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: Uptake of the measles , mumps , and rubella vaccine in the United Kingdom has declined to levels that will allow outbreaks of these preventable diseases to occur . A leaflet sent with a personalized reminder did not increase vaccine uptake in children who had not been immunised at 21 months of age 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 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-year-old children , 64 % have Medicaid ) ; the rest of the city of Rochester ( 38 % have Medicaid ) ; and the suburbs of the county ( 8 % have Medicaid ) . INTERVENTIONS An RRO system was implemented in 8 city practice s in 1995 ( covering 64 % of inner-city children ) and was exp and ed to 10 city practice s by 1999 ( covering 74 % of inner-city children , 61 % of rest-of-city children , and 9 % of suburban children ) . The RRO intervention involved lay community-based outreach workers who were assigned to city practice s to track immunization rates of all 0- to 2-year-olds , and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations ( tracking for all children , mail , or telephone reminders for most children , assistance with transportation or scheduling for some children , and home visits for 5 % of children who were most behind in immunizations and who faced complex barriers ) . STUDY PARTICIPANTS Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993 , 1996 , and 1999 . STUDY DESIGN Immunization rates were measured for each geographic region in Monroe County at 3 time periods : before the implementation of a systematic RRO system ( 1993 ) , during early phases of implementation of the RRO system ( 1996 ) , and after implementation of the RRO system in 10 city practice s ( 1999 ) . Immunization rates were compared for children living in the 3 geographic regions , and for white , black , and Hispanic children . Immunization rates were measured by the same methodology in each of the 3 time periods . A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practice s in the county ( covering 85 % to 89 % of county children ) . A r and om sample of children ( > 500 from the suburbs and > 1200 from the city for each sampling period ) was then selected for medical chart review at practice s to determine demographic characteristics ( including race and ethnicity ) and immunization rates . City children were over sample d to allow detection of effects by geographic region and race . Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling . MAIN OUTCOME MEASURES Immunization rates at 12 and 24 months for recommended vaccines ( 4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella : > or = 1 Haemophilus influenzae type b on or after 12 months of age ) . RESULTS DISPARITIES BY GEOGRAPHIC REGION : Baseline immunization rates ( 1993 ) for 24-month-olds were as follows : inner city ( 55 % ) , rest of city ( 64 % ) , and suburbs ( 73 % ) , with an 18 % difference in rates between the inner city and suburbs . By 1996 , immunization rates rose faster in the inner city ( + 21 % points ) than in the suburbs ( + 14 % points ) so that the difference in rates between the inner city and suburbs had narrowed to 11 % . In 1999 , rates were similar across geographic regions : inner city ( 84 % ) , rest of city ( 81 % ) , and suburbs ( 88 % ) , with a 4 % difference between the inner city and suburbs . DISPARITIES BY RACE AND ETHNICITY : Immunization rates were available in 1996 and 1999 by race and ethnicity . Twenty-four-month immunization rates in 1996 showed disparities : white ( 89 % ) , black ( 76 % ) , and Hispanic ( 74 % ) , with a 13 % difference between rates for white and black children and a 15 % difference between white and Hispanic children . In 1999 , rates were similar across the groups : white ( 88 % ) , black ( 81 % ) , and Hispanic ( 87 % ) , with a 7 % difference between rates for white and black children , and a 1 % difference between white and Hispanic children . CONCLUSIONS A community-wide intervention of patient RRO  raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority population s. By targeting a relatively manageable number of primary care practice s that serve city children and using an effective strategy to increase immunization rates in each practice , it is possible to eliminate disparities in immunizations for vulnerable children OBJECTIVE To determine whether rewording postal reminder cards according to the “ health belief model ” , a theory about preventive health behaviour , would help to improve measles vaccination rates . DESIGN A r and omised controlled trial , with blind assessment of outcome status . Parents of children due for their first measles vaccination were r and omised to one of two groups , one receiving the health belief model reminder card , the other receiving the usual , neutrally worded card . The proportion of children subsequently vaccinated in each group over a five week period was ascertained from clinical ( provider based ) records . SETTING A local government operated public vaccination clinic . PARTICIPANTS Parents of 259 children due for measles vaccination . MAIN RESULTS The proportion of children vaccinated in the health belief model card group was 79 % compared with 67 % of those sent the usual card ( 95 % CI , 2 % to 23 % ) , a modest but important improvement . CONCLUSION This study illustrates how the effectiveness of a minimal and widely practised intervention to promote vaccination compliance can be improved with negligible additional effort The widespread decline in uptake of the measles , mumps and rubella ( MMR ) vaccine started when an association between vaccination and Crohn ’s disease was suggested by research ers at the Royal Free Hospital and elsewhere in a series of papers published between 1993 and 1996 . It accelerated after February 1998 when the same workers hypothesized an association with autism through a putative mechanism of enterocolitis and toxin absorption . The widespread media coverage that the papers received result ed in a substantial minority of parents being misled into believing that there was a large body of medical opinion suspicious of MMR .  Uptake of MMR vaccine  began to decline rapidly and the incidence of measles and mumps infections increased . Novel methods of improving uptake of MMR vaccine  have been explored , but the authors ’ approach – to issue teddy bears wearing T-shirts displaying a website address and telephone number that provided information about MMR – has not been described previously . A pragmatic r and omized controlled trial was design ed with prospect i ve selection of subjects . Children eligible for their first dose of MMR vaccine ( MMR1 ) in Flintshire , being seen by their health visitor ( HV ) for the routine 8-month assessment , were recruited to the study . At the time of planning the study , Flintshire had the lowest uptake rate of all childhood immunizations inWales and the lowest uptake of MMR1 ( 69 % ) in North Wales . Children were r and omized to receive normal management plus a teddy bear ( intervention arm of the study ) or normal management alone ( nonintervention arm of the study ) . The bear ’s T-shirt contained three items of information We conducted a r and omized , controlled trial to determine the effectiveness of an immunization tracking system design ed to increase the number of infants of lower socioeconomic status who receive their primary series of vaccinations at age-appropriate times . By 7 months of age , 91 % ( 274/301 ) of the infants in the intervention group were up-to- date on their primary series of vaccinations versus 72 % ( 214/296 ) of the infants in the control group ( p < 0.0001 ) . The estimated cost of follow-up for each infant in the intervention group was $ 18.05 . ( J PEDIATR 1995 ; 126:583 - 6 Despite the widespread use of home based child health records of varying complexity in Engl and , there is a notable absence of their evaluation . Such a record booklet developed in the West Lambeth Health Authority has been used by parents , doctors , and community nurses to build up an independent chronological record of a child 's birth statistics , health , growth , immunisation , development checks , and contacts with health services . A r and omised controlled evaluation of the record , analyses of entries in it , and a survey of the views of mothers and health professionals using the record have been carried out . The need for such a record was confirmed by those question ed and analyses of entries in the booklet helped to modify and improve it . The evaluation was unable to show , however , any effect of the record on immunisation and developmental assessment service uptake . Its value in improving communication between the numerous health and other care agencies was dependent on its proper use Background . Immunization rates have improved in the United States , but are still far from the national 90 % goal for the year 2000 . There is scant evidence about the effectiveness and costs of automated telephone messages to improve immunization rates among privately insured children . Objective . To evaluate the effectiveness and cost-effectiveness of sending letters , automated telephone messages , or both to families of underimmunized 20-month-olds in a health maintenance organization ( HMO ) . Methods . In this r and omized trial , underimmunized 20-month-olds identified by the HMO 's computerized immunization tracking system were assigned to one of four interventions : 1 ) an automated telephone message alone ; 2 ) a letter alone ; 3 ) an automated telephone message followed by a letter 1 week later ; and 4 ) a letter followed by an automated telephone message 1 week later . The primary outcome was receipt of any needed immunization by 24 months of age . Decision analysis was used to evaluate the projected cost-effectiveness of the alternative strategies . Results . A total of 648 children were r and omized . A letter followed by a telephone message ( 58 % immunized ) was significantly better than either a letter alone ( 44 % immunized ) or a telephone message alone ( 44 % immunized ) . A telephone message followed by a letter ( 53 % immunized ) also was more effective than either alone , although the differences were not statistically significant . Among a similar comparison group that received no systematic intervention , 36 % were immunized . The estimated cost per child immunized was $ 7.00 using letters followed by automated telephone messages , $ 9.80 using automated telephone messages alone , and $ 10.50 using letters alone . Under alternative cost assumptions for automated telephone messages and mailed messages , the cost per child immunized ranged from $ 2.20 to $ 6.50 . Conclusions . For underimmunized 20-month-olds in this HMO setting , letters followed by automated telephone messages were more effective and cost-effective than either message alone . The cost-effectiveness of automated telephone messages and letters may vary widely depending on the setting , and choices among strategies should be tailored to the population s being served BACKGROUND Reminder-recall interventions have improved immunization rates in numerous studies . OBJECTIVE To evaluate the impact of large-scale , registry-based reminder-recall interventions on low immunization rates in an inner-city population . DESIGN R and omized , controlled , effectiveness trial . SETTING Fulton County , Georgia . PARTICIPANTS A total of 3050 children ( 
    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: Uptake of the measles , mumps , and rubella vaccine in the United Kingdom has declined to levels that will allow outbreaks of these preventable diseases to occur . A leaflet sent with a personalized reminder did not increase vaccine uptake in children who had not been immunised at 21 months of age 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 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-year-old children , 64 % have Medicaid ) ; the rest of the city of Rochester ( 38 % have Medicaid ) ; and the suburbs of the county ( 8 % have Medicaid ) . INTERVENTIONS An RRO system was implemented in 8 city practice s in 1995 ( covering 64 % of inner-city children ) and was exp and ed to 10 city practice s by 1999 ( covering 74 % of inner-city children , 61 % of rest-of-city children , and 9 % of suburban children ) . The RRO intervention involved lay community-based outreach workers who were assigned to city practice s to track immunization rates of all 0- to 2-year-olds , and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations ( tracking for all children , mail , or telephone reminders for most children , assistance with transportation or scheduling for some children , and home visits for 5 % of children who were most behind in immunizations and who faced complex barriers ) . STUDY PARTICIPANTS Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993 , 1996 , and 1999 . STUDY DESIGN Immunization rates were measured for each geographic region in Monroe County at 3 time periods : before the implementation of a systematic RRO system ( 1993 ) , during early phases of implementation of the RRO system ( 1996 ) , and after implementation of the RRO system in 10 city practice s ( 1999 ) . Immunization rates were compared for children living in the 3 geographic regions , and for white , black , and Hispanic children . Immunization rates were measured by the same methodology in each of the 3 time periods . A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practice s in the county ( covering 85 % to 89 % of county children ) . A r and om sample of children ( > 500 from the suburbs and > 1200 from the city for each sampling period ) was then selected for medical chart review at practice s to determine demographic characteristics ( including race and ethnicity ) and immunization rates . City children were over sample d to allow detection of effects by geographic region and race . Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling . MAIN OUTCOME MEASURES Immunization rates at 12 and 24 months for recommended vaccines ( 4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella : > or = 1 Haemophilus influenzae type b on or after 12 months of age ) . RESULTS DISPARITIES BY GEOGRAPHIC REGION : Baseline immunization rates ( 1993 ) for 24-month-olds were as follows : inner city ( 55 % ) , rest of city ( 64 % ) , and suburbs ( 73 % ) , with an 18 % difference in rates between the inner city and suburbs . By 1996 , immunization rates rose faster in the inner city ( + 21 % points ) than in the suburbs ( + 14 % points ) so that the difference in rates between the inner city and suburbs had narrowed to 11 % . In 1999 , rates were similar across geographic regions : inner city ( 84 % ) , rest of city ( 81 % ) , and suburbs ( 88 % ) , with a 4 % difference between the inner city and suburbs . DISPARITIES BY RACE AND ETHNICITY : Immunization rates were available in 1996 and 1999 by race and ethnicity . Twenty-four-month immunization rates in 1996 showed disparities : white ( 89 % ) , black ( 76 % ) , and Hispanic ( 74 % ) , with a 13 % difference between rates for white and black children and a 15 % difference between white and Hispanic children . In 1999 , rates were similar across the groups : white ( 88 % ) , black ( 81 % ) , and Hispanic ( 87 % ) , with a 7 % difference between rates for white and black children , and a 1 % difference between white and Hispanic children . CONCLUSIONS A community-wide intervention of patient RRO  raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority population s. By targeting a relatively manageable number of primary care practice s that serve city children and using an effective strategy to increase immunization rates in each practice , it is possible to eliminate disparities in immunizations for vulnerable children OBJECTIVE To determine whether rewording postal reminder cards according to the “ health belief model ” , a theory about preventive health behaviour , would help to improve measles vaccination rates . DESIGN A r and omised controlled trial , with blind assessment of outcome status . Parents of children due for their first measles vaccination were r and omised to one of two groups , one receiving the health belief model reminder card , the other receiving the usual , neutrally worded card . The proportion of children subsequently vaccinated in each group over a five week period was ascertained from clinical ( provider based ) records . SETTING A local government operated public vaccination clinic . PARTICIPANTS Parents of 259 children due for measles vaccination . MAIN RESULTS The proportion of children vaccinated in the health belief model card group was 79 % compared with 67 % of those sent the usual card ( 95 % CI , 2 % to 23 % ) , a modest but important improvement . CONCLUSION This study illustrates how the effectiveness of a minimal and widely practised intervention to promote vaccination compliance can be improved with negligible additional effort The widespread decline in uptake of the measles , mumps and rubella ( MMR ) vaccine started when an association between vaccination and Crohn ’s disease was suggested by research ers at the Royal Free Hospital and elsewhere in a series of papers published between 1993 and 1996 . It accelerated after February 1998 when the same workers hypothesized an association with autism through a putative mechanism of enterocolitis and toxin absorption . The widespread media coverage that the papers received result ed in a substantial minority of parents being misled into believing that there was a large body of medical opinion suspicious of MMR .  Uptake of MMR vaccine  began to decline rapidly and the incidence of measles and mumps infections increased . Novel methods of improving uptake of MMR vaccine  have been explored , but the authors ’ approach – to issue teddy bears wearing T-shirts displaying a website address and telephone number that provided information about MMR – has not been described previously . A pragmatic r and omized controlled trial was design ed with prospect i ve selection of subjects . Children eligible for their first dose of MMR vaccine ( MMR1 ) in Flintshire , being seen by their health visitor ( HV ) for the routine 8-month assessment , were recruited to the study . At the time of planning the study , Flintshire had the lowest uptake rate of all childhood immunizations inWales and the lowest uptake of MMR1 ( 69 % ) in North Wales . Children were r and omized to receive normal management plus a teddy bear ( intervention arm of the study ) or normal management alone ( nonintervention arm of the study ) . The bear ’s T-shirt contained three items of information We conducted a r and omized , controlled trial to determine the effectiveness of an immunization tracking system design ed to increase the number of infants of lower socioeconomic status who receive their primary series of vaccinations at age-appropriate times . By 7 months of age , 91 % ( 274/301 ) of the infants in the intervention group were up-to- date on their primary series of vaccinations versus 72 % ( 214/296 ) of the infants in the control group ( p < 0.0001 ) . The estimated cost of follow-up for each infant in the intervention group was $ 18.05 . ( J PEDIATR 1995 ; 126:583 - 6 Despite the widespread use of home based child health records of varying complexity in Engl and , there is a notable absence of their evaluation . Such a record booklet developed in the West Lambeth Health Authority has been used by parents , doctors , and community nurses to build up an independent chronological record of a child 's birth statistics , health , growth , immunisation , development checks , and contacts with health services . A r and omised controlled evaluation of the record , analyses of entries in it , and a survey of the views of mothers and health professionals using the record have been carried out . The need for such a record was confirmed by those question ed and analyses of entries in the booklet helped to modify and improve it . The evaluation was unable to show , however , any effect of the record on immunisation and developmental assessment service uptake . Its value in improving communication between the numerous health and other care agencies was dependent on its proper use Background . Immunization rates have improved in the United States , but are still far from the national 90 % goal for the year 2000 . There is scant evidence about the effectiveness and costs of automated telephone messages to improve immunization rates among privately insured children . Objective . To evaluate the effectiveness and cost-effectiveness of sending letters , automated telephone messages , or both to families of underimmunized 20-month-olds in a health maintenance organization ( HMO ) . Methods . In this r and omized trial , underimmunized 20-month-olds identified by the HMO 's computerized immunization tracking system were assigned to one of four interventions : 1 ) an automated telephone message alone ; 2 ) a letter alone ; 3 ) an automated telephone message followed by a letter 1 week later ; and 4 ) a letter followed by an automated telephone message 1 week later . The primary outcome was receipt of any needed immunization by 24 months of age . Decision analysis was used to evaluate the projected cost-effectiveness of the alternative strategies . Results . A total of 648 children were r and omized . A letter followed by a telephone message ( 58 % immunized ) was significantly better than either a letter alone ( 44 % immunized ) or a telephone message alone ( 44 % immunized ) . A telephone message followed by a letter ( 53 % immunized ) also was more effective than either alone , although the differences were not statistically significant . Among a similar comparison group that received no systematic intervention , 36 % were immunized . The estimated cost per child immunized was $ 7.00 using letters followed by automated telephone messages , $ 9.80 using automated telephone messages alone , and $ 10.50 using letters alone . Under alternative cost assumptions for automated telephone messages and mailed messages , the cost per child immunized ranged from $ 2.20 to $ 6.50 . Conclusions . For underimmunized 20-month-olds in this HMO setting , letters followed by automated telephone messages were more effective and cost-effective than either message alone . The cost-effectiveness of automated telephone messages and letters may vary widely depending on the setting , and choices among strategies should be tailored to the population s being served BACKGROUND Reminder-recall interventions have improved immunization rates in numerous studies . OBJECTIVE To evaluate the impact of large-scale , registry-based reminder-recall interventions on low immunization rates in an inner-city population . DESIGN R and omized , controlled , effectiveness trial . SETTING Fulton County , Georgia . PARTICIPANTS A total of 3050 children ( 
    Output:
    