Vaccination Programs: Community-Based Interventions Implemented in Combination

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends using a combination of community-based interventions to increase vaccination rates in targeted populations.

Interventions may aim to increase community demand, enhance access to vaccination services, or reduce missed opportunities by vaccination providers.

The full CPSTF Finding and Rationale Statement and supporting documents for Vaccination Programs: Community-Based Interventions Implemented in Combination are available in The Community Guide Collection on CDC Stacks.

Intervention

Community-based interventions implemented in combination involve two or more coordinated interventions to increase vaccination rates. Efforts involve partnerships between community organizations, local government, and vaccination providers to implement:

  • 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 interventions directed at vaccination providers (e.g., provider assessment and feedback, provider education, and provider reminder systems).

About The Systematic Review

The CPSTF 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.

Study Characteristics

  • In 13 of 18 studies, efforts combined interventions to increase community demand with interventions to enhance access
  • Conducted in urban (21 study arms) and rural (1 study arm) settings
  • Targeted children (21 study arms), adolescents (1 study arm), and adults (4 study arms)
  • Evaluated vaccines: recommended childhood series (15 study arms), influenza adults (4 study arms), pneumococcal adults (2 study arms), hepatitis B child (1 study arm)
  • Majority targeted populations with low socioeconomic status (10 study arms)

Summary of Results

Eighteen studies with 21 study arms were included.

  • Overall vaccination rates: median increase of 14 percentage points (18 studies)
    • Older adults (65 years and older): median increase of 30.8 percentage points (4 studies)
    • Children (12 years and younger): median increase of 12 percentage points (14 studies)
  • Studies combining demand interventions with access interventions: median increase of 16 percentage points (14 studies)
  • Combinations including client reminders: median increase of 13 percentage points (15 study arms)

Summary of Economic Evidence

Twenty-two studies qualified for economic review. Monetary values in 2012 U.S. dollars. They evaluated combinations of community-based interventions, such as client reminders, mass media, home visits, and client incentives. Estimates of cost and cost-effectiveness varied between studies.

  • Median intervention cost per person per year: $54 (19 studies)
  • Median cost per additional vaccinated person: $461 (19 studies)
  • Estimates higher for combinations including intensive outreach and home visits
  • Estimates lower for combinations based mostly on mail or telephone reminders

Applicability

Findings applicable to:

  • Populations with low vaccination rates: children ages 12 and younger, older adults ages 65 and older, groups with low socioeconomic status, racial and ethnic minorities
  • Different vaccines: recommended childhood series, pneumococcal adults, influenza adults
  • Urban areas

Evidence Gaps

  • How effective are these programs when applied to adolescents, or in rural settings?
  • What are the economic efficiencies of the more resource-intensive components (i.e., manual outreach and tracking, home visits)?
  • How does program effectiveness differ based on included component interventions and strategic combinations?
  • What are the most efficient ways to sustain these programs, especially for existing community-based organizations?

Implementation Considerations and Resources

Program planners should consider community characteristics, such as mobility and fragmentation of health care, when selecting interventions.

Partnerships between community organizations and vaccination providers are likely essential for effective, sustained community-based efforts.

Intensive combinations (e.g., home visits, monetary and in-kind incentives) may be necessary to increase vaccination rates in populations with continued low rates after less intensive methods have been implemented.

Crosswalks