August 2008 SUPPORT Summary of a systematic review Do parent reminder and recall systems improve the rates of routine childhood immunisations? Routine immunisation during childhood is considered to be the single most effective way of controlling many diseases, including measles, polio, diphtheria, pertussis and tetanus. Not all children receive their recommended vaccinations. One approach to increasing childhood immunisation rates is to remind parents about immunisations that are due (reminders), or overdue (recall). Key messages Reminder and recall interventions are an effective way of increasing the rates of routine childhood immunisations in high-income countries. This review found no direct evidence of how effective reminder and recall interventions are in low and middle-income countries. Reminder and recall interventions rely crucially on a stable health system with ongoing immunisation programmes that can identify and follow potential recipients of vaccination. Health systems in low and middle-income countries are not always able to support this. Other factors that need to be considered to assess whether the intervention effects are likely to be transferable to other settings include the availability of the: Technology or physical infrastructure to provide reminders (e.g. telephones, computers, a functioning postal system) and literacy of parents (e.g. for post cards); Resources to provide the additional clinical and administrative infrastructure to implement reminder and recall programmes; Vaccines. Who is this summary for? People making decisions concering how to improve the rates of routine childhood immunisations. This summary includes: Key findings from research based on a systematic review Considerations about the relevance of this research for low and middleincome countries Not included: Recommendations Additional evidence not included in the systematic review Detailed descriptions of interventions or their implementation This summary is based on the following systematic review: Jacobson Vann JC, Szilagyi P. Patient reminder and recall systems to improve immunization rates. Cochrane Database of Systematic Reviews 2005, Issue 3. What is a systematic review? A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies. SUPPORT an international collaboration funded by the EU 6th Framework Programme to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low and middle-income countries. www.support-collaboration.org Glossary of terms used in this report: www.supportcollaboration.org/summaries/explanat ions.htm Background references on this topic: See back page
Background Vaccination programmes are key components of healthcare services in low and middleincome countries, but coverage is often low, especially in South Asia and sub-saharan Africa. Increasing the number of people who are vaccinated could lower death and disease rates. One approach to increasing immunisation rates involves reminding people about their vaccinations. This summary is based on an update of a Cochrane systematic review first published in 2005. The summary focuses on the part of the review that considered the effects of different types of parent reminder and recall systems in improving the rates of routine childhood immunisations. How this summary was prepared After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low and middle-income countries. The methods used to assess the quality of the review and to make judgements about its relevance are described here: http://www.supportcollaboration.org/summaries/meth ods.htm Knowing what s not known is important A good quality review might not find any studies from low and middleincome countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known. About the systematic review underlying this summary Review objective: To assess the effectiveness of patient reminder and recall systems in improving immunisation rates and compare the effects of various types of reminders in different settings or patient populations Interventions Participants What the review authors searched for Randomised controlled trials (RCT), controlled before after studies (CBA) and interrupted time series (ITS) analyses of interventions that either reminded parents or patients about immunisations that were due (reminders) or were overdue (recall). Healthcare personnel who deliver immunisations. Children (birth to 18 years) or adults (18 years and up) who receive immunisations. What the review authors found 40 RCTs and three CBAs. Interventions included letters, postcards, person-to-person telephone calls, computer-to-person telephone calls and outreach. The type of healthcare personnel involved was not clear. More than one-third of studies examined routine vaccinations of infants and children. Almost half involved influenza immunisations for patients 65 years or older, those with chronic illness, or both. Settings Any Study settings were diverse, including rural, urban, private, public and university-based. Studies from USA (32), Australia (2), Canada (5), Denmark (1), New Zealand (2) and UK (1) were included. Outcomes Primary outcomes: immunisation rates and the proportion of the target population up-to-date on recommended immunisations. Secondary outcomes: costs Date of most recent search: December 2004 Limitations: This is a good quality systematic review with only minor limitations. All studies presented outcome data on number and percent of individuals immunized. Cost data were poor. Jacobson Vann JC, Szilagyi P. Patient reminder and recall systems to improve immunization rates. Cochrane Database of Systematic Reviews 2005, Issue 3. Background 2
Summary of findings The review included 43 studies, most of which were done in the USA; none were done in low or middle-income countries. The included studies were, however, done in diverse settings, some of which were aimed at low-income groups in high-income countries. The focus of this summary is on child health. Therefore studies in the review targeted at adult immunisations are not considered in this summary. 1) Routine childhood immunisations Fourteen of the 43 included studies used a variety of methods to remind parents about their child s routine vaccinations. Two studies were excluded from the meta-analysis, one because of a potential error in its analysis, the other because of its design. Of the 12 remaining studies, eight used a letter alone or in combination with other interventions. Other interventions included postcards, telephone calls and home visits. All types of reminder and recall systems appeared to improve immunisation rates with person-toperson telephone reminders being the most effective single approach. About quality of evidence (GRADE) High: Further research is very unlikely to change our confidence in the estimate of effect. Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: We are very uncertain about the estimate. For more information, see last page. There is moderate quality evidence that reminders and recall strategies can increase routine childhood immunisations. Routine childhood immunisations Patients or population: Children up to the age of 7 Settings: Diverse; some low income, in USA (11 studies) and Australia (1 study) Intervention: Reminder and recall interventions to promote immunisation uptake Comparison: Usual care, except one study which used a printed schedule of routine immunisations Outcomes Comparative risks* Without reminder/recall With reminder/recall (95% CI) Immunized 30 per 100 38 per 100 (35 to 42) Relative effect (95% CI) OR 1.45 (1.28 to 1.66) Number of participants (studies) Quality of the evidence (GRADE) 13 818 (12 studies) Moderate CI: Confidence interval; OR: Odds ratio GRADE: GRADE Working Group grades of evidence (see above and last page) *Illustrative comparative proportions of children with up-to-date immunisations for an assumed proportion of 30 per 100 without reminders or recall, based on the overall relative effect (OR = 1.45). Summary of findings 3
Relevance of the review for low and middle-income countries Findings APPLICABILITY Although all types of reminders and recall were found to be effective in this review, all the studies were done in high-income countries, which have health systems that follow potential recipients of immunisations over time. Without such systems there is little ability to identify the population of eligible vaccine recipiants. The studies reviewed covered a diverse range of settings, including low-income settings in a high-income country. Most studies were done in the USA. The range of settings and consistent pattern of findings suggest that the measured effects may be transferable across settings. Interpretation* The ability to transfer the intervention effects described in this summary to low and middle-income settings depends crucially on the availability in these settings of a stable health system with ongoing immunisation programmes that can identify children in need of immunisation. In addition, it is not clear how applicable results from low-income settings in high-income countries are to low and middle-income countries. Other factors that need to be considered to assess whether the intervention effects are likely to be transferable to other settings include the availability of the: Technology or physical infrastructure to provide reminders (e.g. telephones, computers, a functioning postal system) and literacy of parents (e.g. for post cards); Resources to provide additional clinical and administrative infrastructure to implement reminder and recall programmes; Vaccines. Poor education and literacy may mean that uptake of immunisations is not simply a matter of reminding parents. Programmes may need to provide educational interventions to explain the benefits of immunisation. EQUITY Overall, the included studies provided little data regarding differential effects of the interventions for disadvantaged populations. COST-EFFECTIVENESS The review gave very little information on costs beyond stating that telephone reminders were more costly than letters or postcards and that intervention intensity affects overall cost. MONITORING & EVALUATION No evidence from low and middle-income countries was identified in this review. Immunisations in many low and middleincome countries are done through, for example, mass media campaigns, community health volunteers, village support groups and announcements from mosques and churches. The review did not evaluate these strategies. Some interventions relied on technologies that may not be appropriate for contacting low-income households (e.g. a telephone call or post card). Implementation of interventions in such settings that use such technologies may exacerbate health inequities, or fail to address them adequately. If geographic or financial access to services is unevenly distributed an immunisation programme that does not consider this may exacerbate inequailities. Providing adequate support to programmes is likely to be vital to intervention effectiveness when scaling up. A lack of existing infrastructure (e.g. postal services) that can be used to support programmes is likely to reduce cos- effectiveness when compared to implementing the same programme in a high-income country. Widespread implementation of these programmes can be expected to increase demand for immunisation services. If this demand cannot be met, the programme may be undermined. Where reminder and recall interventions are implemented in low and middleincome countries, robust mechanisms of evaluation should be built into the programme. If alternative forms of reminder and recall systems (or alternative systems of delivering immunisations) more appropriate to low and middle-income countries are considered, then evidence of the effectiveness of these systems should be reviewed before such programmes are taken to scale. Such reviews should also consider costeffectiveness. *Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm Relevance of the review for low and middle-income countries 4
Additional information Related literature This article makes a case for improved vaccination programmes: Andre FE, Booy R, Bock HL, Clemens J, Datta SK, John TJ, Lee BW, Lolekha S, Peltola H, Ruff TA, Santosham M, Schmitt HJ. Vaccination greatly reduces disease, disability, death and inequity worldwide. Bulletin of the World Health Organisation 2008; 86: 140-146. A systematic review of interventions to improve coverage for child immunisation in low and middleincome countries is underway: Oyo-Ita A, Nwachukwu CE, Oringanje CM, Meremikwu MM. Interventions for improving coverage for child immunisation in developing countries (Protocol). Cochrane Database of Systematic Reviews 2008, Issue 3. This summary was prepared by Shaun Treweek and Andy Oxman, Norwegian Knowledge Centre for the Health Services, Oslo, Norway. Conflict of interest None declared. For details, see: http://www.support-collaboration.org/summaries/coi.htm Acknowledgements This summary has been peer reviewed by: Julie Jacobson Vann, USA; Cristian Herrera and Tomás Pantoja, Chile; Tracey Perez Koehlmoos, Bangladesh; Emeka Nwachukwu, Nigeria; Pierre Ongolo Zogo, Cameroon. This summary should be cited as Treweek S, Oxman AD. Do parent reminder and recall systems improve the rates of routine childhood immunisations? A SUPPORT Summary of a systematic review. August 2008. http://www.supportcollaboration.org/summaries.htm About quality of evidence (GRADE) The quality of the evidence is a judgement about the extent to which we can be confident that the estimates of effect are correct. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the type of study design (randomised trials versus observational studies), the risk of bias, the consistency of the results across studies, and the precision of the overall estimate across studies. For each outcome, the quality of the evidence is rated as high, moderate, low or very low using the definitions on page 3. For more information about GRADE: www.supportcollaboration.org/summaries/grade.pdf SUPPORT collaborators: The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration aiming to promote the generation and use of health policy and systems research as a means to improve the health systems of developing countries. www.who.int/alliance-hpsr The Cochrane Effective Practice and Organisation of Care Group (EPOC) is a Collaborative Review Group of the Cochrane Collaboration: an international organisation that aims to help people make well informed decisions about health care by preparing, maintaining and ensuring the accessibility of systematic reviews of the effects of health care interventions. www.epoc.cochrane.org The Evidence-Informed Policy Netowrk (EVIPNet) is is an initiative to promote the use of health research in policymaking. Focusing on low and middleincome countries, EVIPNet promotes partnerships at the country level between policy-makers, researchers and civil society in order to facilitate both policy development and policy implementation through the use of the best scientific evidence available. www.who.int/rpc/evipnet/en/ For more information, see: www.support-collaboration.org To receive e-mail notices of new SUPPORT summaries, go to: www.supportcollaboration.org/summaries/newsl etter/ To provide feedback on this summary, go to: http://www.supportcollaboration.org/feedback/ Additional information 5