Increase Immunization Rates Research Articles

Observations Illustrating the Use of Health Informatics to Link Public Health Immunization Registries and Pharmacies to Increase Adult Immunization Rates and Improve Population Health Outcomes.

The Health Information Technology for Economic and Clinical Health (HITECH) Act encourages health information exchange between clinical care and public health through Meaningful Use measures. Meaningful Use specifically identifies objectives to support a number of public health programs including immunizations, cancer registries, syndromic surveillance, and disease case reports. The objective is to improve public and population health. Stage 2 of Meaningful Use focused on compliance to sending of information to public health. The next phase focuses on bi-directional information exchange to support immunization intelligence and to empower providers, pharmacists, and the consumer.The HITECH Act Stage 2 initiative provided incentive and motivation for healthcare providers to encourage their Electronic Medical Record (EMR) vendors to implement data exchanges with public health, with the expected result being timely awareness of health risks. The empowerment nugget in the HITECH Act is not in the compliance reporting to public health. The nugget is the ability for a provider to receive relevant information on the patient or consumer currently in front of them or to those they will connect to through their outreach efforts.The ability for public health to retain current immunization records of individuals from a variety of providers supports their program goals to increase immunization rates and mitigate the risk of vaccine-preventable disease (VPD). The ability for providers to receive at the point of service more complete immunization histories integrated with decision support enhances their delivery of care, thereby reducing the risk of VPD to their patients. Indirectly payers benefit through healthcare cost savings and when the focus is expanded from a health model to a business model, there are significant return on investment (ROI) opportunities that exponentially increase the value of a bi-directional immunization data exchange. This paper will provide descriptions of case examples to demonstrate the value of electronic data exchanges when pharmacy immunization providers and public health work together.

APhA recognizes 2016’s Immunization Champions

Clinic, a walk-in clinic for patients aged 15 years and older, at a large Indian Health Service medical center in Phoenix. But providing only 10% of the vaccines given on campus, the clinic’s reach isn’t great enough for Van Lew. “We want vaccines addressed at every visit,” Van Lew said. Primary care alone, she noted, can’t cover all adult vaccines. Patients may have many specialty visits between less frequent primary care visits at the time immunizations are due. Van Lew aimed to standardize the approach to immunizations across the medical center campus. Through education campaigns, she has motivated nurses to embrace CDC recommendations to address immunizations at every visit. She successfully advocated for a protocol that would allow all nurses to offer routine vaccines anywhere on campus. In 2015, she provided 20 education sessions to more than 250 providers across specialties and professions to increase vaccine awareness, integrate vaccination into workflows, and devise better ways to use electronic health records and screening tools in this endeavor. Nationally, Van Lew has collaborated on research with CDC and the National Center for Immunization and Respiratory Diseases to better understand and improve adult vaccination rates. “I get involved in so many different arenas because there’s so many different ways we can impact vaccination rates—not just in the clinic.” In 2015, on Van Lew’s watch, more than 44,000 vaccines were administered to children and adults in her health system, substantially increasing immunization rates for zoster, human papillomavirus, tetanus, diphtheria, and pertussis.

Characterizing the Access of Clinical Decision Support Offered by Immunization Information System in Minnesota.

Background: Healthy People 2020 aims to improve population health by increasing immunization rates to decrease vaccine-preventable infectious diseases. Amongst the many strategies, role of immunization information systems (IIS) are recognized by studies and taskforce reports. IIS are unique in their offering of clinical decision support for immunizations (CDSi) which are utilized by healthcare providers. Federal initiatives such as Meaningful Use (MU) and Affordable Care Act (ACA) aim to improve immunization rates through use of technology and expanding access to immunization services respectively. MU, the Electronic Health Record (EHR) incentive program includes use of IIS CDSi functionality as part of Stage 3. It is essential to understand access and use patterns of IIS CDSi, so as to utilize it better to improve immunization services.Objectives: To understand the utilization of clinical decision support for immunizations (CDSi) offered by immunization information system in Minnesota and to analyze the variability of its use across providers and EHR implementations.Methods: IIS in Minnesota (Minnesota Immunization Information Connection: MIIC) offers CDSi that is accessed through EHRs and branded as Alternate Access (AA). Data from MIIC and technical documents were reviewed to create details on organizations which implemented AA functionality. Data on EHR adoption in clinics and local health departments was obtained from Minnesota eHealth assessment reports. Data on access were tracked from January 2015 through mid-October 2015 through weekly specialized reports to track the queries by organization, volume and day of the week. Data were analyzed, findings were synthesized and reviewed with subject matter experts.Results: Currently 25 healthcare systems/organizations which represent 599 individual provider sites have implemented the AA functionality. Analysis of their EHR platform pointed to two EHRs (Epic and PH-Doc) as dominant products in Minnesota for private and public providers respectively. Use of this function was even across study time period. The query volume correlated to size of the organization, with the exception of an outlier organization with huge query count. Query was able to successfully locate a single matching record for 59% of searches, could not find a record for 5% and 31% resulted in blank/error and the match rates varied across health systems.Conclusion: High EHR adoption offers a great opportunity to promote use of IIS CDSi at point of care. Analysis did not track use at individual clinic level and how the queries were being generated. Additional research is needed to understand the provider level use of this CDSi and other organizational and technical factors which influence access to IIS. This is essential for IIS as they execute projects to improve population-level immunization rates, plan provider outreach and prioritize their system enhancements to meet federal requirements.

Pharmacist-administered immunizations: What does your state allow?

As trusted and highly accessible health care providers, pharmacists are well positioned to increase the public's access to immunizations. The use of pharmacists to administer immunizations has evolved rapidly over the past 2 decades. In 1995, only nine states allowed pharmacists to immunize. Today, pharmacists have authority to administer immunizations in all 50 states, the District of Columbia, and Puerto Rico.1,2 Although the extent of pharmacists' authority varies by state, great progress has been made in modernizing states' scope of practice laws and regulations to allow pharmacists to increase immunization rates across the lifespan, while working in coordination and collaboration with the rest of the immunization neighborhood.

Election 2015: Communicating pharmacy's priorities.

Canadians will be heading to the polls in a federal election widely expected to occur October 19, 2015. Although the pundits would argue that political parties have been campaigning for months already, most election-related activities, such as public debates and door-to-door campaigning by candidates, will begin to ramp up in late summer and fall. As the 2015 federal election campaign moves into high gear, the Canadian Pharmacists Association (CPhA) has identified key recommendations and messages for federal political candidates on 3 key national issues of importance to the profession. These 3 issues include the following: Pan-Canadian Pharmacare Program: CPhA is seeking commitment from all federal political parties to work with the provinces/territories, health care professionals and other stakeholders towards the development of a pan-Canadian pharmacare program. Such a program must address coverage gaps between public and private systems, protect Canadians from undue financial hardship and guarantee access to a stable supply of clinically and cost-effective medications. Furthermore, the inclusion of access to pharmacy services under a pharmacare model is key to achieving better health outcomes and cost savings. National Plan for e-Prescribing: CPhA is calling on all parties to work with the provinces/territories, health care professionals and other stakeholders to implement a seamless e-prescribing system in Canada. CPhA is looking for the federal government to support the development and implementation of a common national standard for e-prescribing that ensures that Canadians’ prescription information can be more easily shared and accessed between relevant health providers, while respecting patient privacy and confidentiality. Strengthened National Immunization Strategy for Canada: Given Canada’s relatively low rates of immunization compared with other industrialized countries, CPhA is calling for a revamped National Immunization Strategy. The goal of a revamped strategy would be to increase immunization rates through a comprehensive approach that would include further expanding pharmacists’ scope of practice to administer vaccines. The National Strategy would also target increased research, comparable access and enhanced education/outreach, including building a partnership with the provinces/territories and health professionals to increase public awareness of the importance of vaccinations. In the lead-up to October 19, CPhA is encouraging pharmacists and other Canadians to promote and discuss these key recommendations with political candidates from all parties. To assist you, CPhA has assembled an election website at www.pharmacists.ca/election. On this website, you will find a print-ready brochure that summarizes the key recommendations, a more detailed platform document that provides background and rationale for these recommendations and an online tool that allows you to quickly and easily contact the candidates in your riding and send them messages of support for the above-mentioned priorities. Elections provide voters with an excellent opportunity to learn about and pin down the views of candidates and political parties on specific issues. This election is no different. Go to www.pharmacists.ca/election to share your thoughts with your candidates, and help CPhA advance these core issues. ■

Implementation and Evaluation of a School-Based Human Papillomavirus Vaccination Program in Rural Kentucky.

Human papillomavirus (HPV) vaccination rates remain marginal across the U.S., including Kentucky, a state recognized for increased HPV-related cancer burden. School-based HPV immunization programs may be a viable approach to improving vaccination initiation and completion rates among youth. Therefore, the purpose of this study was to design, implement, and evaluate a school-based HPV vaccination program conducted in rural south-central Kentucky. Guided by evidence-based approaches to increasing immunization rates, the practical expertise of school nursing staff, and a detailed study protocol, academic and health department-based investigators implemented an HPV vaccination project in two high schools during the 2012-2013 academic year; data were analyzed in 2013-2014. Rates of returned parental consent forms, parental consent/declination, and HPV vaccination rates were documented. At the beginning of the school year, all 935 students at the two schools were given HPV vaccination parental consent forms. Five hundred eleven students returned consent forms (55% return rate), and 447 of these students were HPV vaccine naïve (87%). Of these students, 315 (70%) initiated the vaccine series, with 276 (62%) completing the entire three-dose series, so that 88% of students initiating the vaccine series successfully completed the series. In estimating rates for the entire school body, 45% of students had received all three doses by the end of the project. Despite study design limitations, results of this project provide further evidence about school-based immunization programs as an effective strategy for improving HPV vaccination rates among Kentucky and U.S. adolescents.

Pharmacists as immunizers: a survey of community pharmacists' willingness to administer adult immunizations.

Adult immunization rates worldwide fall below desired targets. Pharmacists are highly accessible healthcare providers with the potential to increase immunization rates among adults by administering vaccines in their practice setting. To determine the attitudes of community-based Canadian pharmacists with respect to expanding their scope of practice to include administration of immunizations. An internet-based survey was emailed to community pharmacists across Canada. The survey was piloted through focus groups for qualitative feedback, tested for content validity, and test-retest reliability prior to dissemination. There were 495 responses to the survey. The majority (88 %) agreed that pharmacists as immunizers would increase public access, improve rates (84 %), and be acceptable to the public (72 %). However, only 68 % agreed that pharmacists should be permitted to immunize. The majority of respondents (90 %) agreed that certification in vaccine administration should be required for pharmacists to administer vaccines. Pharmacists identified education, reimbursement, and negative interactions with other providers as barriers to pharmacists administering vaccines. Canadian pharmacists are willing to expand their scope of practice to include immunization. However, implementation requires professional development and certification in vaccine administration.

Increasing engagement of clinicians in adult immunizations: Reflections on a decade and a half of research

Increasing engagement of clinicians in adult immunizations: Reflections on a decade and a half of research

More evidence on the impact of India's conditional cash transfer program, Janani Suraksha Yojana: quasi-experimental evaluation of the effects on childhood immunization and other reproductive and child health outcomes.

BackgroundIn 2005, India established a conditional cash transfer program called Janani Suraksha Yojana (JSY), to increase institutional delivery and encourage the use of reproductive and child health-related services.ObjectiveTo assess the effect of maternal receipt of financial assistance from JSY on childhood immunizations, post-partum care, breastfeeding practices, and care-seeking behaviors.MethodsWe use data from the latest district-level household survey (2007–2008) to conduct a propensity score matching analysis with logistic regression. We conduct the analyses at the national level as well as separately across groups of states classified as high-focus and non-high-focus. We carry out several sensitivity analyses including a subgroup analysis stratified by possession of an immunization card.ResultsReceipt of financial assistance from JSY led to an increase in immunization rates ranging from 3.1 (95%CI 2.2–4.0) percentage points for one dose of polio vaccine to 9.1 (95%CI 7.5–10.7) percentage points in the proportion of fully vaccinated children. Our findings also indicate JSY led to increased post-partum check-up rates and healthy early breastfeeding practices around the time of childbirth. No effect of JSY was found on exclusive breastfeeding practices and care-seeking behaviors. Effect sizes were consistently larger in states identified as being a key focus for the program. In an analysis stratified by possession of an immunization card, there was little to no effect of JSY among those with vaccination cards, while the effect size was much larger than the base case results for those missing vaccination cards, across nearly all immunization outcomes.ConclusionsEarly results suggest the JSY program led to a significant increase in childhood immunization rates and some healthy reproductive health behaviors, but the structuring of financial incentives to pregnant women and health workers warrants further review. Causal interpretation of our results relies on the assumption that propensity scores balance unobservable characteristics.

VA partners with community pharmacies to improve immunization rates

In today’s health care landscape, information sharing and integration among medical entities are critical elements to improving patient care. The U.S. Department of Veterans Affairs (VA) recently launched an innovative program called the VA Retail Care Coordination Program, which integrates a veteran’s immunization information from a community pharmacy into the VA’s health records system. In today’s health care landscape, information sharing and integration among medical entities are critical elements to improving patient care. The U.S. Department of Veterans Affairs (VA) recently launched an innovative program called the VA Retail Care Coordination Program, which integrates a veteran’s immunization information from a community pharmacy into the VA’s health records system. This novel program is designed to improve immunization rates across the VA population by automating clinical reminders for immunizations, giving a more real-time view of the VA’s total population immunization rates, and identifying high-risk individuals who may not have received immunizations. “Typically when a veteran receives a flu shot at a retail pharmacy, the veteran reports back to the VA about the shot, and it was a manual process,” said Douglas Trauner, Entrepreneur in Residence at the VA Center for Innovation (VACI). “This new program fully automates this process. It focuses on how the VA can scale access to immunizations at retail pharmacist and other health care outlets outside the VA.” VACI was launched in 2010 with the goal of introducing new technologies, methods, and processes into the VA system. The VACI identifies, tests, and evaluates innovative solutions to help VA better serve veterans by targeting endeavors that can be developed, piloted, and evaluated for broader deployment. The concept of immunization information integration and increasing immunization rates was Trauner’s brainchild. The VA currently tracks an ongoing week-by-week immunization status of the VA population during influenza season, and there is a major effort to keep immunization rates up. According to Trauner, VA immunizations rates are typically good, around mid-70% in the population of adults older than age 65 years, but the VA’s target is to reach a 90% immunization rate for certain populations. Trauner believes that tracking influenza vaccinations received by veterans at community partners will give a clearer picture of immunization rates and ultimately improve patient care. The big question, according to Trauner, is how the VA can work more effectively with community partners. “We know that veterans are already receiving immunizations when they go the pharmacy, but the VA has no visibility to that,” he said. The VA Retail Care Coordination Program was piloted in 2013 at more than 800 Walgreens locations in Florida and included around 2,000 individuals. “The VA has about 80 locations in Florida, so the program gave veterans 10 times the access to immunizations,” said Trauner. HIGHLIGHTS■The VA Retail Care Coordination Program is being rolled out nationwide at more than 8,000 Walgreens locations.■VA is also piloting a program in which around 75,000 VA-funded influenza vaccinations will be given to any enrolled veteran regardless of insurance coverage. ■The VA Retail Care Coordination Program is being rolled out nationwide at more than 8,000 Walgreens locations.■VA is also piloting a program in which around 75,000 VA-funded influenza vaccinations will be given to any enrolled veteran regardless of insurance coverage. Based on the success of the pilot, the VA Retail Care Coordination Program is being rolled out nationwide at more than 8,000 Walgreens locations. “In addition, we are pleased to be offering approximately 75,000 VA-funded flu shots for any enrolled veteran regardless of insurance coverage,” said Trauner. “Our intent is to make the program available nationally through a variety of retail partners or organizations with large regional or national footprints who are providing immunizations.”“[The new program] focuses on how the VA can scale access to immunizations at retail pharmacist and other health care outlets outside the VA.” As the Entrepreneur in Residence at the VACI, Trauner’s role is to figure out ways for the VA to scale more effectively with non-VA entities. The VA Retail Care Coordination Program “is an opportunity for the VA to work more effectively with non-VA providers. We see this as a very good example of that public-private partnership capability in a way that supports a need for veterans,” said Trauner.

ECDC Social marketing toolkit

Europe has committed to eliminate measles and rubella by 2015. This requires sustained vaccination coverage above 95%. Recently, measles has re-emerged in the EU, due to insufficient vaccination coverage caused by a complex set of factors affecting vaccine uptake. ECDC research identified a priority need for evidence-based methods and tools to support health managers and practitioners in their communication challenges related to increasing immunization rates. Social marketing is as …

HHS--supporting global immunization through policies, programs, and partnerships.

HHS--supporting global immunization through policies, programs, and partnerships.

Vaccination management and vaccination errors: a representative online-survey among primary care physicians.

BackgroundEffective immunizations require a thorough, multi-step process, yet few studies comprehensively addressed issues around vaccination management.ObjectivesTo assess variations in vaccination management and vaccination errors in primary care.MethodsA cross sectional, web-based questionnaire survey was performed among 1157 primary physicians from North Rhine-Westphalia, Germany: a representative 10% random sample of general practitioners (n = 946) and all teaching physicians from the University Duisburg-Essen (n = 211). Four quality aspects with three items each were included: patient-related quality (patient information, patient consent, strategies to increase immunization rates), vaccine-related quality (practice vaccine spectrum, vaccine pre-selection, vaccination documentation), personnel-related quality (recommendation of vaccinations, vaccine application, personnel qualification) and storage-related quality (storage device, temperature log, vaccine storage control). For each of the four quality aspects, “good quality” was reached if all three criteria per quality aspect were fulfilled. Good vaccination management was defined as fulfilling all twelve items. Additionally, physicians’ experiences with errors and nearby-errors in vaccination management were obtained.ResultsMore than 20% of the physicians participated in the survey. Good vaccination management was reached by 19% of the practices. Patient-related quality was good in 69% of the practices, vaccine-related quality in 73%, personnel-related quality in 59% and storage-related quality in 41% of the practices. No predictors for error reporting and good vaccination management were identified.ConclusionsWe identified good results for vaccine- and patient-related quality but need to improve issues that revolve around vaccine storage.

Engaging Communities to Enhance and Strengthen Medical Education: Rationale and Summary of Experience

Change in medical education through curricular reform has gained momentum in recent years due to multiple external forces. In addition, health access issues have coalesced to require that a broad set of voices be heard and served through the current health-care system. This requires that medical professionals be especially attuned to their communities and the multitude of cultures and voices that reside within them. In an attempt to illustrate how these changes can be practically incorporated into a medical education curriculum, this article highlights one institution's experience with a community-based health solution. The Georgetown University School of Medicine (GUSOM) Service-Learning program provides an example of how a community-based health solution can bridge the gap of social and clinical medicine through the framework of systems thinking principles and focus on teamwork to facilitate collaboration among faculty, community members, and students. This article will briefly explain the history, learning objectives, and context of the program, and in addition, provide a brief case study examining how the program engaged the problem of increasing immunization rates in the Washington, DC area.

Age-specific strategies for immunization reminders and recalls: a registry-based randomized trial.

Although previous studies have found reminder/recall to be effective in increasing immunization rates, little guidance exists regarding the specific ages at which it is optimal to send reminder/recall notices. To assess the relative effectiveness of centralized reminder/recall strategies targeting age-specific vaccination milestones among children in urban areas during June 2008-June 2009. Three reminder/recall strategies used capabilities of the Michigan Care Improvement Registry (MCIR), a statewide immunization information system: a 7-month recall strategy, a 12-month reminder strategy, and a 19-month recall strategy. Eligible children were randomized to notification (intervention) or no notification groups (control). Primary study outcomes included MCIR-recorded immunization activity (administration of ≥1 new dose, entry of ≥1 historic dose, entry of immunization waiver) within 60 days following each notification cycle. A total of 10,175 children were included: 2,072 for the 7-month recall, 3,502 for the 12-month reminder, and 4,601 for the 19-month recall. Immunization activity was similar between notification versus no notification groups at both 7 and 12 months. Significantly more 19-month-old children in the recall group (26%) had immunization activity compared to their counterparts who did not receive a recall notification (19%). Although recall notifications can positively affect immunization activity, the effect may vary by targeted age group. Many 7- and 12-month-olds had immunization activity following reminder/recall; however, levels of activity were similar irrespective of notification, suggesting that these groups were likely to receive medical care or immunization services without prompting.

A179: Improving Pneumococcal Vaccination Rate in the Pediatric Rheumatology Clinic

Background/Purpose:This quality improvement project was conducted to increase pneumococcal vaccination rates in eligible Pediatric Rheumatology Clinic patients. Streptococcus pneumoniae is a leading cause of bacteremia, meningitis, pneumonia, sinusitis, and acute otitis media. Many patients in the Pediatric Rheumatology Clinic are at increased risk of pneumococcal disease secondary to a deficient immune system and/or immunosuppressive medications. Infections remain one of the leading causes of hospitalization and death in patients with certain rheumatic diseases. The Centers for Disease Control and Prevention recommends both the 13‐valent pneumococcal conjugate vaccine (PCV13) and the 23‐valent pneumococcal polysaccharide vaccine (PPSV23) for this high‐risk population.Methods:Baseline immunization rates were assessed for eligible clinic patients over a four week period. Eligible patients include children at least two years old and adults with systemic lupus erythematosus and patients currently on or starting an immunosuppressive medication. Interventions included a presentation to rheumatology providers and nurses, creation of clinic document with immunization algorithm, previsit planning, placing reminders on patient clinic forms, and sending letters to out‐of‐state patients. Chart reviews of eligible patients occurred throughout the study period. Control charts were established to portray change in immunization rate.Results:The pre‐intervention immunization rate for 90 eligible Pediatric Rheumatology Clinic patients was 6.7% for PCV13, 8.9% for PPSV23, and 0% for both vaccines. Data from 53 weeks were analyzed following the interventions for a total of 1123 eligible patient visits and 306 separate patients. The average post‐intervention immunization rate was 48.4% for PCV13, 28.4% for PPSV23, and 23.3% for both vaccines. These rates are statistically higher than the pre‐intervention rates (all p < 0.001). There was an increase in immunization rates following each major intervention. imageConclusion:Pneumococcal vaccination is an important part of the care for systemic lupus erythematosus patients and pediatric rheumatology patients on immunosuppressive medications. Simple interventions through this quality improvement project led to a marked increase in pneumococcal vaccination rates in this vulnerable population.

How Might Immunization Rates Change if Cost Sharing is Eliminated?

There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines. We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not. We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations. The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.

Notes from the Field: Planting, Nurturing, and Watching Things Grow

Editors' Note: We invited a sample of AJPM's Editorial Board, supplement guest editors, and longtime colleagues and contributors to share their experiences and impressions of the impact of AJPM on their respective domains. We were particularly fond of Ken Powell's analogy to being "tenders of the planted seed"--as planters, weeders, and harvesters--watching and nurturing the growth of AJPM, and have elected to lead with his commentary.

Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis.

To assess the effectiveness of interventions to improve the mental health of women in the perinatal period and to evaluate any effect on the health, growth and development of their offspring, in low- and middle-income (LAMI) countries. Seven electronic bibliographic databases were systematically searched for papers published up to May 2012 describing controlled trials of interventions designed to improve mental health outcomes in women who were pregnant or had recently given birth. The main outcomes of interest were rates of common perinatal mental disorders (CPMDs), primarily postpartum depression or anxiety; measures of the quality of the mother-infant relationship; and measures of infant or child health, growth and cognitive development. Meta-analysis was conducted to obtain a summary measure of the clinical effectiveness of the interventions. Thirteen trials representing 20 092 participants were identified. In all studies, supervised, non-specialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children. The pooled effect size for maternal depression was -0.38 (95% confidence interval: -0.56 to -0.21; I (2) = 79.9%). Where assessed, benefits to the child included improved mother-infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates. In LAMI countries, the burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists. Such interventions benefit both women and their children, but further studies are needed to understand how they can be scaled up in the highly diverse settings that exist in LAMI countries.

A Quality Improvement Evaluation Case Study

Quality improvement (QI) is increasingly recognized as an important strategy to improve healthcare services and health outcomes, including reducing health disparities. However, there is a paucity of evidence documenting the value of QI to public health agencies and services. The purpose of this project was to support and assess the impact on the outcomes and organizational culture of a QI project to increase immunization rates among children aged 2 years (4:3:1:3:3:1 series) within a large public health agency with a major pediatric health mission. The intervention consisted of the use of a model-for-improvement approach to QI for the delivery of immunization services in public health clinics, utilizing plan-do-study-act cycles and multiple QI techniques. A mixed-method (qualitative and quantitative) model of evaluation was used to collect and analyze data from June 2009 to July 2011 to support both summative and developmental evaluation. The Florida Immunization Registry (Florida SHOTS [State Health Online Tracking System]) was used to monitor and analyze changes in immunization rates from January 2009 to July 2012. An interrupted time-series application of covariance was used to assess significance of the change in immunization rates, and paired comparison using parametric and nonparametric statistics were used to assess significance of pre- and post-QI culture items. Up-to-date immunization rates increased from 75% to more than 90% for individual primary care clinics and the overall county health department. In addition, QI stakeholder scores on ten key items related to organizational culture increased from pre- to post-QI intervention. Statistical analysis confirmed significance of the changes. The application of QI combined with a summative and developmental evaluation supported refinement of the QI approach and documented the potential for QI to improve population health outcomes and improve public health agency culture.