vaccination requirements for child care, school, and college attendance among all relevant populations (Briss et al., 2000). TFCPS found that the extent to which specific legal characteristics or intensity of enforcement influenced the effectiveness of state requirements could not be determined.

Client or Family Incentives. Many immunization programs offer positive incentives (e.g., baby toys, money, or discount coupons) to motivate their clients to seek vaccinations for themselves or their children. Incentives can also be negative (penalties that can lead to the client’s exclusion from a program). After reviewing the relevant literature, TFCPS concluded that insufficient evidence exists to assess the effectiveness of client incentives in improving vaccination coverage, and observed further that the potential for coercion represents a potential barrier to their implementation.

Enhancing Awareness of Immunization Status. Client-held (also called hand-held) medical records are provided to members of a target population or their families to indicate which vaccinations have been received. The records can improve a client’s awareness of vaccinations needed or due and can be used to assess immunization status in medical and other settings. Many state and local health departments and providers have encouraged use of client-held medical records to improve coverage rates by increasing clients’ knowledge about vaccinations and/or reducing missed opportunities in health care settings.

Based on the small number of studies of this strategy, limitations in study designs, and variations in the interventions and research findings, TFCPS concluded that insufficient evidence exists to assess the effectiveness of client-held medical records in improving vaccination coverage (Briss et al., 2000). Furthermore, although 80 percent of providers in one survey reported positive or very positive overall reactions to a “health diary,” 17 percent also believed that such records negatively affect client flow (Dickey and Petitti, 1992).

Finding 4–11. There is sufficient evidence in the research literature to support strongly recommending the use of certain strategies to improve immunization rates across the United States, within either the general population or targeted groups. These strategies include client and provider reminder-recall; assessment and feedback for vaccination providers; multicomponent interventions that include education; lowering of out-of-pocket costs to families for vaccinations; elimination of the gap in immunization coverage rates between minority groups and the general population; expanded access to vaccinations in health care settings; and

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