human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background In the UK public concern about the safety of the combined measles , mumps and rubella [ MMR ] vaccine continues to impact on MMR coverage . Whilst the sharp decline in uptake has begun to level out , first and second dose uptake rates remain short of that required for population immunity . Furthermore , international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children . Together , this work suggests that effective interventions are required to support parents to make informed decisions about MMR.This trial assessed the impact of a parent-centred , multi-component intervention ( balanced information , group discussion , coaching exercise ) on informed parental decision-making for MMR . Methods This was a two arm , cluster r and omised trial . One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations . The intervention arm received an MMR information leaflet and participated in the intervention ( parent meeting ) . The control arm received the leaflet only . The primary outcome was decisional conflict . Secondary outcomes were actual and intended MMR choice , knowledge , attitude , concern and necessity beliefs about MMR and anxiety . Results Decisional conflict decreased for both arms to a level where an ' effective ' MMR decision could be made one-week ( effect estimate = -0.54 , p < 0.001 ) and three-months ( effect estimate = -0.60 , p < 0.001 ) post-intervention . There was no significant difference between arms ( effect estimate = 0.07 , p = 0.215 ) . Heightened decisional conflict was evident for parents making the MMR decision for their first child ( effect estimate = -0.25 , p = 0.003 ) , who were concerned ( effect estimate = 0.07 , p < 0.001 ) , had less positive attitudes ( effect estimate = -0.20 , p < 0.001 ) yet stronger intentions ( effect estimate = 0.09 , p = 0.006 ) . Significantly more parents in the intervention arm reported vaccinating their child ( 93 % versus 73 % , p = 0.04 ) . Conclusions Whilst both the leaflet and the parent meeting reduced parents ' decisional conflict , the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake OBJECTIVE To improve health outcomes of children  , the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practice s and more coordination between practice s and community-based agencies . However , applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them . To improve the way that preventive health care services are organized and delivered in 1 community , we design ed , implemented , and assessed the impact of a health care system-level approach , which involved addressing multiple care delivery processes , at multiple levels in the community , the practice , and the family . Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community , with particular attention to health outcomes for low-income mothers and infants . DESIGN Observational intervention study in 1 North Carolina county ( population 182 000 ) involving low- income pregnant mothers and their infants , primary care practice s , and departments of health and mental health . An interrupted time-series design was used to assess rates of preventive services in office practice s before and after the intervention , and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program 's initiation . Outcomes were assessed when the infants reached 12 months of age . INTERVENTIONS Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families . We selected interventions that were directed toward major risk factors ( eg , poverty , ineffective care systems for preventive care in office practice s ) and for which there was existing evidence of efficacy . The interventions involved community- , practice - , and family-level strategies to improve processes of care delivery  to families and children . The objectives of the community-level intervention were : 1 ) to achieve policy level changes that would result in changes in re sources available at the level of clinical care , 2 ) to engage multiple practice organizations in the intervention to achieve an effect on most , if not all , families in the community , and 3 ) to enhance communication between , among , and within public and private practice organizations to improve coordination and avoid duplication of services . The objective of the practice -level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered . To assist the health department in implementing the family-level intervention , we provided assistance in hiring and training staff and ongoing consultation on staff supervision , including the use of structured protocol s for care delivery , and regular feedback data about implementation of the program . Interventions with primary care practice s focused on the design of the delivery system within the office and the use of teamwork and data in an " office systems " approach to improving clinical preventive care . All practice s ( N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems ( eg , preventive services flow sheets ) for preventive services delivery . Family-level interventions addressed the process of care delivery to high-risk pregnant women ( < 100 % poverty ) and their infants . Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center , the county 's largest provider of prenatal care to underserved women . The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant 's first year of life to provide parental education on fetal and infant health and development , enhance parents ' informal support systems , and link parents with needed health and human services . We included training in injury prevention and discipline , and home visitors assisted mothers in obtaining care from one of the primary care offices . RESULTS There were high levels of participation , changes in the organization of the delivery system , and improvements in preventive health outcomes . Agencies cooperated in joint contracting , staff training , and defining program eligibility . All 8 eligible practice s agreed to participate and 7/8 implemented at least 1 new office system element . Of eligible women , 89 % agreed to participate , and outcome data were available on 80 % ( 180/225 ) . After adjusting for differences in baseline characteristics , intervention group women were significantly more likely than comparison group women to use contraceptives ( 69 % vs 47 % ) , not smoke tobacco ( 27 % vs 54 % ) and have a safe and stimulating home environment for their children . Intervention group children were more likely to have had an appropriate number of well-child care visits ( 57 % vs 37 % ) and less likely to be injured ( 2 % vs 7 % ) . Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child ( 7.7 months vs 11.3 months ) . CONCLUSIONS We observed a number of positive effects at all 3 levels of intervention . Policy-level changes at the state and community led to lasting changes in the organization and financing of care , which enabled changes in clinical services to take place . These changes have now been exp and ed beyond this community to other communities in the state . We were also able to engage multiple practice organizations , reduce duplication , and improve the coordination of care . Changes in the process of preventive services delivery were noted in participating practice s. Finally , the outcomes of the family-level intervention  were comparable in direction and magnitude to the outcomes of previous r and omized trials of the intervention . All the changes were achieved over a relatively brief 3-year study period , and many have been sustained since the project was completed . Tiered , interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children We sought to determine if a simple educational intervention initiated at the first wellchild care visit , with reinforcement at subsequent visits , can improve inner-city infant immunization rates . We conducted a controlled trial involving 315 newborn infants and their primary caregivers in 3 inner-city primary care centers . Child health care providers gave caregivers in the intervention group an interactive graphic card with verbal reinforcement . At later visits , stickers were applied to the card when immunizations were given . Routine information was given to controls . After the trial , age-appropriate immunization rates at 7 months were 58 % in each group . Intervention infants had 50 % fewer missed opportunities to immunize ( p=0.01 ) but cancelled 77 % more appointments ( p=0.04 ) than controls . We conclude that a brief educational intervention at the first well-child care visit did not boost 7-month immunization rates , although it was associated with fewer missed opportunities to immunize Background In Pakistan , only 59 - 73 % of children 12 - 23 months of age are fully immunized . This r and omized , controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates . Methods Three hundred and sixty-six mother-infant pairs , with infants aged ≤ 6 weeks , were enrolled and r and omized into either the intervention or control arm between August - November 2008 . The intervention , administered by trained community health workers , consisted of three targeted pictorial messages regarding vaccines . The control group received general health promotion messages based on Pakistan 's Lady Health Worker program curriculum . Assessment of DPT/Hepatitis B vaccine completion ( 3 doses ) was conducted 4-months after enrollment . A Poisson regression model was used to estimate effect of the intervention . The multivariable Poisson regression model included maternal education , paternal occupation , ownership of home , cooking fuel used at home , place of residence , the child 's immunization status at enrollment , and mother 's perception about the impact of immunization on child 's health . Results Baseline characteristics among the two groups were similar . At 4 month assessment , among 179 mother-infant pairs in the intervention group , 129 ( 72.1 % ) had received all 3 doses of DPT/Hepatitis B vaccine  , whereas in the control group 92/178 ( 51.7 % ) had received all 3 doses . Multivariable analysis revealed a significant improvement of 39 % ( adjusted RR = 1.39 ; 95 % CI : 1.06 - 1.81 ) in DPT-3/Hepatitis B completion rates in the intervention group . Conclusion A simple educational intervention design ed for low-literate population s , improved DPT-3/Hepatitis B vaccine completion rates by 39 % . These findings have important implication s for improving routine immunization rates in Pakistan Background Vaccination is a cost-effective public health measure and is central to the Millennium Development Goal of reducing child mortality . However , childhood vaccination coverage remains sub-optimal in many setting s. While communication is a key feature of vaccination programmes , we are not aware of any comprehensive approach to organising the broad range of communication interventions that can be delivered to parents and communities to improve vaccination coverage . Developing a classification system ( taxonomy ) organised into conceptually similar categories will aid in : underst and ing the relationships between different types of communication interventions ; facilitating conceptual mapping of these interventions ; clarifying the key purpose s and features of interventions to aid implementation and evaluation ; and identifying areas where evidence is strong and where there are gaps . This paper reports on the development of the ‘ Communicate to vaccinate ’ taxonomy . Methods The taxonomy was developed in two stages . Stage 1 included : 1 ) forming an advisory group ; 2 ) search ing for descriptions of interventions in trials ( CENTRAL data base ) and general health literature ( Medline ) ; 3 ) developing a sampling strategy ; 4 ) screening the search results ; 5 ) developing a data extraction form ; and 6 ) extracting intervention data . Stage 2 included : 1 ) grouping the interventions according to purpose ; 2 ) holding deliberative forums in English and French with key vaccination stakeholders to gather feedback ; 3 ) conducting a targeted search of grey literature to supplement the taxonomy ; 4 ) finalising the taxonomy based on the input provided . Results The taxonomy includes seven main categories of communication interventions : inform or educate , remind or recall , teach skills , provide support , facilitate decision making , enable communication and enhance community ownership . These categories are broken down into 43 intervention types across three target groups : parents or soon-to-be-parents ; communities , community members or volunteers ; and health care providers . Conclusions Our taxonomy illuminates and organises this field and identifies the range of available communication interventions to increase routine childhood vaccination uptake . We have utilised a variety of data sources , capturing information from rigorous evaluations such as r and omised trials as well as experiences and knowledge of practitioners and vaccination stakeholders . The taxonomy reflects current public health practice and can guide the future development of vaccination programmes CONTEXT An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations . Disparities in US childhood immunization rates persist , with inner-city , black , and Hispanic children having lower rates . Although practice or clinic-based interventions , such as patient reminder/recall systems , have been found to improve immunization rates in specific setting s , there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level . OBJECTIVE To assess the effect of a community-wide reminder , recall , and outreach ( RRO ) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban population s and among white , black , and Hispanic children within an entire county . SETTING Monroe County , New York ( birth cohort : 10 000 , total population : 750 000 ) , which includes the city of Rochester . Three geographic regions within the county were compared : the inner city of Rochester , which contains the greatest concentration of poverty ( among 2- 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background In the UK public concern about the safety of the combined measles , mumps and rubella [ MMR ] vaccine continues to impact on MMR coverage . Whilst the sharp decline in uptake has begun to level out , first and second dose uptake rates remain short of that required for population immunity . Furthermore , international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children . Together , this work suggests that effective interventions are required to support parents to make informed decisions about MMR.This trial assessed the impact of a parent-centred , multi-component intervention ( balanced information , group discussion , coaching exercise ) on informed parental decision-making for MMR . Methods This was a two arm , cluster r and omised trial . One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations . The intervention arm received an MMR information leaflet and participated in the intervention ( parent meeting ) . The control arm received the leaflet only . The primary outcome was decisional conflict . Secondary outcomes were actual and intended MMR choice , knowledge , attitude , concern and necessity beliefs about MMR and anxiety . Results Decisional conflict decreased for both arms to a level where an ' effective ' MMR decision could be made one-week ( effect estimate = -0.54 , p < 0.001 ) and three-months ( effect estimate = -0.60 , p < 0.001 ) post-intervention . There was no significant difference between arms ( effect estimate = 0.07 , p = 0.215 ) . Heightened decisional conflict was evident for parents making the MMR decision for their first child ( effect estimate = -0.25 , p = 0.003 ) , who were concerned ( effect estimate = 0.07 , p < 0.001 ) , had less positive attitudes ( effect estimate = -0.20 , p < 0.001 ) yet stronger intentions ( effect estimate = 0.09 , p = 0.006 ) . Significantly more parents in the intervention arm reported vaccinating their child ( 93 % versus 73 % , p = 0.04 ) . Conclusions Whilst both the leaflet and the parent meeting reduced parents ' decisional conflict , the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake OBJECTIVE To improve health outcomes of children  , the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practice s and more coordination between practice s and community-based agencies . However , applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them . To improve the way that preventive health care services are organized and delivered in 1 community , we design ed , implemented , and assessed the impact of a health care system-level approach , which involved addressing multiple care delivery processes , at multiple levels in the community , the practice , and the family . Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community , with particular attention to health outcomes for low-income mothers and infants . DESIGN Observational intervention study in 1 North Carolina county ( population 182 000 ) involving low- income pregnant mothers and their infants , primary care practice s , and departments of health and mental health . An interrupted time-series design was used to assess rates of preventive services in office practice s before and after the intervention , and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program 's initiation . Outcomes were assessed when the infants reached 12 months of age . INTERVENTIONS Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families . We selected interventions that were directed toward major risk factors ( eg , poverty , ineffective care systems for preventive care in office practice s ) and for which there was existing evidence of efficacy . The interventions involved community- , practice - , and family-level strategies to improve processes of care delivery  to families and children . The objectives of the community-level intervention were : 1 ) to achieve policy level changes that would result in changes in re sources available at the level of clinical care , 2 ) to engage multiple practice organizations in the intervention to achieve an effect on most , if not all , families in the community , and 3 ) to enhance communication between , among , and within public and private practice organizations to improve coordination and avoid duplication of services . The objective of the practice -level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered . To assist the health department in implementing the family-level intervention , we provided assistance in hiring and training staff and ongoing consultation on staff supervision , including the use of structured protocol s for care delivery , and regular feedback data about implementation of the program . Interventions with primary care practice s focused on the design of the delivery system within the office and the use of teamwork and data in an " office systems " approach to improving clinical preventive care . All practice s ( N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems ( eg , preventive services flow sheets ) for preventive services delivery . Family-level interventions addressed the process of care delivery to high-risk pregnant women ( < 100 % poverty ) and their infants . Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center , the county 's largest provider of prenatal care to underserved women . The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant 's first year of life to provide parental education on fetal and infant health and development , enhance parents ' informal support systems , and link parents with needed health and human services . We included training in injury prevention and discipline , and home visitors assisted mothers in obtaining care from one of the primary care offices . RESULTS There were high levels of participation , changes in the organization of the delivery system , and improvements in preventive health outcomes . Agencies cooperated in joint contracting , staff training , and defining program eligibility . All 8 eligible practice s agreed to participate and 7/8 implemented at least 1 new office system element . Of eligible women , 89 % agreed to participate , and outcome data were available on 80 % ( 180/225 ) . After adjusting for differences in baseline characteristics , intervention group women were significantly more likely than comparison group women to use contraceptives ( 69 % vs 47 % ) , not smoke tobacco ( 27 % vs 54 % ) and have a safe and stimulating home environment for their children . Intervention group children were more likely to have had an appropriate number of well-child care visits ( 57 % vs 37 % ) and less likely to be injured ( 2 % vs 7 % ) . Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child ( 7.7 months vs 11.3 months ) . CONCLUSIONS We observed a number of positive effects at all 3 levels of intervention . Policy-level changes at the state and community led to lasting changes in the organization and financing of care , which enabled changes in clinical services to take place . These changes have now been exp and ed beyond this community to other communities in the state . We were also able to engage multiple practice organizations , reduce duplication , and improve the coordination of care . Changes in the process of preventive services delivery were noted in participating practice s. Finally , the outcomes of the family-level intervention  were comparable in direction and magnitude to the outcomes of previous r and omized trials of the intervention . All the changes were achieved over a relatively brief 3-year study period , and many have been sustained since the project was completed . Tiered , interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children We sought to determine if a simple educational intervention initiated at the first wellchild care visit , with reinforcement at subsequent visits , can improve inner-city infant immunization rates . We conducted a controlled trial involving 315 newborn infants and their primary caregivers in 3 inner-city primary care centers . Child health care providers gave caregivers in the intervention group an interactive graphic card with verbal reinforcement . At later visits , stickers were applied to the card when immunizations were given . Routine information was given to controls . After the trial , age-appropriate immunization rates at 7 months were 58 % in each group . Intervention infants had 50 % fewer missed opportunities to immunize ( p=0.01 ) but cancelled 77 % more appointments ( p=0.04 ) than controls . We conclude that a brief educational intervention at the first well-child care visit did not boost 7-month immunization rates , although it was associated with fewer missed opportunities to immunize Background In Pakistan , only 59 - 73 % of children 12 - 23 months of age are fully immunized . This r and omized , controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates . Methods Three hundred and sixty-six mother-infant pairs , with infants aged ≤ 6 weeks , were enrolled and r and omized into either the intervention or control arm between August - November 2008 . The intervention , administered by trained community health workers , consisted of three targeted pictorial messages regarding vaccines . The control group received general health promotion messages based on Pakistan 's Lady Health Worker program curriculum . Assessment of DPT/Hepatitis B vaccine completion ( 3 doses ) was conducted 4-months after enrollment . A Poisson regression model was used to estimate effect of the intervention . The multivariable Poisson regression model included maternal education , paternal occupation , ownership of home , cooking fuel used at home , place of residence , the child 's immunization status at enrollment , and mother 's perception about the impact of immunization on child 's health . Results Baseline characteristics among the two groups were similar . At 4 month assessment , among 179 mother-infant pairs in the intervention group , 129 ( 72.1 % ) had received all 3 doses of DPT/Hepatitis B vaccine  , whereas in the control group 92/178 ( 51.7 % ) had received all 3 doses . Multivariable analysis revealed a significant improvement of 39 % ( adjusted RR = 1.39 ; 95 % CI : 1.06 - 1.81 ) in DPT-3/Hepatitis B completion rates in the intervention group . Conclusion A simple educational intervention design ed for low-literate population s , improved DPT-3/Hepatitis B vaccine completion rates by 39 % . These findings have important implication s for improving routine immunization rates in Pakistan Background Vaccination is a cost-effective public health measure and is central to the Millennium Development Goal of reducing child mortality . However , childhood vaccination coverage remains sub-optimal in many setting s. While communication is a key feature of vaccination programmes , we are not aware of any comprehensive approach to organising the broad range of communication interventions that can be delivered to parents and communities to improve vaccination coverage . Developing a classification system ( taxonomy ) organised into conceptually similar categories will aid in : underst and ing the relationships between different types of communication interventions ; facilitating conceptual mapping of these interventions ; clarifying the key purpose s and features of interventions to aid implementation and evaluation ; and identifying areas where evidence is strong and where there are gaps . This paper reports on the development of the ‘ Communicate to vaccinate ’ taxonomy . Methods The taxonomy was developed in two stages . Stage 1 included : 1 ) forming an advisory group ; 2 ) search ing for descriptions of interventions in trials ( CENTRAL data base ) and general health literature ( Medline ) ; 3 ) developing a sampling strategy ; 4 ) screening the search results ; 5 ) developing a data extraction form ; and 6 ) extracting intervention data . Stage 2 included : 1 ) grouping the interventions according to purpose ; 2 ) holding deliberative forums in English and French with key vaccination stakeholders to gather feedback ; 3 ) conducting a targeted search of grey literature to supplement the taxonomy ; 4 ) finalising the taxonomy based on the input provided . Results The taxonomy includes seven main categories of communication interventions : inform or educate , remind or recall , teach skills , provide support , facilitate decision making , enable communication and enhance community ownership . These categories are broken down into 43 intervention types across three target groups : parents or soon-to-be-parents ; communities , community members or volunteers ; and health care providers . Conclusions Our taxonomy illuminates and organises this field and identifies the range of available communication interventions to increase routine childhood vaccination uptake . We have utilised a variety of data sources , capturing information from rigorous evaluations such as r and omised trials as well as experiences and knowledge of practitioners and vaccination stakeholders . The taxonomy reflects current public health practice and can guide the future development of vaccination programmes CONTEXT An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations . Disparities in US childhood immunization rates persist , with inner-city , black , and Hispanic children having lower rates . Although practice or clinic-based interventions , such as patient reminder/recall systems , have been found to improve immunization rates in specific setting s , there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level . OBJECTIVE To assess the effect of a community-wide reminder , recall , and outreach ( RRO ) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban population s and among white , black , and Hispanic children within an entire county . SETTING Monroe County , New York ( birth cohort : 10 000 , total population : 750 000 ) , which includes the city of Rochester . Three geographic regions within the county were compared : the inner city of Rochester , which contains the greatest concentration of poverty ( among 2- 
    Output:
    