Cochrane for Clinicians
Putting Evidence into Practice
Interventions Aimed at Increasing Childhood Vaccination Rates
Am Fam Physician. 2015 Nov 1;92(9):775-776.
Are interventions to inform and educate about childhood vaccinations effective?
Community discussions, community meetings, and information campaigns may increase immunization uptake in areas with only moderate vaccine use. There is no clear evidence to guide face-to-face educational interventions, and the impact of face-to-face interventions is uncertain in areas where immunization use is already relatively high.
A recent decision analysis suggested that in the United States, routine administration of the nine immunizations recommended in the 2009 childhood immunization schedule prevents approximately 42,000 early deaths and 20 million cases of disease.1 However, vaccine coverage of the general population is less than optimal because of missed opportunities and misconceptions by parents and clinicians.2 A previous systematic review found evidence that multicomponent interventions, which include education, may be effective at improving vaccination coverage.3 The Communicate to Vaccinate project developed two Cochrane reviews on the effectiveness of interventions to educate parents and communities about childhood vaccinations. Although Communicate to Vaccinate focused on low- and middle-income countries, the Cochrane reviews are designed to be applied globally.
In the first of these two reviews, Saeterdal and colleagues identified two cluster-randomized trials of interventions targeting communities in low- and middle-income countries with baseline immunization rates of 45% to 51%. One study from India found that an information campaign, including community meetings conducted with low-, middle-, and high-income households and distribution of posters and leaflets, increased the number of children who received one or more vaccinations (relative risk [RR] = 1.67; 95% confidence interval [CI], 1.21 to 2.31). This study did not assess participants' knowledge about vaccine-preventable diseases, attitudes towards vaccination, or involvement in decision making. A second study from a lower middle–income district in Pakistan found that a series of community discussions focusing on information about childhood vaccines, the costs and benefits of vaccination, and local action plans to address barriers increased the uptake of the measles vaccine (RR = 1.63; 95% CI, 1.03 to 2.58) and the full course of the diphtheria, pertussis, and tetanus (DPT) vaccine (RR = 2.17; 95% CI, 1.43 to 3.29). It also increased participants' knowledge of vaccine-preventable diseases and the number of parents who think it worthwhile to vaccinate children. It did not affect the number of mothers included in decisions about vaccination. Neither community-focused study assessed resource use or costs.
In the second Cochrane review, Kaufman and colleagues examined face-to-face interventions and identified seven randomized controlled trials involving 2,978 participants. Most interventions were directed at mothers. One was directed at expectant parents, and three were directed at mothers facing additional barriers to accessing vaccination, including drug use and low socioeconomic status. Study settings included Australia, Canada, the United States, Pakistan, and Nepal. All but one were in urban or peri-urban locations. There was considerable variety in specific interventions tested, but all involved some type of face-to-face intervention with parents as individuals or in groups. The review authors indicate that the varying trial designs and target populations made pooling of data challenging or impossible. However, they concluded that the effect of single-session and multi-session face-to-face interventions on immunization status and on knowledge or understanding of vaccination is uncertain, and the relevant evidence is of low quality.
In high-income countries, barriers may include parental concern about the risks of adverse effects, concerns that vaccinations are painful, distrust of those advocating vaccines, and beliefs that vaccination should not occur when the child has a minor illness.4 Although there is no clear evidence to guide face-to-face education, current guidelines suggest that family physicians intervene at every office visit, reiterate that children can get shots even when they have minor illnesses, and be aware of patient barriers as well as options for overcoming those barriers (e.g., community resources for low-cost or free vaccinations).5
Saeterdal I, Lewin S, Austvoll-Dahlgren A, Glenton C, Munabi-Babigumira S. Interventions aimed at communities to inform and/or educate about early childhood vaccination. Cochrane Database Syst Rev. 2014;(11):CD010232; and Kaufman J, Synnot A, Ryan R, et al. Face to face interventions for informing or educating parents about early childhood vaccination. Cochrane Database Syst Rev. 2013;(5):CD010038.
REFERENCESshow all references
1. Zhou F, Shefer A, Wenger J, et al. Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics. 2014;133(4):577–585....
2. Epling JW, Savoy ML, Temte JL, Schoof BK, Campos-Outcalt D. When vaccine misconceptions jeopardize public health. J Fam Pract. 2014;63(12):E1–E7.
3. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med. 2000;18(1 suppl):97–140.
4. Mills E, Jadad AR, Ross C, Wilson K. Systematic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccination. J Clin Epidemiol. 2005;58(11):1081–1088.
5. Nordin J, Anderson R, Anderson R, et al. Immunizations. Bloomington, Minn.: Institute for Clinical Systems Improvement; 2012:1–81.
These are summaries of reviews from the Cochrane Library.
This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.
A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.
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