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Increasing Appropriate Vaccination: Health Care System-Based Interventions Implemented in Combination

Task Force Finding

The Community Preventive Services Task Force recommends health care system-based interventions implemented in combination on the basis of strong evidence of effectiveness in increasing vaccination rates in targeted client populations.

Based on findings from 37 of the 64 included studies, the Task Force further recommends a combination of interventions that include the following:

At least one intervention to increase client demand for vaccinations, such as:

And one or more interventions that address either, or both, of the following strategies:

The interventions listed as examples for each strategy were those that showed the greatest effect on vaccination rates.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

Health care system-based interventions implemented in combination involve the use of two or more coordinated interventions to increase vaccination rates within a targeted client population. Interventions are implemented primarily in health care settings, although efforts may include additional activities within the community. Specific interventions may include client reminder and recall systems; clinic-based client education; expanded access in health care settings; provider assessment and feedback; provider reminders; and standing orders. The selection and implementation of coordinated interventions may result from an overall quality improvement effort in a health care setting.

About the Systematic Review

This Task Force finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012).

It updates and replaces the 2010 finding for Health System-Based Interventions Implemented in Combination.

The review was conducted on behalf of the 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 64 studies with 76 study arms.

  • Overall change in vaccination rates from the combination of at least two interventions: median increase of 9.0 percentage points (interquartile interval [IQI]: 4 to 21 percentage points; 58 studies, 70 study arms)
    • Increases in vaccination rates were larger when implemented in settings with low rates at baseline.
  • Change in vaccination rates from the combination of at least one intervention each from two or more strategies: median increase of 17.0 percentage points (IQI: 6 to 27 percentage points; 37 studies, 44 study arms)

Study Characteristics

  • Studies were conducted in urban (34 study arms), rural (1 study arm), and mixed urban, suburban, and rural (9 study arms) settings.
  • Interventions targeted children (29 study arms), adolescents (2 study arms), adults (14 study arms) and older adults (22 study arms).
  • Studies evaluated the following vaccines:
    • Childhood recommended (24 study arms)
    • Influenza - child (5 study arms)
    • Influenza – adult (27 study arms), child (1 study arm)
    • Pneumococcal - adult (19 study arms)
    • Tetanus booster (4 study arms)
    • Adolescent recommended (1 study arm)
  • Nearly one-third of the studies evaluated interventions that targeted populations with low socioeconomic status (22 study arms).


Based on the settings and populations from included studies, results are applicable to the following;

  • Interventions were implemented in a range of clinical settings, communities, and client populations
  • Combined approaches were effective when delivered to:
    • Children ages 12 years and younger
    • Adults ages 18 to 65 years
    • Older adults ages 65 years and older
  • Urban settings
  • For different vaccines, including:
    • Childhood vaccination series
    • Pneumococcal –adults and children
    • Influenza – adults and children
    • Tetanus booster

Economic Evidence

The five studies that qualified for the economic review assessed various combinations of provider reminders, standing orders, provider assessment and feedback, provider education, and provider incentives. All monetary values are reported in 2012 U.S. dollars.

  • The median intervention cost per person per year was $4 (IQI: $0.84 to $13; 4 studies)
  • The mean cost per additional vaccinated person was $12, ranging from $6 to $21 (3 studies)
  • One study evaluated an intensive intervention that included home visits to immunize and care for newborns. The cost reported in this study is considered an outlier and was not included in the cost estimates provided above.

Considerations for Implementation

The Task Force also recommends community-based interventions implemented in combination giving decision-makers a range of options to consider when selecting and coordinating interventions to meet local needs and resources.

Supporting Materials


Jacob V, Chattopadhyay SK, Hopkins DP, Murphy Morgan J, Pitan AA, Clymer JM, the Community Preventive Services Task Force. Increasing coverage of appropriate vaccinations: a Community Guide systematic economic review. Adobe PDF File [PDF - 440 kB] Am J Prev Med 2016;50(6):797–808.

Read other Community Guide publications about Increasing Appropriate Vaccinations in our library.

Promotional Materials

Community Guide News

More promotional materials for Community Guide reviews about Increasing Appropriate Vaccination.


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.

Sample Citation

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: health care system-based interventions implemented in combination. Last updated: MM/DD/YYYY.

Review completed: October 2014