Increasing Appropriate Vaccination: Community-Based Interventions Implemented in Combination
Task Force Finding
The Community Preventive Services Task Force recommends community-based interventions implemented in combination to increase vaccinations in targeted populations, on the basis of strong evidence of effectiveness in increasing vaccination rates.
The conclusion of strong evidence was based on findings from 18 studies that evaluated coordinated interventions to:
- Increase community demand
- Enhance access to vaccination services
- Reduce missed opportunities by vaccination providers
In 13 of the 18 studies, the community-based effort combined one or more interventions to increase community demand for vaccinations with one or more interventions to enhance access to vaccination services.
The Task Force notes that implementing manual outreach and tracking or home visits can be resource-intensive and costly, relative to other options for increasing vaccination rates. Such interventions should be used only when there is demonstrated need, and resources are available.
Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.
Community-based interventions implemented in combination involve the use of two or more coordinated interventions to increase vaccination rates within a targeted population. Efforts involve partnerships between community organizations, local government, and vaccination providers to implement and coordinate the following:
- One or more interventions to increase community demand (client reminder and recall systems, manual outreach and tracking, client or community-wide education, client incentives, client-held paper immunization records, and case management)
- One or more interventions to enhance access to vaccination services (expanded access in healthcare settings, home visits, and reduced client out-of-pocket costs)
Efforts may also include additional interventions directed at vaccination providers (e.g. provider assessment and feedback, provider education, and provider reminder systems).
About the Systematic Review
This Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (17 studies; search period 1980 - 2010) combined with more recent evidence (1 study, search period 2010 - February 2012).
It updates and replaces the 2010 finding for Community-Based Interventions Implemented in Combination.
The review was conducted on behalf of the Community Preventive Services Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to increasing appropriate vaccination.
The systematic review included 18 studies with 21 study arms.
- Overall vaccination rates: median increase of 14 percentage points (interquartile interval [IQI]: 7 to 24 percentage points; 18 studies)
- Older adults (65 years and older): median increase of 30.8 percentage points (range of values: 16 to 53 percentage points; 4 studies)
- Children (12 years and younger): median increase of 12 percentage points (IQI: 5 to 18 percentage points; 14 studies)
- Studies that combined one or more interventions to increase client and community demand with one or more interventions to enhance access to vaccination services saw a median increase in vaccination rates of 16 percentage points (IQI: 12 to 26 percentage points; 14 studies)
- Intervention combinations that included client reminders reported a median increase in vaccination rates of 13 percentage points (IQI: 8 to 18 percentage points; 15 study arms)
- Interventions were conducted in urban (21 study arms) and rural (1 study arm) settings.
- Interventions targeted children (21 study arms), adolescents (1 study arm) and adults (4 study arms).
- Studies evaluated the following vaccines:
- Childhood recommended (15 study arms)
- Influenza – adults (4 study arms)
- Pneumococcal – adults (2 study arms)
- Hepatitis B - child (1 study arm)
- Majority of the studies evaluated interventions that targeted populations with low socioeconomic status (10 study arms).
Based on the settings and populations from included studies, results are applicable to the following.
- Populations with low vaccination rates:
- Children ages 12 years and younger
- Older adults ages 65 years and older
- Groups with low socioeconomic status
- Racial and ethnic minorities
- For different vaccines, including:
- Childhood recommended
- Pneumococcal – adults
- Influenza – adults
- Urban areas
Twenty-two studies that qualified for the economic review evaluated combinations of community-based interventions such as client reminders, mass media, home visits, and client incentives. All monetary values provided are in 2012 U.S. dollars.
- Estimates of cost and cost-effectiveness varied between studies.
- The median intervention cost per person per year was $54 (IQI: $14 to $214; 19 studies).
- The median cost per additional vaccinated person was $461 (IQI: $51 to $798; 19 studies)
- Estimates were higher for combined interventions that included intensive outreach and home visits.
- Estimates were lower for combined interventions that were substantially based on mail or telephone reminders.
Considerations for Implementation
The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.
- Program planners should consider community characteristics, such as mobility and fragmentation of health care, in the selection and combination of interventions to increase vaccination rates and reduce disparities in populations with low vaccination rates.
- Partnerships between community organizations and vaccination providers are likely to be an essential component of effective, sustained community-based efforts.
- Intensive combinations of interventions (e.g. home visits, monetary and in-kind incentives) may be necessary to increase vaccination rates in populations that continue to have low rates of immunization after less intensive methods (e.g. client reminders, provider reminders) have been implemented.
- Analytic Framework [PDF - 99 kB]
- Evidence Gaps
- Summary Evidence Table - Effectiveness Review [PDF - 214 kB]
- Summary Evidence Table - Economic Review [PDF - 230 kB]
- Included Studies - Effectiveness Review
- Included Studies - Economic Review
Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Increasing appropriate vaccination: community-based interventions implemented in combination. www.thecommunityguide.org/vaccines/universally/communityinterventions.html. Last updated: MM/DD/YYYY.
Review completed: October 2014
- Page last reviewed: September 2, 2015
- Page last updated: September 2, 2015
- Content source: The Guide to Community Preventive Services