Client Reminders Research Articles

Immunization information systems to increase vaccination rates: a community guide systematic review.

Immunizations are the most effective way to reduce incidence of vaccine-preventable diseases. Immunization information systems (IISs) are confidential, population-based, computerized databases that record all vaccination doses administered by participating providers to people residing within a given geopolitical area. They facilitate consolidation of vaccination histories for use by health care providers in determining appropriate client vaccinations. Immunization information systems also provide aggregate data on immunizations for use in monitoring coverage and program operations and to guide public health action. Methods for conducting systematic reviews for the Guide to Community Preventive Services were used to assess the effectiveness of IISs. Reviewed evidence examined changes in vaccination rates in client populations or described expanded IIS capabilities related to improving vaccinations. The literature search identified 108 published articles and 132 conference abstracts describing or evaluating the use of IISs in different assessment categories. Studies described or evaluated IIS capabilities to (1) create or support effective interventions to increase vaccination rates, such as client reminder and recall, provider assessment and feedback, and provider reminders; (2) determine client vaccination status to inform decisions by clinicians, health care systems, and schools; (3) guide public health responses to outbreaks of vaccine-preventable disease; (4) inform assessments of vaccination coverage, missed vaccination opportunities, invalid dose administration, and disparities; and (5) facilitate vaccine management and accountability. Findings from 240 articles and abstracts demonstrate IIS capabilities and actions in increasing vaccination rates with the goal of reducing vaccine-preventable disease.

Recommendation for use of immunization information systems to increase vaccination rates.

Based on findings of a systematic review, the Community Preventive Services Task Force recommends immunization information systems on the basis of strong evidence of effectiveness in increasing vaccination rates. Evidence is considered strong, based on the findings from 108 published articles and 132 conference abstracts showing that immunization information systems are effective in increasing vaccination rates and reducing vaccine-preventable disease through their capabilities to (1) create or support effective interventions such as client reminder and recall systems, provider assessment and feedback, and provider reminders; (2) generate and evaluate public health responses to outbreaks of vaccine-preventable disease; (3) facilitate vaccine management and accountability; (4) determine client vaccination status for decisions made by clinicians, health departments, and schools; and (5) aid surveillance and investigations on vaccination rates, missed vaccination opportunities, invalid dose administration, and disparities in vaccination coverage.

Abstract B75: Referral and completion rates for colorectal cancer screening with fecal immunochemical test (FIT) in a medical home for underserved populations

Abstract This study assessed the referral and completion rates of colorectal cancer screening with fecal immunochemical test (FIT) in a primary care medical home serving an underserved population. The Good Samaritan Clinic (Clinic) provides medical care to over 600 uninsured clients annually and is staffed by volunteer health care providers (Providers). All clients have an income at or below 200 % of the Federal Poverty Line; 63.8 % are Latino or Hispanic, 22.3 % are non-Hispanic Caucasians, and 10.1 % are African American. Acute client care for co-morbidities such as hypertension and uncontrolled diabetes is often the focus of clinical visits, thus limiting health promotion referrals, including routine cancer screenings. To promote evidence-based recommended cancer screenings the Clinic and the Lewis Cancer & Research Pavilion utilized guidelines from the American Cancer Society, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network to create a Cancer Assessment Tool (CAT) with age and sex appropriate screenings for breast, cervical, prostate, colorectal, and head and neck cancers. This cancer screening intervention was implemented in March 2013. During clinic visits, Providers used the CAT to review age and sex recommended cancer screenings and then, based on the CAT, referred clients as indicated. For example, if colorectal cancer screening was indicated based on age or family history, the CAT prompted the Provider to give the client a FIT to take home and to also counsel the client on how to collect the sample and return the test. No other interventions to promote FIT referral, FIT completion, or other colorectal screening methods were implemented during this time. To evaluate Provider FIT referrals and client FIT return compliance, data on CAT implementation was collected from March 28 – July 31, 2013. Measurements collected included the number of clients eligible for age-appropriate colorectal cancer screening; the number of clients with whom the CAT was completed; the number of clients given FIT; the number of FIT returned; and the number of positive FIT. Providers utilized the CAT to consider screening for colorectal cancer based on age and family history with 25.5 % (110) of the 431 total clients seen at the Clinic during this time period. Review of medical records indicate that 34.8 % (150) of total clients met age only criteria (over age 50) for colorectal cancer screening. Of the 150 total age-eligible clients (not considering additional clients with family history), 44.7 % (67) were referred for colorectal screening and were given a take-home FIT. Of the 67 clients given a FIT, 53.7 % (36) returned the results, resulting in a FIT completion rate of 24 % of all 150 age-eligible clients. 100 % (36) of FIT exams returned were negative. FIT drop-off occurred at both the provider referral level (55.3 % non-referral rate) and the client completion level (46.3 % non-completion rate). Based on these drop-off points several provider and client-based interventions recommended by the Guide to Community Preventive Services (Community Guide) may support improved colorectal cancer screening completion. First, strengthening provider-based interventions such as provider feedback and reminder systems so that the CAT is utilized for all client visits may support increased referral for FIT screening. Second, client-based interventions such as one-on-one education, client reminders such as follow-up phone calls, and reducing structural barriers such as putting postage stamps on the FIT may support client compliance to complete and return the FIT. Potential exists to conduct similar analysis of the CAT with breast, cervical, prostate, and head and neck cancers. Citation Format: Sarah Dobra, Krista Aliffi, Sandra Bond. Referral and completion rates for colorectal cancer screening with fecal immunochemical test (FIT) in a medical home for underserved populations. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B75. doi:10.1158/1538-7755.DISP13-B75

The "long tail" and public health: new thinking for addressing health disparities.

The prevailing approach to improving population health focuses on shifting population means through a few targeted and universal interventions. The success of this approach for eliminating health disparities depends on an assumption about the distribution of demand for such interventions. We explored whether long tail thinking from business might yield greater progress in eliminating disparities. We examined 2011 to 2013 data from 513 state and local health agency representatives in 47 states who used an online system to create 4351 small media and client reminder products promoting colorectal cancer screening. Products in the long tail were more likely to target minority groups with higher rates of colorectal cancer and lower rates of screening than Whites. Long tail thinking could help improve the public's health and eliminate disparities.

Barriers and facilitators to pre-exposure prophylaxis (PrEP) eligibility screening and ongoing HIV testing among target populations in Bondo and Rarieda, Kenya: results of a consultation with community stakeholders.

BackgroundAs pre-exposure prophylaxis (PrEP) moves closer to availability in developing countries, practical considerations for implementation become important. We conducted a consultation with district-level community stakeholders experienced in HIV-prevention interventions with at-risk populations in Bondo and Rarieda, Kenya to generate locally grounded approaches to the future rollout of oral PrEP to four populations: fishermen, widows, female sex workers, and serodiscordant couples.MethodsThe 20 consultation participants represented the Ministry of Health, faith- and community-based organizations, health facilities, community groups, and nongovernmental organizations. Participants divided into breakout groups and followed a structured discussion guide asking them to identify barriers to implementing HIV-prevention interventions (including PrEP) with each population. Questions also solicited solutions for addressing these barriers, as well as other facilitators for PrEP implementation. In particular, questions focused on how to encourage people to screen for PrEP eligibility by having HIV and other blood tests and how to encourage compliance with ongoing HIV testing.ResultsThe barriers and facilitators/solutions discussants provided were frequently population-specific, but there were also broad-level similarities across populations. Service delivery barriers to HIV-prevention interventions concerned the need for staff trained to address the needs of particular populations. Service delivery facilitators to provision of ongoing HIV testing consisted of offering testing options besides facility-based testing. Stigma was the main community-level barrier for all groups, whereas barriers at the level of target populations included mobility; lifestyle and life circumstances, especially cultural norms among fishermen and widows; and fears, lack of awareness, and misinformation. Proposed facilitators and strategies for addressing community- and population-level barriers included topic-specific education within the populations and community, involvement of partners and family members, mass HIV testing, and peer educators. Barriers to PrEP uptake included non-adherence to pill taking and missing clinic visits. For drug adherence, facilitators were counselling and involving family members. Discussants suggested that client reminders, e.g., home visits, were needed to encourage clients to keep their clinic appointments.ConclusionsStrategies for encouraging eligibility screening and ongoing HIV testing will have local and population-specific aspects. Our results nonetheless apply to similar populations throughout sub-Saharan Africa and reach beyond oral PrEP to other ARV-based PrEP formulations.

Using Client Reminders to Increase Colorectal Cancer Screening in Montana, 2012

BackgroundColorectal cancer (CRC) is the third leading cause of cancer death for men and women in the United States. CRC screening can save lives by detecting precancerous polyps that are then removed or by detecting cancer early when treatment is most effective.Community ContextCRC screening participation in Montana is low. To increase screening participation among Montanans with health insurance, the Montana Cancer Control Programs (MCCP) partnered with a small association health organization (AHO). This partnership implemented a postcard campaign to increase CRC screening participation among the AHO’s enrollees.MethodsPostcards were sent to 1,011 people insured through the AHO; 504 people were mailed 1 postcard and 507 people were mailed 2 postcards. Evaluation of the campaign assessed recall of the campaign among people who received 1 postcard versus people who received 2 postcards.OutcomeWomen were 60% more likely to recall receiving the postcards than were men. People who received 2 postcards were 2.3 times as likely to recall receiving them as were people who received 1 postcard.InterpretationThe MCCP considers this collaborative project with an AHO a promising approach to implementing evidence-based colorectal cancer screening interventions. The MCCP plans to partner with additional AHOs in Montana to evaluate CRC screening participation among their enrollees.

Implementing a Client Reminder Intervention for Colorectal Cancer Screening at a Health Insurance Worksite

BackgroundAmong cancers that affect both men and women, colorectal cancer is one of the leading causes of cancer-related death in Michigan. The American Cancer Society estimates 4,730 new cases and 1,700 deaths due to colorectal cancer in Michigan for 2013. Screening can detect colorectal cancer earlier, when treatment is more successful.Community ContextThe Michigan Department of Community Health represents 1 of 25 states and 4 tribes to receive a multiyear grant from the Centers for Disease Control and Prevention (CDC) to increase colorectal cancer screening rates through population health interventions and clinical services for the underserved. Michigan’s Colorectal Cancer Control Program is implemented in partnership with its Comprehensive Cancer Control Program, which supports the Michigan’s cancer control coalition composed of 114 partner organizations.MethodsThis project had 2 primary objectives: 1) develop a collaborative partnership with 1 Michigan Cancer Consortium organization in which to pilot the intervention and 2) increase colorectal cancer screening rates by implementing a client reminder intervention and measuring the increase in screening rates.OutcomesA partnership was established with HealthPlus of Michigan. Of the 95 HealthPlus employees and spouses who received the intervention, 15 completed screening, accounting for a 16% increase in the screening rate. The project was considered successful because both of its objectives were achieved.InterpretationTranslating evidence-based interventions into practice requires building a relationship with a partner organization, incorporating flexibility, and establishing a realistic timeline.

Effect size and cost-effectiveness estimates of breast and cervical cancer screening reminders by population size through complete enumeration of Japanese local municipalities

BackgroundClient reminders are known to increase cancer screening attendance rates. However, there are significant costs associated with them, and their effect by population size is unknown.MethodsIn 2007 and 2008, the Japanese Government surveyed breast and cervical cancer screening in every municipality in Japan. From the results, we selected all 1,464 municipalities that carried out both screening types. We examined whether changes in screening attendance rates between 2007 and 2008 were associated with client reminders, number of public health nurses per 100,000 population, financial strength index, and 2007 attendance rates for different population sizes. We then calculated cost-effectiveness estimates of client reminders by population size and screening type.ResultsClient reminders were associated with increased attendance rates in populations <100,000. For populations of 50,000–100,000, there was a 2.76% increase in breast cancer screening (95% CI: 0.41, 5.11), and a 2.25% increase in cervical cancer screening (95% CI: 0.89, 3.61). The incremental cost per additional attendance was higher in populations <50,000 than in populations of 50,000–100,000 (breast, $100 versus $54; cervical, $149 versus $67 respectively).ConclusionsClient reminders for breast and cervical cancer screening increased attendance rates in smaller municipalities in Japan.

A pilot test of a church-based intervention to promote multiple cancer-screening behaviors among Latinas.

We assessed the feasibility, acceptability, and initial impact of a church-based educational program to promote breast, cervical, and colorectal cancer screening among Latinas ages 18 years and over. We used a one-group pre-/post-evaluation within a low-income, Latino Baptist church in Boston, MA. Participants completed interviewer-administered assessments at baseline and at the end of the 6-month intervention. Under the guidance of a patient navigator (PN), women from the church (peer health advisors, or PHAs) were trained to deliver evidence-based screening interventions, including one-to-one outreach, small group education, client reminders, and reduction of structural barriers to screening. The PN and PHAs also implemented a health fair, and the pastor integrated health information into regular sermons. At pre-intervention, nearly half of the sample did not meet screening guidelines. The majority (97%, n = 35) of those who completed the post-intervention assessment participated in intervention activities. Two thirds (67%) reported talking with the PN or PHAs about health issues. Participation in small group education sessions was highest (72%), with health fairs (61%) and goal setting (50%) also being popular activities. Fourteen percent also reported receiving help from the PN in finding a primary care provider. This study supports the feasibility and acceptability of churches as a setting to promote cancer screening among Latinas.

Colorectal Cancer Control Program Grantees’ Use of Evidence-Based Interventions

Colorectal cancer (CRC) screening is recommended for adults aged 50-75 years, yet screening rates are low, especially among the uninsured. The CDC initiated the Colorectal Cancer Control Program (CRCCP) in 2009 with the goal of increasing CRC screening rates to 80% by 2014. A total of 29 grantees (states and tribal organizations) receive CRCCP funding to (1) screen uninsured adults and (2) promote CRC screening at the population level. CRCCP encourages grantees to use one or more of five evidence-based interventions (EBIs) recommended by the Guide to Community Preventive Services. The purpose of the study was to evaluate grantees' EBI use. A web-based survey was conducted in 2011 measuring grantees' use of CRC screening EBIs and identifying their implementation partners. Data were analyzed in 2012. Twenty-eight grantees (97%) completed the survey. Most respondents (96%) used small media. Fewer used client reminders (75%); reduction of structural barriers (50%); provider reminders (32%); or provider assessment and feedback (50%). Provider-oriented EBIs were rated as harder to implement than client-oriented EBIs. Grantees partnered with several types of organizations to implement EBIs, many with county- or state-wide reach. Almost all grantees implement EBIs to promote CRC screening, but the EBIs that may have the greatest impact with CRC screening are implemented by fewer grantees in the first 2 years of the CRCCP.

One-on-one education and client reminders increase uptake of colorectal, breast and cervical cancer screening

Implications for practice and research: Client reminders and one-on-one education are effective community-based interventions for improving screening rates for colorectal cancer (CRC), breast and cervical cancers. Group education is now...

Small Media and Client Reminders for Colorectal Cancer Screening: Current Use and Gap Areas in CDC's Colorectal Cancer Control Program

IntroductionCDC’s Colorectal Cancer Control Program (CRCCP) funds 25 states and 4 tribal organizations to promote and increase colorectal cancer screening population-wide. The CRCCP grantees must use evidence-based strategies from the Guide to Community Preventive Services, including small media and client reminders.MethodsTo assess the existing resources and needs to promote colorectal cancer screening, we conducted 2 web-based surveys of CRCCP grantees and their community partners. Survey 1 sought to identify priority populations, the number and quality of existing colorectal cancer resources for different population subgroups, and the types of small media and client reminder they were most interested in using. Survey 2 assessed screening messages that were used in the past or might be used in the future, needs for non-English–language information, and preferences for screening-related terminology.ResultsIn survey 1 (n = 125 from 26 CRCCPs), most respondents (83%) indicated they currently had some information resources for promoting screening but were widely dissatisfied with the quality and number of these resources. They reported the greatest need for resources targeting rural populations (62% of respondents), men (53%), and Hispanics (45%). In survey 2 (n = 57 from 25 CRCCPs), respondents indicated they were most likely to promote colorectal cancer screening using messages that emphasized family (95%), role models (85%), or busy lives (83%), and least likely to use messages based on faith (26%), embarrassment (25%), or fear (22%). Nearly all (85%) indicated a need for resources in languages other than English; 16 different languages were mentioned, most commonly Spanish.ConclusionThese findings provide the first picture of CRCCP information resources and interests, and point to specific gaps that must be addressed to help increase screening.

Increasing information-seeking about human papillomavirus vaccination through community partnerships in African American and Hispanic communities.

This study tested the feasibility of promoting 1-800-4-CANCER through partnerships with organizations serving African American and Hispanic communities. Small-media and client reminders about human papillomavirus vaccination were made available through local agents to 28 community organizations. Organizations ordered 79 932 resources and distributed them to young women and parents of girls-;African Americans in St Louis, Missouri, and Hispanics in the Lower Rio Grande Valley of Texas. Pre- to postintervention calls to 1-800-4-CANCER increased 38% in these communities, while declining 15% in comparison communities of Kansas City, Missouri, and El Paso, Texas (F = 8.6, P = .004) and 1.4% in the United States as a whole.

What implementation interventions increase cancer screening rates? a systematic review

BackgroundAppropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. As part of a larger agenda to create an implementation guideline, we conducted a systematic review to evaluate interventions designed to increase the rate of breast, cervical, and colorectal cancer (CRC) screening. The interventions considered were: client reminders, client incentives, mass media, small media, group education, one-on-one education, reduction in structural barriers, reduction in out-of-pocket costs, provider assessment and feedback interventions, and provider incentives. Our primary outcome, screening completion, was calculated as the overall median post-intervention absolute percentage point (PP) change in completed screening tests.MethodsOur first step was to conduct an iterative scoping review in the research area. This yielded three relevant high-quality systematic reviews. Serving as our evidentiary foundation, we conducted a formal update. Randomized controlled trials and cluster randomized controlled trials, published between 2004 and 2010, were searched in MEDLINE, EMBASE and PSYCHinfo.ResultsThe update yielded 66 studies new eligible studies with 74 comparisons. The new studies ranged considerably in quality. Client reminders, small media, and provider audit and feedback appear to be effective interventions to increase the uptake of screening for three cancers. One-on-one education and reduction of structural barriers also appears effective, but their roles with CRC and cervical screening, respectively, are less established. More study is required to assess client incentives, mass media, group education, reduction of out-of-pocket costs, and provider incentive interventions.ConclusionThe new evidence generally aligns with the evidence and conclusions from the original systematic reviews. This review served as the evidentiary foundation for an implementation guideline. Poor reporting, lack of precision and consistency in defining operational elements, and insufficient consideration of context and differences among populations are areas for additional research.

Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline

BackgroundAppropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. Several high-quality systematic reviews and practice guidelines exist to inform the most effective screening options. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. We developed an implementation guideline to answer the question: What interventions have been shown to increase the uptake of cancer screening by individuals, specifically for breast, cervical, and colorectal cancers?MethodsA guideline panel was established as part of Cancer Care Ontario's Program in Evidence-based Care, and a systematic review of the published literature was conducted. It yielded three foundational systematic reviews and an existing guidance document. We conducted updates of these reviews and searched the literature published between 2004 and 2010. A draft guideline was written that went through two rounds of review. Revisions were made resulting in a final set of guideline recommendations.ResultsSixty-six new studies reflecting 74 comparisons met eligibility criteria. They were generally of poor to moderate quality. Using these and the foundational documents, the panel developed a draft guideline. The draft report was well received in the two rounds of review with mean quality scores above four (on a five-point scale) for each of the items. For most of the interventions considered, there was insufficient evidence to support or refute their effectiveness. However, client reminders, reduction of structural barriers, and provision of provider assessment and feedback were recommended interventions to increase screening for at least two of three cancer sites studied. The final guidelines also provide advice on how the recommendations can be used and future areas for research.ConclusionUsing established guideline development methodologies and the AGREE II as our methodological frameworks, we developed an implementation guideline to advise on interventions to increase the rate of breast, cervical and colorectal cancer screening. While advancements have been made in these areas of implementation science, more investigations are warranted.

Use of Evidence-Based Strategies to Promote Mammography Among Medically Underserved Women

Several web-based resources recommend effective intervention strategies to promote use of mammography but there is limited information on whether the strategies are used, particularly by organizations that serve medically underserved women. In 2010, data collected by the Avon Breast Health Outreach Program (BHOP) were analyzed to examine the diffusion of evidence-based intervention strategies among funded organizations. Data on intervention strategies were obtained from a 2009 survey of Avon BHOP organizations funded during 2006-2009. Self-reported use of mammography was reported from annual intake forms administered to medically underserved women aged ≥40 years, excluding those with a history of breast cancer or initial enrollees not exposed to the strategies. Strategies reflected interventions reviewed in the Guide to Community Preventive Services. Those recommended to increase demand and use of mammography included (1) client reminders; (2) small media; (3) one-to-one education; (4) removal of structural barriers to rescreening; and (5) group education-and one that lacked sufficient evidence to warrant a recommendation (6) client incentives. Among 86 organizations, 96% used three or more intervention strategies. The most common strategies were group education (91%) and client reminders (83%). The overall crude-percentage of recent mammography use was 84%. This percentage was similar for clinical sites and nonclinical sites, despite the disproportionate enrollment of medically underserved women in nonclinical sites. The wide use of evidence-based strategies among Avon BHOP-funded organizations and high percentage of recent mammography use among women exposed to the strategies suggests that medically underserved women are benefiting from effective interventions to increase use of mammography.

Abstract P1-10-10: Organizational Use of Evidence-Based Strategies To Promote Timely Mammography among Medically Underserved Clients Recruited through the Avon Breast Health Outreach Program

Abstract Background: Income-related disparities in breast cancer screening rates are due to barriers to mammography that are more prevalent among lower-income groups. To address barriers to completion of screening mammography, the US Preventive Services Task Force recommends client-oriented interventions to increase demand and improve access. While evidence-based strategies have shown increased use of mammography for lower-income populations, little is known about the use of these strategies in real-world settings. Since 2001 the Avon Foundation for Women Breast Health Outreach Program (Avon BHOP) has granted over $53 million to more than 200 organizations to promote screening for breast cancer. Data collection and reporting requirements examine the reach of the program and utilization of evidenced-based interventions in diverse settings to promote repeat use of mammography among low-income women. Methods: This cross-sectional study describes the use of evidence-based strategies among Avon BHOP grantees to promote rescreening among returning clients, age 40-64, with no history of breast cancer; and examines associations between the strategies and use of mammography within the previous two years. Data were collected from two sources: 1) online survey administered to 149 organizations in 2009 to ascertain program strategies and 2) client intake form completed by clients or staff at Avon-funded agencies when women returned for annual mammograms. Organizational-level analysis included agencies that responded to the online survey and were funded by Avon from 2006-2009. Results: Characteristics of the 86 organizations in the sample included: US geographic location (17% Mid-West, 27% Northeast, 30% South, and 26% West); 45% clinical sites; and delivery of the program to underserved populations including a high percentage of clients that: belonged to racial or ethnic minority group (62%), reported annual income of $25k or less (72%), and/or were uninsured (62%). Use of evidence-based strategies was common across organizations, including use of client reminders to schedule appointments (83% printed reminders, 74% telephone calls) and provision of patient navigation (51%). Use of strategies did not differ between clinical sites and community groups, and the rate of recent mammogram use was similar for both (clinical sites 84%, community groups 88%) and exceeded the target rate for Healthy People 2010 (70%). Figure 1. The Proportion of Returning Clients Age 40-64 Yeats Who Had a Mammogram Within the Past 2 Years, by Type of Organization, Avon BHOP. 2007-2009. Discussion: Avon BHOP programs are effective in recruiting underserved women for mammography screening. Both clinical and non-clinical organizations reported high rates of use of evidence-based strategies and high rates of recent mammogram for returning clients. These results suggest that strategies used to promote use of mammography among underserved populations previously enrolled in programs may be equally effective if implemented in clinical or non-clinical settings. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-10.

Challenges to Vaccinating Adolescents

Adolescent immunization is a growing field, with many new vaccines in development and new or expanded immunization recommendations on the horizon. Characteristics of adolescents and their health care are discussed, focusing specifically on the challenges of incorporating a potential recommendation to replace tetanus-diphtheria toxoid with tetanus-diphtheria-acellular pertussis vaccine during early or middle adolescence as part of routine preventive care. Using the framework created by the Centers for Disease Control and Prevention's Task Force on Community Preventive Services, three overlapping levels at which there are opportunities for vaccine intervention are reviewed: (1) health care systems (enhancing access to vaccination services); (2) health care providers (provider-based interventions); and (3) patients and families ("increasing community demand"). There are several barriers to vaccine implementation that make achieving high immunization coverage rates among adolescents a challenge. Promising interventions for improving vaccination rates at the health care system level include reducing out-of-pocket costs, expanding access to immunizations, and implementing vaccination programs in schools. Provider-based interventions for improving vaccination rates include regular assessments of immunization rate with feedback to all office personnel, provider reminders, and standing orders. Client recall and reminders, education, and requirements for school entry can assist in "increasing community demand" for vaccinations in that they motivate parents and adolescents to follow through with immunizations. Adolescents are unique from other populations. Previously studied interventions need to be tested in this age group as immunization becomes a more salient issue in adolescent health care.

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback.

BackgroundInterventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia.MethodsThe intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management.ResultsLevels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period.ConclusionsImprovements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.