Vaccination Programs: Home Visits to Increase Vaccination Rates

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to increasing appropriate vaccination.

The systematic review included 23 studies. Of these, 20 studies with 21 study arms used a common measure of change in vaccination rates.

• Overall vaccination rates increased by a median of 11 percentage points (20 studies with 21 study arms).
• Home visits led to meaningful improvements in vaccination rates when used in the following ways:
  • With all clients in a designated population (12 study arms)
  • With only clients who did not respond to other interventions (9 study arms)
  • When focused on vaccinations alone (12 study arms)
  • When used to address vaccinations and other health concerns (9 study arms)
  • When vaccinations were provided on-site (8 study arms)
  • When clients were referred to vaccination services outside the home (13 study arms)
  • As the sole intervention (8 study arms)
  • As part of a larger healthcare system or community-based program (13 study arms)

Findings from the economic review show that home visits are resource-intensive and high-cost interventions relative to other available options.

Nine studies were included in the review (search period: 1980 – 2012). Monetary values are in reported in 2013 US dollars.

• The median for intervention group size was 575 (9 studies)
• Median cost per person was $56.30 (9 studies)
• Median cost per additional vaccinated person was $786.79 (9 studies)
• Studies were conducted in the United States (5 studies), the United Kingdom (2 studies), Australia (1 study), and Canada (1 study).
• One study looked at adolescent vaccines; eight studies evaluated interventions focused on the childhood vaccination series.

• Urban settings
• Lower income populations
• Children and adults
• Influenza and childhood vaccinations

• What are the effectiveness and economic benefits of this intervention among adolescent populations or when used in rural settings?
• What portion of home visits can be attributed solely to improving vaccination rates when home visits include other activities and objectives?

• Included studies were conducted primarily in urban settings (15 studies) and among lower income populations (10 studies).
• Studies were directed at children (15 studies) and adults (7 studies)
• Evaluated interventions addressed influenza vaccinations (7 studies) and childhood vaccinations (14 studies).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

No content is available for this section.

Effectiveness Review

Arthur AJ, Matthews RJ, Jagger C, Clarke M, Hipkin A, Bennison DP. Improving uptake of influenza vaccination among older people: a randomised controlled trial. Br J Gen Pract 2002;52:717-22.

Banach DB, Ornstein K, Factor SH, Soriano TA. Seasonal influenza vaccination among homebound elderly receiving home-based primary care in New York City. J Community Health 2012;37(1):10-4.

Bartu A, Sharp J, Ludlow J, Doherty DA. Postnatal home visiting for illicit drug-using mothers and their infants: a randomised controlled trial. Aust N Z J Obstet Gynaecol 2006; 46:419-26.

Black ME, Ploeg J, Walter SD, Hutchinson BG, Scott EAF, Chambers LW. The impact of a public health nurse intervention on influenza acceptance. Am J Public Health 1993;83:1751-3.

Bond LM, Nolan TM, Lester RA. Home vaccination for children behind in their immunisation schedule: a randomised controlled trial. Med J Aust 1998;168:487-90.

Browngoehl K, Kennedy K, Krotki K, Mainzer H. Increasing immunization: a Medicare managed care model. Pediatrics 1997;99(1):e4.

Dalby DM, Sellors JW, Fraser FD, Fraser C, van Ineveld C, Howard M. Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial. CMAJ 2000;162:497-50.

Deuson RR, Brodovicz KG, Barker L, Zhou FJ, Euler GL. Economic analysis of a child vaccination project among Asian Americans in Philadelphia, PA. Arch Pediatr Adolesc Med 2001;155:909-14.

Dietz VJ, Baughman AL, Dini EF, Stevenson JM, Pierce BK, Hersey JC. Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics. Arch Pediatr Adolesc Med 2000;154:184-9.

El-Mohandes AA, Katz KS, El-Khorazaty MN, McNeely JD, Sharps PW, Jarrett MH, et al. The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study. Pediatrics 2003;111:1324-32.

Johnston BD, Huebner CE, Anderson ML, Tyll LT, Thompson RS. Healthy steps in an integrated delivery system: child and parent outcomes at 30 months. Arch Pediatr Adolesc Med 2006;160:793-800.

Kitzman H, Olds DL, Henderson CR, Hanks C, Cole R, Tatelbaum R, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA 1997;278:644-52.

LeBaron CW, Starnes DM, Rask KJ. The impact of reminder-recall interventions on low vaccination coverage in an inner-city population. Arch Pediatr Adolesc Med 2004;158:255-61.

Lemstra M, Rajakumar D, Thompson A, Moraros J. The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children. Paediatrics and Child Health 2011;16(1):e1-5.

Margolis PA, Stevens R, Bordley WC, Stuart J, Harlan C, Keyes-Elstein L, et al. From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children. Pediatrics 2001;108(3):e42.

Nicholson KG, Wiselka MJ, May A. Influenza vaccination of the elderly: perceptions and policies of general practitioners and outcome of the 1985-86 immunization programme in Trent, UK. Vaccine 1987;5:302-6.

Nuttall D. The influence of health professionals on the uptake of the influenza immunization. Br J Community Nurs 2003 Sep;8(9):391-6.

Parry MF, Grant B, Iton A, Parry PD, Baranowsky D. Influenza vaccination: A collaborative effort to improve the health of the community. Infect Control Hosp Epidemiol 2004;25:929-32.

Rodewald LE, Szilagyi PG, Humiston SG, Barth R, Kraus R, Raubertas RF. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics 1999; 103(1):31-8.

Rosenberg Z, Findley S, McPhiliips S, Penachio M, Silver P. Community-based strategies for immunizing the ‘hard-to-reach’ child: the New York State Immunization and Primary Health Care Initiative. Am J Prev Med 1995;11:14-20.

Szilagyi PG, Schaffer S, Shone L, Barth R, Humiston SG, Sandler M, et al. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002;110:e58.

Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Arch Pediatr Adolesc Med 2011;165(6):547-53.

Wood D, Halfon N, Donald SC, Mazel RM, Schuster M, Hamlin JS, et al. Increasing immunization rates among inner-city, African American children. A randomized trial of case management. JAMA 1998; 279:29-34.

Economic Review

Bond LM, Nolan TM, Lester RA. Home vaccination for children behind in their immunisation schedule: a randomised controlled trial. Med J Aust 1998;168(10):487-90.

Jefferson N, Sleight G, Macfarlane A. Immunisation of children by a nurse without a doctor present. BMJ Clin Res 1987;294(6569):423. http://dx.doi.org/10.1136/bmj.294.6569.423.

Jones AE. Domiciliary immunisation for preschool child defaulters. BMJ Clin Res 1984;289(6456):1429. http://dx.doi.org/10.1136/bmj.289.6456.1429.

LeBaron CW, Starnes DM, Rask KJ. The impact of reminder-recall interventions on low vaccination coverage in an inner-city population. Arch Pediatr Adolesc Med 2004;158(3):255-61. http://dx.doi.org/10.1001/archpedi.158.3.255.

Lemstra M, Rajakumar D, Thompson A, Moraros J. The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children. Pediatr Child Health 2011;16(1):e1.

Rask KJ, LeBaron CW, Starnes DM. The costs of registry-based immunization interventions. Am J Prev Med 2001;21(4):267-271. http://dx.doi.org/10.1016/S0749-3797(01)00370-1.

Rodewald LE, Szilagyi PG, Humiston SG, Barth R, Kraus R, Raubertas RF. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics 1999;103(1):31-38. http://dx.doi.org/10.1542/peds.103.1.31.

Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Arch Pediatr Adolesc Med 2011;165(6):547. http://dx.doi.org/10.1001/archpediatrics.2011.73.

Szilagyi PG, Schaffer S, Shone L, et al. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002;110(5):e58. http://dx.doi.org/10.1542/peds.110.5.e58.

Vora S, Verber L, Potts S, Dozier T, Daum RS. Effect of a novel birth intervention and reminder-recall on on-time immunization compliance in high-risk children. Hum Vaccin 2009;5(6):395. http://dx.doi.org/10.4161/hv.5.6.7282.

Wood D, Halfon N, Donald-Sherbourne C, et al. Increasing immunization rates among inner-city, African American children. JAMA 1998;279(1):29. http://dx.doi.org/10.1001/jama.279.1.29.

Effectiveness Review

The CPSTF findings are based on studies included in the original review (search period 1980-1997) combined with studies identified in the updated search (search period 1997- February 2012). Reference lists of articles reviewed as well as lists in review articles were also searched, and members of our coordination team were consulted for additional references.

Details of the original search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included in the review, a study had to:

• have a publication date of 1980 1997;
• address universally recommended adult, adolescent, or childhood vaccinations;
• be a primary study rather than, for example, a guideline or review;
• take place in an industrialized country or countries;
• be written in English;
• meet the evidence review and Guide chapter development team’s definition of the interventions; provide information on one or more outcomes related to the analytic frameworks; and
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Details of the update search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing the effectiveness of Vaccine Preventable Disease interventions in improving vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. Reference lists of articles reviewed as well as lists in review articles were also searched, and subject matter experts consulted for additional references. To be included in the updated review, a study had to:

• have a publication date of 1997- February 2012;
• evaluate vaccinations with universal recommendations;
• meet the evidence review and Guide chapter development team’s definition of the interventions;
• be a primary research study with one or more outcomes related to the analytic frameworks;
• take place in an high income country or countries;
• be written in English
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive

Search Terms

1. Immunization
2. Vaccination
3. Immunization Programs

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

• Immunization
• Vaccination
• Immunization Programs

To be included in the updated review, a study had to do the following:

• Have a publication date of 1997- February 2012
• Evaluate vaccinations with universal recommendations
• Meet the evidence review and Community Guide review team’s definition of the interventions
• Be a primary research study with one or more outcomes related to the analytic framework(s)
• Take place in a high income country or countries
• Be written in English; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.

Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

• Have a publication date of 1980 1997
• Address universally recommended adult, adolescent, or childhood vaccinations
• Be a primary study rather than, for example, a guideline or review
• Take place in an industrialized country or countries
• Be written in English
• Meet the definition of the interventions
• Provide information on one or more outcomes related to the analytic frameworks; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

• Home visits that serve multiple purposes (e.g., parent education, home safety assessment, vaccination promotion) may be logistically challenging.
• Timing for vaccinations and other home visit services may be difficult (i.e. seasonal influenza and childhood series).
• Clients may not open their homes to strangers because of security or privacy concerns.
• Resource-intensive interventions such as home visits may be necessary to increase vaccination rates among populations with very low vaccination rates or communities where disparities in coverage persist. Interventions are likely to cost less if used as part of a stepped approach that begins with something less resource-intensive such as client reminder and recall systems.
• Included studies noted that home visits give providers additional opportunities to assess clients’ undetected health risks or medical problems.
• Although no specific harms were identified in the included studies, potential harms described in the literature include difficulties managing clients who have adverse reactions to vaccinations, and stigmatization of socially or economically disadvantaged clients who are identified as needing special services.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children who get no recommended vaccines by age 2 years — IID‑02
• Maintain the vaccination coverage level of 1 dose of the MMR vaccine in children by age 2 years — IID‑03
• Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten — IID‑04
• Increase the coverage level of 4 doses of the DTaP vaccine in children by age 2 years — IID‑06
• Increase the proportion of people who get the flu vaccine every year — IID‑09
• Increase the proportion of adults age 19 years or older who get recommended vaccines — IID‑D03