Name

HEALTH PROMOTION IMPLEMTATION & EVALUATION

LITERATURE REVIEW


i

Contents
1. Introduction ................................................................................................................................................................................................................. 1
2. Review ......................................................................................................................................................................................................................... 3
2.1 Methodology ........................................................................................................................................................................................................ 3
2.2 Results .................................................................................................................................................................................................................. 6
3. Summary .................................................................................................................................................................................................................... 20
4. Conclusion.................................................................................................................................................................................................................. 23
5. References ..................................................................................................................................................................................................................... 24




1

1. Introduction
Childhood immunisation rates on the Sunshine Coast, Queensland are among the
lowest in Australia, placing the community at risk of potentially life threatening
diseases and possible outbreak of measles and whooping cough.
(1)
The Australian
Childhood Immunisation Register (ACIR) indicated that 89% of children under two
were fully immunised on the Sunshine Coast in 2011-2012.
(1)
The World Health
Organisation advocates an estimated herd immunity of 9395% for measles
(1)
and the
US Centres for Disease Control and Prevention estimates herd immunity of 92-94% for
pertussis.
(1)
In 2010, there were 785 cases of pertussis (whooping cough) recorded on
the Sunshine Coast.
(2)
In 2009 a Sunshine Coast high school had 25 cases of measles
linked to an imported case from India; none of the 25 cases were vaccinated at the
time of exposure.
(3)
Risk of serious disease warrants investigation into health
promotion strategies to improve immunisation rates on the Sunshine Coast.
This literature review critically examines a range of health promotion strategies that
have been implemented to increase immunisation uptake. An inclusion/exclusion
methodology was applied in order to target the scope of health promotion strategies.
The review methodology identified that the most effective strategies for increasing
immunisation rates were policy and financial incentives, provider-based strategies and
communication interventions.
Twenty articles reporting on health promotion projects were examined using a Schema
for evaluating public health interventions.
(4)
The review investigated the context and
theoretical foundations of these programs, the methods used to evaluate results and
2

interpreted the quality and applicability of the health promotion strategies. Projects
were examined for evidence of meeting the Ottawa Charter areas for Health
Promotion
(5)
. These findings are described in the Results section, and are further
discussed in the Summary section of this literature review.













3

2. Review
2.1 Methodology
Types of studies
This review will include randomised control tests, comparative studies and case series.
To examine interventions which are appropriate to the current context and the Ottawa
Charter, studies must have been published after 2002.
Types of participants
Participants will be preschool aged children aged 0-6, parents or guardians of
preschool aged children, healthcare workers in hospitals and general practices, in
Australian and international settings.
Types of interventions
Interventions must include impact on immunisation rates as an objective.
Interventions which include primary service uptake may also be included.
Types of outcome measures
Increase in immunisation uptake will be the primary outcome. Other outcome
measures will include: improved parent or health care worker immunisation
knowledge, and change in attitude towards immunisation.



4

Search methods for identification of studies
Extensive searches will be performed DL to collect all relevant studies available by
September 2013. Searches will only include peer-reviewed journal articles. Only the
English-language literature will be included in the searches.
Electronic searches
Electronic databases that will be searched include: PubMed, ScienceDirect and Google
Scholar. Text words and medical subject heading (MeSH) terms, for example vaccine,
immunisation, will be used. These terms will be used in varying combinations. Table 1
shows the main search strategy we will use.
Table 1: Search strategy
Search PubMed
1 (immunisation) OR (immunization) OR (vaccination) OR (vaccine)
2 (rates) OR (uptake) OR (increase) OR (coverage)
3 (strategy) OR (intervention)
4 (legislation) OR (policy) OR (laws)
5 (Communication) OR (education) OR (attitudes)
6 (health care workers) OR (physician) OR (nurse) OR (midwives) OR
(health professional)
7 1 and 2
8 1 and 3
9 1,2 and 3
10 1 and 4
11 1 and 5
12 1, 5 and 6

5

Table 2: Search Strategy
Search ScienceDirect
1 (immunisation) OR (immunization) OR (vaccination) OR (vaccine)
2 (rates) OR (uptake) OR (increase) OR (coverage)
3 (strategy) OR (intervention)
4 (legislation) OR (policy) OR (laws)
5 (Communication) OR (education) OR (attitudes)
6 (health care workers) OR (physician) OR (nurse) OR (midwives) OR
(health professional)
7 1 and 2
8 1 and 3
9 1,2 and 3
10 1 and 4
11 1 and 5
12 1, 5 and 6


Table 3: Search Strategy
Search Google Scholar
1 (immunisation) OR (immunization) OR (vaccination) OR (vaccine)
2 (rates) OR (uptake) OR (increase) OR (coverage)
3 (strategy) OR (intervention)
4 (legislation) OR (policy) OR (laws)
5 (Communication) OR (education) OR (attitudes)
6 (health care workers) OR (physician) OR (nurse) OR (midwives) OR
(health professional)
7 1 and 2
8 1 and 3
9 1,2 and 3
10 1 and 4
11 1 and 5
12 1, 5 and 6



6

2.2 Results
Table 4: Results

Articl
e ID
Brief
description
of strategy
being
evaluated
(refer to 2B,
2.1)
Strategy
context/
setting
(refer to 2C)
Research
question or
purpose
(refer to 2D,
2.9)
Theories,
methods,
constructs
used (refer to
2B, 2.1)
Ottawa
Charter
action
area/s
and
ecologic
al level
Evaluation methods,
measures and results
(refer to 2D, 2E, 3)
Interpretation
with respect to
quality and
applicability to
your project (refer
to 4)
Level of
evidence
(I-IV)
(refer to
Append
1)
Other:
cost
7

Policy & Financial Incentives
ID: 1
Bond
et al.
2002
(6)

Increase
vaccination
coverage
(VC) through
government
policy
1998
Australian
Federal
Gov. initiate
childcare
payments
to parents
of
immunised
children.
Vic. Gov.
make
childcare
immunisati
on reports
mandatory
What is the
VC of
children in
child care
before
and after
implementati
on of
Government
immunisation
strategies?
Legislation
and parent
financial
incentives.

OC 1 Cross sectional
parent survey of VC
for children.
Questionnaire
obtained
immunisation
records, verified
with ACIR.
9% increase in VC.
Showed an
increase in VC
Difficult to show
this was related
to government
intervention as
other
interventions
may have had an
impact.

IV
ID: 2
Abrevaya
&
Mulligan
2011
(7)

Legislation
to
improve
VC
Schools
and
childcares
in US
Did Varicella
VC improve
after
mandates?
Mandatory
immunisation
for school
and childcare
entry
OC 1 Longitudinal design
measured VC post
mandate
Results showed 20%
increase in VC,
Greatest increase
shown immediately
after mandate
Significant
increase in VC,
though was short
lived
Results limited to
Varicella vaccine.
Usefulness
depends on
parent
perception of
seriousness of
vaccine
Uncertain how
mandate is
effective -
through raised
public awareness
or reactions by
insurance
companies?
III-2 Cost of
varicell
a
$439.9
8 per
child
vs
vaccine
cost
$159.1
4

Overall
cost
$5.70
per
child
ID: 3
Davis &
Gaglia
2005
(8)

Legislation
to
improve
VC
Schools
and
childcares
in US
School
and/or
daycare entry
requirements
are
associated
with
higher
Mandatory
immunisation
for school
and childcare
entry
OC1 Cross sectional
study sample from
National
Immunisation
Survey (NIS)
Found strong link
between mandates
and up- to -date
Shows mandates
have a strong
association with
VC
Data from NIS
limited to
households with
telephones,
III-2
8

varicella
immunizatio
n rates
vaccination.
Suggests mandates
boost vaccination
for children living in
a broad variety of
circumstances

possible that
families without
telephonesi.e.,
disadvantaged
familiesare

underrepresented

ID: 4
Lopez et
al. 2008
(9)

Legislation
to
improve
VC
Schools
and
childcares
in US
Are day care
and
school entry
requirements
for varicella
vaccination
associated
with varicella
vaccination
coverage?
Mandatory
immunisation
for school
and childcare
entry
OC1 Reviewed day care
and school entry
requirements
for each state
Compared
NIS coverage data
to
the year of
implementation
of strategy.

VC among children
increased from
25.8% to 87.9%.

Consistent with
results of
ID: 3 strong
link
mandates and
VC
VC cannot be
attributed solely
to mandate - not
all children
attend day care.

Other factors
may promote
vaccination eg.
increased
availability
of free vaccine
III-2
ID: 5
Lawrence
Parent
financial
Australian
parents of
Does the
policy impact
National
legislation for
OC1 Population-based
case control study
Increase in VC
Study revealed
III-2
9

et al. 2004
(10)

incentives
to
increase
VC
immunise
d and
non-
immunise
d children
who were
registered
with the
ACIR
aged 28
31
months
on parental
decisions and
on the
immunisation
status of
their
children?
receipt of
maternity
allowance
conditional
on evidence
of
immunisation
Interviewed
parents, measured
variables including
knowledge of
maternity
allowance.
Results showed
knowledge of
payments was
associated with
immunisation of
children
encouragement
by provider
important
factor, parents
most at risk for
not immunising
were unaware of
benefits.
Equitable
strategy.
Inability to
sample
conscientious
objectors may
have led to over
estimation of
result.
Provider-based
ID: 6
Brousseau
et al. 2010
(11)

Increase
VC
through
provider
feedback
2008
Quebec
City
vaccinatin
g clinics
Does
feedback
increase VC
and is it
feasible?
Provider
feedback.

OC 5 Pre and post
questionnaire.
Significant increase
in vaccination
demand.
Found to be a
feasible strategy
Useful for
increasing
vaccine demand
Low impact
strategy.
VC may improve
if combined with
other strategies.
IV Low

ID: 7
Williams
Primary
care
Preschool
children in
How can
primary care
Reminder/Re
call, parental
OC 4, 5 System review,
articles graded for
Strong research
to show
III-2 researc
h
10

et al. 2011
(12)

strategies
to
improve
VU
developed
countries.
practitioners
in developed
countries
improve
preschool
immunisation
uptake?
education,
patient held
records,
provider
education
and multi
component
interventions
methodological
quality.
Combining parental
and provider
strategies led to
greatest increase in
VU.
Most successful
strategies target
healthcare
provider
and children to
be
immunised.
reminder recall,
educating
parents and
feedback to
providers are
effective in
increasing VC
Studies on
education only
occurred in GP
setting
require
d to
test
cost-
effectiv
eness
of
these
interve
ntions
ID: 8
Uskun et
al. 2008
(13)

Provider
training
interventi
on to
increase
VU
Health
care
workers in
Turkey
Does
participation
in training
increase
knowledge
and increase
VU?
Education
about
vaccines,
schedules,
planning and
regulation,
tracking
OC4,5 Pre-test/Post-test
questionnaire
Data collection
from immunisation
forms
Results showed
increase in
knowledge, little
impact on
experienced
participants.
GPs gained more
knowledge.
Significant increase
Short study
duration
(3months)
Participants
were responsible
for vaccination
therefore likely
to show increase
in knowledge.
Useful as
highlights need
to keep GPs up
to date
IV
11

in VC
ID: 9
Irogoyen
et al. 2006
(14)

Reminder
systems to
improve
VU
Inner city
practices
in New
York
Do reminder
systems have
an effect on
immunisation
rates?
Immunisation
Registry
identifies
children due
for
immunisation
s
and
generates
reminders to
increase VU
OC 5 RCT measured
immunisation and
up to date status.
Found improved
coverage rates for
children sent
continuous
reminders
no independent
effect on
immunisation
outcomes
Reminders are
not effective due
to system
barriers
Useful as
highlights need
to combine with
other strategies
II
ID: 10
Fiks et al.
2006
(15)

Clinical
alerts
increase
VC
Four
primary
care
centres in
Philadelph
ia
Clinical alerts
increase
immunisation
opportunities
captured at
health care
visits,
improve
immunisation
rates
and decrease
the age when
children
become up-
to date.
Electronic
health
records
(EHRs)
with alerts
delivered to
clinicians at
the point of
care to
improve
vaccination
rates
OC 5 1 year intervention
study historical
control design
Measured rates of
captured
immunisation
opportunities and
overall
immunisation rates.
Significant
improvement in
immunisation rates.
Immediate
increase in
immunisation
rates.
Historical control
subject to bias
from vaccine
shortages.
Relies on
patients having
access to and
visiting a
physician.
III-3 Cost
effectiv
e as
require
s less
resourc
es than
remind
er
system
s
12

Communication
ID:11
Dexter et
al. 2012
(16)

Primary
care
strategies
to
improve
vaccinatio
n rates
795
general
practices
across
England
Which
strategies are
associated
with
increased flu
vaccine
uptake?
Practice
strategies
OC 5 Cross sectional
online
questionnaire
measuring flu
vaccination rates
Results found clear
leadership, effective
communication
and
recall methods
associated with
higher
rates of flu
vaccination.
Financial targets an
incentive to
maximise influenza
vaccine uptake.

Large sample but
low participation
rate reduced
evidence.
Outcome
measures
objective and
corrected for
practice size.
Strategies used
to encourage
vaccination were
self-reported.
Highlights
leadership and
communication
as necessary
provider
strategies


IV
ID: 12
Jackson et
al. 2011
(17)

Support
parent
decision
making for
vaccinatio
n uptake
2006 UK
primary
care and
childcare
centres
Does a leaflet
or leaflet and
parent
meeting
reduce
decisional
Education
and
engagement
model of
communicati
on
OC 4 RCT measuring
impact of parent
meeting and leaflet
using Decisional
Conflict Scale.
Parent meeting
A multi
component
strategy rated
by system review
(12)
as most
effective
II
13

(VU) conflict and
act on
vaccination
uptake (VU)?
enabled parents to
act upon decision
leading to VU
Trial held in one
city, only 10% of
parents invited
attended
Acknowledges
community
action and
influence of
social
environment on
VU
ID: 13
Wallace et
al. 2006
(18)

Support
parent
decision
making for
VU
2004
Website
decision
aid
promoted
through
search
engines ,
online
parenting
and
health
websites
targeting
Australia
and New
Zealand
Could a
decision aid
improve
attitudes to
MMR
vaccination?
Community
Development
-responding
to parental
values ,
engage with
parents as
decision
makers,
transform
views
collaborativel
y
OC 3,4 Before and after
design, measuring
outcome of change
in attitude towards
MMR vaccine.
Results showed
improved parents
attitudes
Useful strategy
as acknowledges
social context in
which people
interpret
messages.
52% of
participants
were parents
with children -
other
respondents
answers may not
be relevant.
IV
14

ID: 14
Kaufman
et al.
2013
(19)

Communic
ation
interventi
on to
educate
parents
and
improve
VU
Single and
multi-
session
education
al
sessions,
delivered
to
individual
s and to
groups of
parents or
soon-to-
be
parents,
mostly
urban,
settings in
Aus, US,
Canada
What are the
effects of
face to face
interventions
for improving
VU?
Behaviour
change
theory
OC 4 System review
suggests face to
face strategies do
not consistently
improve
immunisation rates
or parent
understanding of
vaccination


E Evidence of all
s strategies
reviewed were
low
overall result is
u unreliable

Useful as
highlights need for
more research in this
area area



I
ID: 15
Wilson et
al. 2005
(20)

Communic
ation
interventi
on to
increase
VU
Final year
students
at a
large
Canadian
alternativ
e
medicine
Anecdotal
evidence
more
effective
than
evidence
based
presentation
vividness
hypothesis
in the form
of a well-
described
anecdote is
more
persuasive
OC 4 Comparative
design, one group
presented
epidemiology
lecture, other group
received anecdotal
lecture from polio
survivor.
Useful article as
shows
persuasive type
strategies can
have a cognitive
dissonance
effect - attitudes
are more
IV
15

school to persuade
populations
than pallid
information
such as
epidemiologic
al data
Pre and post survey
of student
attitudes.
No significant
difference between
two groups in
change in response.
25% of students
less likely to
recommend the
vaccine after
hearing evidence
supporting
vaccination.
entrenched.
Small sample
size, students
were not
blinded,
potential for bias
ID: 16
Abbott et
al. 2013
(21)

Communic
ation
strategy
aimed at
improving
Indigenou
s VU
Aboriginal
communit
y in
Western
Sydney
Do
personalised
calendars
prompt
timely
childhood
immunisation
in Aboriginal
children?
Community
based
intervention
OC 5 Retrospective
cohort design
Data from ACIR
measured
timeliness of
immunisation of
Aboriginal children
who received
calendar compared
to those who did
not.
Post interview with
carers and staff.
Results showed
Intervention
assists in
expression of
cultural identity,
contributes to
Aboriginal
community
control.
Interpretation
complicated by a
small number of
very delayed
doses.
III-2 Simple
cost
effectiv
e tool
16

reduced delays in
immunisation.
ID: 17
Saha &
Beach
2011
(22)

Communic
ation
strategy to
increase
VC
248
patients
from
hospital-
based,
adult
primary
care clinic
in the
Western
United
States
What is the
impact of
patient-
centered
communicati
on (PCC) on
patients
evaluations
of physicians
and
acceptance
of clinical
recommenda
tions?
Concept of
mutuality,
involving
power
sharing and
collaboration
between
physicians
and
patients
OC 4,5 Comparative study
used vignettes to
compare patients
ratings of the
physician and their
decision making in
response to the
physicians
recommendation.
Patients expressed
greater confidence
in physicians who
used more PCC
behaviours,
Greater willingness
to accept an
evidence-based
recommendation.
Highlights
importance of
communication
approach for
health care
professionals in
delivering the
message to
vaccinate.
Study applied to
non-vaccine
related health
issue- evidence is
limited
III-2
ID: 18
Smith et
al. 2006
(23)

Support
parent
decision
making to
increase
VU
Parents of
7695
children
19 to 35
months of
age
sampled
by the
How is VU
associated
with provider
influence on
parent
decision to
vaccinate?
Physician
recommenda
tion to
increase VU
OC 4,5 Random sample of
parents from NIS
surveyed
Measured how
much provider
influenced decision
to vaccinate.
20% parents said
Demonstrates
providers do
influence parents
decisions
Did not identify
how providers
influence parents
Highlights need
III-2
17

National
Immuniza
tion
Survey in
US
decision was not
influenced by
provider.
Parents who
considered vaccines
unsafe were more
likely to be
influenced by
provider.
to establish trust
and build
rapport with
parents.
Large national
survey.
Results not
measured
continuously-
difficult to
identify a
consistent theme
over time.
ID: 19
Davis et
al. 2002
(24)

Parent
education
to
improve
VU
Two
private
pediatric
practices
in US.

What is the
feasibility of
an
Immunsiatio
n Education
Package?
Practice-
based in-
service and
distribution
and
discussion of
ready-to-use
materials
including an
exam room
poster.
OC 2, 3,5 Before and after
comparative study
Measured content
and duration of
immunisation
discussions.
Increase in verbal
teaching about the
vaccine and parent
initiation of
questions
Increase in
discussion of major
immunisation
concerns.
Trial study
results are
preliminary.
Presence of
observer may
have affected
physician/nurse
behaviour.
Strong evidence -
parents blinded
to intent of
research, staff
masked to
variables
recorded.
III-2
18

Design did not
include follow up
however 9
months post
intervention
physicians
indicated
changes were
maintained
ID:20
OMalley
et al. 2004
(25)

Communic
ation
strategy to
improve
uptake of
preventati
ve services
961
African-
American
women
over age
40 in
Washingt
on, DC.
What is the
role of
patient trust
on the
use of
preventive
services for
low-income
African-
American
women?
Improving
patient-
provider
relationships
to encourage
use of service
OC 2,4,5 Cross-sectional,
population-based
telephone survey
examined trust in
regular primary care
provider.
Index recorded use of
preventative
interventions as the
main outcome
variable. Two-thirds
of respondents
reported high trust in
regular physician.
Older respondents
were more trusting
than younger
respondents. Higher
trust = greater use of
Highlights
importance of
trust as a
strategy
Did not include
vaccination in
study, strategy
could be used to
to increase VU.
III-2
19


recommended
preventive services
20

3. Summary
This review found that political interventions are associated with increased
immunisation uptake. Legislation making immunisation conditional for childcare entry
has been associated with increased immunisation uptake in studies in the United
States of America.
(7-9)
In Australia, the New South Wales Government has recently
introduced this type of legislation for childcare entry, based on US studies.
(26)
The
Australian Federal Government has linked maternity allowance and childcare rebates
to immunisation, and review of this type of strategy shows some impact on increasing
immunisation uptake.
(6, 10)
The success of these strategies may not be attributed to
political interventions alone; other health promoting programs within the context of
these interventions may have had an impact on increasing immunisation uptake.

Reports on provider-based strategies suggest that independent interventions are not
effective, however, when strategies such as reminder/recall are combined with other
strategies, they become more effective in promoting immunisation uptake.
(12, 14)

Clinical alerts used in electronic health records, provider feedback on immunisation
performance and provider training have all been shown to be useful strategies for
targeting provider-based barriers to immunisation uptake.
(11, 13, 15)
The delivery of
multi component strategies addresses multiple areas of the Ottawa Charter
(5)
for
example, a provider-based strategy which offers education to professionals and
parents and uses reminder/ recall systems creates a supportive environment, develops
personal skills and reorientates health services.
21


This review found extensive literature on the broad use of communication strategies to
address parent-based barriers to immunisation uptake. Strategies involved supporting
parent decision making for immunisation through parent meetings, education and web
based decision aids.
(17, 18, 24)
The review found these types of strategies to be useful in
providing parents with knowledge to make an informed decision on immunisation, and
results showed increased immunisation uptake.

While the internet can be a useful information resource, the problem of
misinformation relating to vaccines is widely recognised and contributes to distrust in
physicians and the medical system.
(27)
This literature review sought for health
promotion projects which addressed this barrier, but found a significant gap in the
literature.

Lack of trust in the medical system has been observed on the Sunshine Coast, with
parents refusing to immunise their children because of fear of adverse effects and
vaccine additives.
(28)
A national survey found that 53% of Australians have some
concerns around vaccination.
(29)
Royal
(28)
advocates a communication approach to
overcome this barrier. This approach requires physicians to actively listen and build a
rapport with parents, and is a strategy which is often considered time-consuming.
(28)


22

Face to face interventions
(19)
were identified in this review and reflect Royals
communication approach. These interventions had low evidence of effectiveness in
increasing immunisation uptake and more research is required to provide evidence for
this approach. In light of this, trust building strategies that increased primary service
uptake in general were included for an evidence based approach, and the impact of
these strategies are promising.
(25)


In a conversation with A. Agapow, CHN , Nambour Clinic (July 2013) a lack of advocacy
for immunisation from paediatricians and hospital staff was highlighted as a barrier to
immunisation on the Sunshine Coast. Physicians recommending against vaccines
contributes to parent vaccine refusal
(29)
and contributes to low immunisation uptake.
This review found that leadership among health professionals and educating
physicians to ensure they are up to date with vaccine schedules, are strong strategies
for increasing immunisation uptake.
(12, 13, 16)







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4. Conclusion
Immunisation rates on the Sunshine Coast, Queensland are among the lowest in
Australia. The community is at risk of an outbreak in serious diseases, and requires a
health promotion project to boost immunisation uptake. This literature review
searched for current evidence of health promotion strategies that have been used in
the Australian and International setting to address this issue. The methodology
involved an inclusion/exclusion criteria to collect data and results were analysed using
a public health interventions Schema and the Ottawa Charter for health promotion.
Results indicate substantial evidence for political and provider based interventions.
Communication strategies, including the development of trustful relationships, were
considered a key intervention for addressing parent barriers to immunisation. The
findings from this review may be used to develop an ecological based health
promotion project for the Sunshine Coast community.
(1294 words)





24

5. References
1. National Health Performance Authority. 2013. Healthy Communities: Immunisation
rates for children in 201112. NHPA, Sydney.
2
3