions (such as efforts to expand and enhance access to vaccinations). In another review, the Task Force found strong evidence of effectiveness for community-based interventions implemented in combination to increase vaccination rates, and five of the included studies used community-wide education in the combination of interventions.","This CPSTF report states that although the evidence identified in this systematic review is insufficient to determine the effectiveness of community-wide education when implemented alone, two studies suggest that these interventions may be useful with certain communities. More research is needed to understand the potential applicability of these interventions to other populations, and for other vaccines.\n\nThe Task Force acknowledges an important role for mass media (and the potential role of social media) in disseminating\ninformation to large audiences and shaping public attitudes and behaviours.\n\nVaccine manufacturers have been increasing direct-to-consumer mass and small media advertising to promote new vaccines. While evidence from private sector marketing campaigns on vaccine uptake was not included in this review, the Task Force considered the applicability of these marketing experiences to public health efforts. They determined that community-wide educational efforts may have greater impact when used to inform members of the community about new vaccines (such as HPV), or new recommendations (such as the universal recommendation for seasonal influenza), and in situations of public health urgency (such as the H1N1 pandemic). The effectiveness of community-wide education to increase vaccination rates in these circumstances remains an important issue for further evaluation research.\n"]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Client or Family Incentive Rewards. The Community Guide; 2015. \nAvailable here.","Age not specified","The CPSTF recommends client or family incentive rewards, used alone or in combination with additional interventions, based on sufficient evidence of effectiveness in increasing vaccination rates in children and adults.\n\nThis Task Force finding is based on evidence from a Community Guide systematic review completed in 2011 (6 studies with 7 study arms, search period 1980-2009) combined with more recent evidence (1 study, search period 2009-2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on sufficient evidence of effectiveness.\n\nIncluded studies showed vaccination rates increased by a median of 8 percentage points (IQI: 4 to 16 percentage points). Two study arms that assessed the effectiveness of incentive rewards alone showed similar changes in vaccination rates (8.5 and 9.0 percentage points). In the six remaining study arms, incentive rewards were combined with additional interventions.\n\nAmong the studies included in this review, the type of incentive reward offered to clients included government payments (i.e., of $208 AUD and childcare assistance), lottery prizes (i.e., $50 grocery voucher or $175 in monetary prizes), gift cards (i.e., $10 for baby products), baby products, and food vouchers. \n\nOverall, the Task Force considers the evidence to be applicable to vaccinations for children and adults in a wide range of clinical and community settings, and for various types of incentive rewards.","This CPSTF concludes that client or family incentive rewards can also be one component of an effective combined approach to increase vaccination rates in both clinical and community settings. Based on updated, concurrent reviews the Task Force finds strong evidence to recommend health care system-based interventions implemented in combination and community-based\ninterventions implemented in combination.\n\nAdditional research could focus on the independent effects of incentive rewards, examine the relationship between the value of the reward and effectiveness, and explore the duration of intervention impact. It also would be useful to have more information about the effectiveness of these interventions with adolescents and adults as most of the included studies examined the use of incentive rewards on vaccination rates for children."]
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[null,"Community Preventive Services Taskforce Task Force Finding and Rationale Statement. Increasing Appropriate Vaccination: Health Care System-Based Interventions Implemented in Combination. The Community Guide; 2014. \nAvailable here.","Under 5s\n","The CPSTF recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.\n\nBased on findings from 37 of the 64 included studies, the Task Force further recommends a combination that includes the following:\nAt least one intervention to increase client demand for vaccinations, such as:\n- Client reminder and recall systems\n- Clinic-based client education\n- Manual outreach and tracking\nAnd one or more interventions that address either, or both, of the following strategies:\n- Interventions to enhance access to vaccinations: Expanded access in health care settings, reduced client out-of-pocket costs, home visits\n- Interventions directed at vaccination providers or systems: Provider reminders, standing orders, provider assessment and feedback\n\nInterventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.\n\nThe Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness. \n\nOf the combined 64 included studies (76 study arms), 58 of them (70 study arms) provided a common measure of change in vaccination rates and showed a median increase of 9 percentage points (IQI: 4 to 21 percentage points). In general, changes in vaccination rates were greater when interventions were implemented in settings with low baseline rates.\n\nThe included studies evaluated a variety of interventions in different combinations. The Task Force examined the evidence of differences attributable to specific interventions and combinations of interventions using different strategic approaches. These strategic approaches included the following:\n- Interventions to increase client demand (client reminder and recall systems, clinic-based client education, client\nor family incentives, client-held paper immunization records, case management, and manual outreach and\ntracking)\n- Interventions to enhance access to vaccination services (expanded access in health care settings, reduced client\nout-of-pocket costs, and home visits)\n- Interventions directed at vaccination providers (provider reminder systems, standing orders, provider\nassessment and feedback, provider education, and provider incentives)\n\nThe most common individual interventions implemented in a combined approach were client reminder and recall\nsystems (34 study arms) and provider reminders (31 study arms).\n\nThirty-seven studies (44 study arms) evaluated a combination of interventions across two or three of the strategic approaches and showed a median increase in vaccination rates of 17 percentage points (IQI: 6 to 27 percentage points). In 26 study arms, interventions were combined within only one strategic approach and found a median increase in vaccination rates of 4 percentage points (IQI: 2 to 9 percentage points).\n\nNine studies evaluated combinations of interventions implemented as a part of a health care system quality improvement effort. The most commonly implemented interventions were those directed at vaccination providers (provider education, provider reminders, and provider assessment and feedback). The studies included in this evaluation were typically short in duration and reported mixed results.\n\nEvidence did not show a direct relationship between the number of interventions implemented and changes in vaccination rates. Included studies evaluated combinations of between two and nine interventions. The majority of studies implemented two (31 study arms) or three (18 study arms) interventions.","This CPSTF concludes that overall, included studies provided evidence of effectiveness for intervention combinations implemented in a range of clinical settings and communities, although evidence from rural settings was limited. Studies also demonstrated effectiveness across a range of client populations and vaccinations, including young children (childhood series, influenza) and older adults (influenza, pneumococcal, and tetanus vaccines). Two of the included studies evaluated interventions targeted at increasing vaccination rates among adolescents. Finally, the included studies demonstrated increases in vaccination rates for populations of low socioeconomic status (22 study arms) and across a range of racial and ethnic groups. Most of the included evidence evaluated client populations with low to moderate baseline vaccination rates,\nand findings are most applicable to these situations.\n\nMore evidence is needed on the effectiveness of these interventions in rural settings and when applied to increase vaccinations recommended for adolescents. Future research on quality improvement activities in these settings should incorporate study periods sufficient to evaluate continuous quality improvement efforts."]
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[null,"Saeterdal I et al. Interventions aimed at communities to inform and/or educate about early childhood vaccination. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010232. DOI: 10.1002/14651858.CD010232.pub2.\nAvailable here.","Under 5s\n5 to 18 years","This Cochrane review aimed to assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.\n\nThe reviewers included two cluster‐randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.\n\nThe trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine‐preventable diseases among intervention participants (adjusted mean difference (MD) 0.121, 95% CI 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (RR 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted MD 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision‐making regarding childhood vaccination (adjusted MD 0.043, 95% CI ‐0.009 to 0.097).\n\nThe studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.","This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.’"]

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[null,"ABBREVIATIONS WITH FULL FORMS"]
[null,"ABBREVIATION","FULL FORM"]
[null,"ATCS","Automated telephone communication systems"]
[null,"CHIS","Child health information system"]
[null,"CI","Confidence interval"]
[null,"CPSTF","Community Preventive Services Task Force"]
[null,"DTP","Diphtheria‐tetanus‐pertussis"]
[null,"FFS","Fee for service"]
[null,"GP","General practitioner "]
[null,"HPV","Human papillomavirus "]
[null,"IQI","Inter quartile interval"]
[null,"IQR","Inter quartile range"]
[null,"LMHIC","Low‐, middle‐ or high‐income countries"]
[null,"LMIC","Low‐ and middle‐income"]
[null,"MD","Mean difference"]
[null,"MNCH","Maternal, neonatal and child health"]
[null,"OR","Odds ratio"]
[null,"P4P","Pay for performance"]
[null,"PCP","Primary care physician"]
[null,"RCT","Randomised controlled trials"]
[null,"RR","Risk ratio"]
[null,"SBHC","School-based health centers"]
[null,"SMD","Standardised mean difference"]
[null,"TCCMD","Targeted client communication via mobile devices"]
[null,"Tdap","Tetanus–diphtheria–acellular–pertussis"]
[null,"WIC","Women, infants and children"]