Assignment Prompt & Instructions
– 2 years ago
**files (3)**
– ## WK7DIS.DATA.docx
– ## HazelT_2023_Executive_Summary_Quality_Improvement.pdf
– GriefandposttraumaticStress.pdf
**## WK7DIS.DATA.docx**
Self-Study: Correlation
Throughout the course, there will be a self-study Discussion pertaining to an important concept or topic covered within the assigned week. These Discussions are designed to give you the opportunity to collaborate with your peers and faculty, test your knowledge, ask questions, practice research analysis, and assist your peers.
You are not required to post to this forum; however, you are encouraged to post, review the posts of others, as well as answer questions and/or provide clarity and collaboration with your peers. Discussions will be graded as either Complete or Incomplete.
Resources
**To prepare:**
· Read and view the Learning Resources.
**Use** this Discussion to collaborate with your peers and faculty as an open office hours/ Q&A forum.
**Post** answers to the following:
· What is the relationship between correlation and causality?
· What is the role of previous research and theory with regard to causality?
· How does a scatterplot help to visualize a correlation?
· Identify and interpret the correlation used in Turgut and Yıldız (2023) and in Hazel (2023).
· Laerd Statistics
·
[Pearson Correlation in SPSSLinks to an external site.](https://statistics.laerd.com/premium/spss/pc/pearson-correlation-in-spss.php)
https://statistics.laerd.com/premium/spss/pc/pearson-correlation-in-spss.php
· Salkind, N., & Frey, B. (2019). Statistics for people who (think they) hate statistics (7th ed.). SAGE Publications.
· Chapter 6, “Computing Correlation Coefficients: Ice Cream and Crime” (pp. 119–144)
· Chapter 16, “Testing Relationships Using the Correlation Coefficient: Cousins or Just Good Friends" (pp. 303–312)
· Vigen, T. (n.d.).
[_Spurious correlation_ Links to an external site.](https://www.tylervigen.com/spurious-correlations). https://www.tylervigen.com/spurious-correlations
·
**Document:** [Correlation, Scatterplot Exercise (Excel)](https://waldenu.instructure.com/courses/157739/files/12465881?wrap=1) [Download Correlation, Scatterplot Exercise (Excel)](https://waldenu.instructure.com/courses/157739/files/12465881/download?download_frd=1)
·
**Document:** [Correlation Matrix, Data Output (Word document)](https://waldenu.instructure.com/courses/157739/files/12465955?wrap=1)
[Required Resources for Topic: Correlation](https://waldenu.instructure.com/courses/157739/pages/week-7-learning-resources?module_item_id=6373822)
· Turgut, M., & Yıldız, H. (2023).
[Investigation of grief and posttraumatic growth related to patient loss in pediatric intensive care nurses: A cross-sectional studyLinks to an external site.](https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-023-01316-z).
_BMC Palliative Care, 22_(1), 195. https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-023-01316-z
· Document: Hazel, T. (2023, November).
[_Executive summary: Quality improvement initiative pediatric vaccine appointment compliance after text messaging reminders: A retrospective program evaluation of a local quality improvement initiative_](https://waldenu.instructure.com/courses/157739/files/12465870?wrap=1) [Download Executive summary: Quality improvement initiative pediatric vaccine appointment compliance after text messaging reminders: A retrospective program evaluation of a local quality improvement initiative](https://waldenu.instructure.com/courses/157739/files/12465870/download?download_frd=1). Walden University.
**## HazelT_2023_Executive_Summary_Quality_Improvement.pdf**
Walden University
College of Nursing
This is to certify that the doctoral study by
Terrie LaVern Hazel
has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Barbara Niedz, Committee Chairperson, Nursing Faculty
Dr. Marisa Wilson, Committee Member, Nursing Faculty
Chief Academic Officer and Provost
Sue Subocz, Ph.D.
Walden University
2023
Executive Summary: Quality Improvement Initiative
Pediatric Vaccine Appointment Compliance After Text Messaging Reminders: A
Retrospective Program Evaluation of a Local Quality Improvement Initiative
by
Terrie Hazel
MS, Walden University, 2016
BS, Kaplan University, 2012
Executive Summary Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
November 2023
1
Summary
This DNP project presents an evaluation of a local quality improvement initiative
assessing whether the deployment of phone call reminders improved child immunization
appointment adherence in an underserved pediatric patient population. Childhood
immunizations are critical to preventive healthcare, reducing the burden of vaccine-
preventable diseases. Insufficient appointment completion wastes healthcare resources
and increases the frustration of personnel and clients who are forced to wait weeks for an
available visit, compromising access. Data across 12 months on appointment completion
for well-child visits were analyzed; 6 months of data were provided from 2021, prior to
the implementation of the telephone reminders. Data were also provided from an
additional 6-month period in 2022 following the telephone reminder strategy. A
comparative analysis demonstrated an increase in appointment completion from 44.29%
in 2021 to 50.71% in 2022. Correlational analyses showed a strong correlation (r = .710,
p = .004) between completed appointments and time. The proposals of this initiative
center on the need to develop an effective evidence-based intervention to help decrease
no-show appointments and boost vaccination adherence. A key recommendation from
this DNP project emerged: the pediatric practice must keep the automated reminder
system in place to maintain compliance and reduce wasteful spending. The project
confirms that the telephone reminder system is working to improve available
appointments and reduce access disparity in the patient population, a positive social
change that addresses diversity, inclusion, and equity in this underserved population.
2
Background
Primary preventive healthcare focuses on keeping people well, preventing illness
and injury, and educating people about adopting healthier behaviors (Posadzki et al.,
2016). Childhood immunizations are fundamental to preventing the spread of infectious
diseases and safeguarding public health. Despite advancements in immunization
programs, challenges related to adherence to recommended vaccine schedules persist.
The COVID pandemic exacerbated the already prevalent problem of missed
appointments. In the early phases of the global health crisis, the Centers for Disease
Control in 2020 instructed health personnel to delay nonemergency and routine medical
procedures to help maintain the healthcare system's capacity and minimize the possibility
of spread. Pediatric outpatient care visits for children under the age of 18 fell by 70% in
2021 due to parental concerns about COVID-19 exposure to their children and
themselves (Teasdale et al., 2022). Between 18.7 and 20.1 million minors failed to obtain
a final injection of diphtheria, tetanus toxoid, pertussis-containing antigens (DTP3), or
measles vaccine (Gibson et al., 2017). Child immunization is crucial in mitigating and
eradicating infectious diseases; however, adherence remains a pivotal challenge. Engaged
parental participation in immunization services is among the most significant obstacles to
achieving adequate immunization coverage (Feldman et al., 2022). A review of the local
pediatric primary care clinic discovered a 44.28% gap in patients keeping their planned
well-child immunization appointments in 2021. In a time with the growing complexity of
vaccination timelines, higher standards for healthcare provider efficiency, and mounting
requirements on medical providers, it is imperative to recognize and support effective
initiatives in clinical settings. Vaccinations are often skipped for plausible explanations,
3
such as individuals' forgetfulness, skipping visits, or being unfamiliar with immunization
schedules (Jacobson Vann et al., 2018). In recent years, adherence to child immunization
schedules has been identified as a crucial aspect of public health, significantly reducing
the prevalence of preventable diseases. Primary preventive healthcare focuses on
maintaining good health, avoiding illness and injury, and encouraging healthy lifestyle
choices. With children missing out on timely vaccinations, there has been a noted gap in
practice. Addressing these challenges requires innovative strategies, such as phone call
reminders, which leverage technology to enhance patient engagement and adherence.
Evidence suggests that theory-driven behavior change interventions can dramatically
improve health behaviors (Muathe et al., 2020). The project question that guided this
initiative was “Will a retrospective program evaluation of a local QI initiative at the site
demonstrate that child immunization care adherence improves with the deployment of
phone call reminders?” Experts have recommended centralized reminders from state
immunization information systems or healthcare systems as a scalable strategy (Szilagyi
et al., 2020). This quality improvement project occurred at a local pediatric primary care
health center serving a low-income, minority population. The center's historical
immunization data revealed suboptimal up-to-date vaccination rates among pediatric
patients each month. Phone call reminders are a feasible strategy to augment
immunization coverage even in low-resource settings (Brown & Oluwatosin, 2017).
Research by Gibson et al. (2017) and a systematic review by Jacobson Vann et al. (2018)
have further demonstrated the effectiveness of mobile phone-delivered reminders in
improving childhood immunization coverage and timeliness. Given the rapid
advancements in technology and increased accessibility to mobile phones, this project
4
explored the impact of phone call reminders on child immunization adherence through a
retrospective program evaluation of a local quality improvement (QI) initiative.
Project Development
I designed this initiative to implement and assess the impact of mobile text
messaging on well-child visits and immunization care adherence. I aimed to reduce
missed well-child visit appointments and increase vaccination compliance. These
outcomes were assessed by comparing the cumulative data of missed well-child
appointments and vaccine completion in 2021 to those collected on missed well-child
appointments and vaccine completion in 2022 following implementation. Obtaining de-
identified data for this retrospective project was performed by the principal owner of the
pediatric medical practice and the office manager. Successful implementation of the
initiative depended on the collaboration and participation of healthcare personnel within
the organizational structure. The office manager and staff thoroughly understood the
disparity and the proposed protocol by engaging in the early phases of the project
development. Three nurses and four administrative staff members implemented the text
messaging protocol in June 2022. Medical staff texted appointment reminders to the
patients 24 hours before scheduled appointments. Frequent progress updates and open
dialogue were crucial to maintaining worker engagement and guaranteeing the
dissemination of information. Data obtained from 2021 historical appointment attendance
and vaccination records did not contain any personally identifiable information (PII) to
maintain patient privacy. I analyzed the project's data using comparative analysis. Data
was collected from June 2021 to December 2021 before the process and from June 2022
5
to December 2022 after initiation. The comparative period spanned from June 2022 to
December 2022 post initiative launch.
Results
Historical data from June through December 2021 for well-child vaccination
appointment completion (Table 1) and postimplementation data from June through
December 2022 (Table 2) were evaluated through descriptive and correlational analysis.
The attendance rates were calculated by dividing the total number of appointment
completions by the total number of appointments scheduled. There was an overall
increase from 44.29% in 2021 to 50.71% in 2022. Correlational analysis showed a
statistically significant relationship between the passage of time (2021 to 2022) on
completed appointments (r = .710, p =.004). Thus, nearly half of the variance in
appointment completion can be explained by a comparison of 2021 to 2022 appointment
completion rates (r2 = 0.505), see Figure 1. Based on the trend analysis of the intervention
outcome, there was an increase in appointment completion for well-child vaccination
appointments beginning July 2022 that continued through December 2022 as compared
to the same timeframe in 2021. The relationship of the completed appointments to
vaccination rates was 100%. That is, when appointments were completed, vaccinations
were given 100% of the time. Cancelled or no show appointments compromise the
workflow at the site and sometimes result in delayed vaccinations, and at worst,
incomplete or lost vaccinations. Thus, the appointment completion rate in this DNP
project serves as a proxy for completed vaccinations.
6
Table 1
2021 Appointments Pediatric Primary Care
Dates Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21
Total
attendance
152 155 170 190 165 156 128
Total
appointments
scheduled
350 380 380 375 350 350 300
Total
appointment
completion rate
43.00% 40.00% 44.00% 50.00% 47.00% 44.00% 42.00%
Table 2
2022 Appointment Pediatric Primary Care
Dates Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22
Total
attendance
138 158 208 205 187 180 146
Total
appointments
scheduled
300 325 375 375 350 350 300
Total
appointment
completion rate
46.00% 48.00% 55.00% 54.00% 53.00% 51.00% 48.00%
7
Figure 1
Scatterplot: Appointment Completion Rates by Month/Year
The text messaging reminders impacted the pediatric clinic by enhancing
convenience, reducing missed appointments, and ultimately contributing to better
healthcare outcomes for children while improving overall clinic productivity. A
limitation of the effort was that the pediatric clinic treats underserved patients. The
primary challenge does not lie in providing care for this particular population but in the
relatively successful implementation of the intervention, hindered by the difficulty of
ensuring that patients attend their healthcare sessions. That is, the underserved patients
may have other factors that compromise their ability to keep appointments like
transportation issues, interruption of patient caregiver work schedules, and perhaps some
lacking technology advantages (Jacobson Vann et al., 2018). The importance of this
initiative beyond the local site where it took place was the positive social change it
8
brought. It promoted access to care, reduced disparities, and contributed to better
community health. Text messaging reminders for pediatric clinic appointments are
essential to ensure healthcare services are accessible, respectful, and inclusive to all
patients regardless of their socio-economic status or abilities (Brown & Oluwatosin,
2017). It also fostered diversity, equity, inclusion, and justice.
Conclusions
In conclusion, ensuring that children receive their vaccinations on time is crucial
for individual health, the well-being of communities, and the resilience of public health
systems. Text messaging reminders can support healthcare duties, such as illness
prevention and chronic condition management, and even bridge the gap between those
needing care and those who can provide it (Feldman et al., 2022). Evidence showed that
using mobile-delivered reminders considerably increased the rate of childhood
vaccination coverage. In particular, text messaging reminder strategies have shown
efficacy in enhancing vaccination rates and alleviating potential burdens on healthcare
systems and providers by streamlining information delivery and reminder systems
(Posadzki et al., 2016). Recommendations for this initiative focus on the disparity, which
was well defined as the need to implement an effective evidence-based intervention to
help reduce no-show appointments and increase vaccination adherence. Continued use of
the automated reminder system should remain intact for continued compliance and cost-
effectiveness improvements. Despite the hurdles introduced by the pandemic, nursing
observed a positive trend in immunization adherence rates following the implementation
of phone call reminders. Regarding the effect this initiative had on nursing practice, the
COVID-19 pandemic served as a reminder of the importance of maintaining essential
9
healthcare services, and this study reaffirms the role of evidence-based practices, such as
phone call reminders, in achieving this goal. It emphasizes the resilience of pediatric
healthcare and its capacity to overcome obstacles and continue to provide essential care
to children (see Teasdale et al., 2022).
10
References
Brown, V. B., & Oluwatosin, O. A. (2017). Feasibility of implementing a cellphone-
based reminder/recall strategy to improve childhood routine immunization in a
low-resource setting: a descriptive report. BMC Health Services Research,
17(Suppl 2), 703. https://doi.org/10.1186/s12913-017-2639-8
Feldman, A. G., Moore, S., Bull, S., Morris, M. A., Wilson, K., Bell, C., Collins, M. M.,
Denize, K. M., & Kempe, A. (2022). A smartphone app to increase
immunizations in the pediatric solid organ transplant population: Development
and initial usability study. JMIR Formative Research, 6(1), e32273.
https://doi.org/10.2196/32273
Gibson, D. G., Ochieng, B., Kagucia, E., Were, J., Hayford, K., Moulton, L. H., Levine,
O. S., Odhiambo, F., O'Brien, K. L., & Feikin, D. R. (2017). Mobile phone-
delivered reminders and incentives to improve childhood immunization coverage
and timeliness in Kenya (m-simu): A randomized controlled trial. Lancet Global
Health, 5(4), e428–e438. https://doi.org/10.1016/s2214-109x(17)30072-4
Jacobson Vann, J. C., Jacobson, R. M., Coyne-Beasley, T., Asafu-Adjei, J. K., &
Szilagyi, P. G. (2018). Patient reminder and recall interventions to improve
immunization rates. Cochrane Database of Systematic Reviews, 2018(1).
https://doi.org/10.1002/14651858.cd003941.pub3
Muathe, E., Kamau, M., & Rajula, E. (2020). Exploring strategies to improve adherence
to immunization schedule: A study among children attending maternal and child
health clinic at Kenyatta National Hospital, Nairobi, Kenya. International Journal
of Pediatrics, 2020, Article 4730205, 1–8. https://doi.org/10.1155/2020/4730205
11
Posadzki, P., Mastellos, N., Ryan, R., Gunn, L. H., Felix, L. M., Pappas, Y., Gagnon, M.-
P., Julious, S. A., Xiang, L., Oldenburg, B., & Car, J. (2016). Automated
telephone communication systems for preventive healthcare and management of
long-term conditions. Cochrane Database of Systematic Reviews, 2016(12).
https://doi.org/10.1002/14651858.cd009921.pub2
Szilagyi, P. G., Albertin, C., Casillas, A., Valderrama, R., Duru, O., Ong, M. K.,
Vangala, S., Tseng, C.-H., Rand, C. M., Humiston, S. G., Evans, S., Sloyan, M.,
& Lerner, C. (2020). Effect of patient portal reminders sent by a health care
system on influenza vaccination rates. JAMA Internal Medicine, 180(7), 962.
https://doi.org/10.1001/jamainternmed.2020.1602
Teasdale, C. A., Borrell, L. N., Shen, Y., Kimball, S., Zimba, R., Kulkarni, S., Rane, M.,
Rinke, M. L., Fleary, S. A., & Nash, D. (2022). Missed routine pediatric care and
vaccinations in us children during the first year of the COVID-19 pandemic.
Preventive Medicine, 158, 107025. https://doi.org/10.1016/j.ypmed.2022.107025
**GriefandposttraumaticStress.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/griefandposttraumaticstress-pdf)
**GriefandposttraumaticStress.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/griefandposttraumaticstress-pdf)
**## WK7DIS.DATA.docx**
Self-Study: Correlation
Throughout the course, there will be a self-study Discussion pertaining to an important concept or topic covered within the assigned week. These Discussions are designed to give you the opportunity to collaborate with your peers and faculty, test your knowledge, ask questions, practice research analysis, and assist your peers.
You are not required to post to this forum; however, you are encouraged to post, review the posts of others, as well as answer questions and/or provide clarity and collaboration with your peers. Discussions will be graded as either Complete or Incomplete.
Resources
**To prepare:**
· Read and view the Learning Resources.
**Use** this Discussion to collaborate with your peers and faculty as an open office hours/ Q&A forum.
**Post** answers to the following:
· What is the relationship between correlation and causality?
· What is the role of previous research and theory with regard to causality?
· How does a scatterplot help to visualize a correlation?
· Identify and interpret the correlation used in Turgut and Yıldız (2023) and in Hazel (2023).
· Laerd Statistics
·
[Pearson Correlation in SPSSLinks to an external site.](https://statistics.laerd.com/premium/spss/pc/pearson-correlation-in-spss.php)
https://statistics.laerd.com/premium/spss/pc/pearson-correlation-in-spss.php
· Salkind, N., & Frey, B. (2019). Statistics for people who (think they) hate statistics (7th ed.). SAGE Publications.
· Chapter 6, “Computing Correlation Coefficients: Ice Cream and Crime” (pp. 119–144)
· Chapter 16, “Testing Relationships Using the Correlation Coefficient: Cousins or Just Good Friends" (pp. 303–312)
· Vigen, T. (n.d.).
[_Spurious correlation_ Links to an external site.](https://www.tylervigen.com/spurious-correlations). https://www.tylervigen.com/spurious-correlations
·
**Document:** [Correlation, Scatterplot Exercise (Excel)](https://waldenu.instructure.com/courses/157739/files/12465881?wrap=1) [Download Correlation, Scatterplot Exercise (Excel)](https://waldenu.instructure.com/courses/157739/files/12465881/download?download_frd=1)
·
**Document:** [Correlation Matrix, Data Output (Word document)](https://waldenu.instructure.com/courses/157739/files/12465955?wrap=1)
[Required Resources for Topic: Correlation](https://waldenu.instructure.com/courses/157739/pages/week-7-learning-resources?module_item_id=6373822)
· Turgut, M., & Yıldız, H. (2023).
[Investigation of grief and posttraumatic growth related to patient loss in pediatric intensive care nurses: A cross-sectional studyLinks to an external site.](https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-023-01316-z).
_BMC Palliative Care, 22_(1), 195. https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-023-01316-z
· Document: Hazel, T. (2023, November).
[_Executive summary: Quality improvement initiative pediatric vaccine appointment compliance after text messaging reminders: A retrospective program evaluation of a local quality improvement initiative_](https://waldenu.instructure.com/courses/157739/files/12465870?wrap=1) [Download Executive summary: Quality improvement initiative pediatric vaccine appointment compliance after text messaging reminders: A retrospective program evaluation of a local quality improvement initiative](https://waldenu.instructure.com/courses/157739/files/12465870/download?download_frd=1). Walden University.
**## HazelT_2023_Executive_Summary_Quality_Improvement.pdf**
Walden University
College of Nursing
This is to certify that the doctoral study by
Terrie LaVern Hazel
has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Barbara Niedz, Committee Chairperson, Nursing Faculty
Dr. Marisa Wilson, Committee Member, Nursing Faculty
Chief Academic Officer and Provost
Sue Subocz, Ph.D.
Walden University
2023
Executive Summary: Quality Improvement Initiative
Pediatric Vaccine Appointment Compliance After Text Messaging Reminders: A
Retrospective Program Evaluation of a Local Quality Improvement Initiative
by
Terrie Hazel
MS, Walden University, 2016
BS, Kaplan University, 2012
Executive Summary Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
November 2023
1
Summary
This DNP project presents an evaluation of a local quality improvement initiative
assessing whether the deployment of phone call reminders improved child immunization
appointment adherence in an underserved pediatric patient population. Childhood
immunizations are critical to preventive healthcare, reducing the burden of vaccine-
preventable diseases. Insufficient appointment completion wastes healthcare resources
and increases the frustration of personnel and clients who are forced to wait weeks for an
available visit, compromising access. Data across 12 months on appointment completion
for well-child visits were analyzed; 6 months of data were provided from 2021, prior to
the implementation of the telephone reminders. Data were also provided from an
additional 6-month period in 2022 following the telephone reminder strategy. A
comparative analysis demonstrated an increase in appointment completion from 44.29%
in 2021 to 50.71% in 2022. Correlational analyses showed a strong correlation (r = .710,
p = .004) between completed appointments and time. The proposals of this initiative
center on the need to develop an effective evidence-based intervention to help decrease
no-show appointments and boost vaccination adherence. A key recommendation from
this DNP project emerged: the pediatric practice must keep the automated reminder
system in place to maintain compliance and reduce wasteful spending. The project
confirms that the telephone reminder system is working to improve available
appointments and reduce access disparity in the patient population, a positive social
change that addresses diversity, inclusion, and equity in this underserved population.
2
Background
Primary preventive healthcare focuses on keeping people well, preventing illness
and injury, and educating people about adopting healthier behaviors (Posadzki et al.,
2016). Childhood immunizations are fundamental to preventing the spread of infectious
diseases and safeguarding public health. Despite advancements in immunization
programs, challenges related to adherence to recommended vaccine schedules persist.
The COVID pandemic exacerbated the already prevalent problem of missed
appointments. In the early phases of the global health crisis, the Centers for Disease
Control in 2020 instructed health personnel to delay nonemergency and routine medical
procedures to help maintain the healthcare system's capacity and minimize the possibility
of spread. Pediatric outpatient care visits for children under the age of 18 fell by 70% in
2021 due to parental concerns about COVID-19 exposure to their children and
themselves (Teasdale et al., 2022). Between 18.7 and 20.1 million minors failed to obtain
a final injection of diphtheria, tetanus toxoid, pertussis-containing antigens (DTP3), or
measles vaccine (Gibson et al., 2017). Child immunization is crucial in mitigating and
eradicating infectious diseases; however, adherence remains a pivotal challenge. Engaged
parental participation in immunization services is among the most significant obstacles to
achieving adequate immunization coverage (Feldman et al., 2022). A review of the local
pediatric primary care clinic discovered a 44.28% gap in patients keeping their planned
well-child immunization appointments in 2021. In a time with the growing complexity of
vaccination timelines, higher standards for healthcare provider efficiency, and mounting
requirements on medical providers, it is imperative to recognize and support effective
initiatives in clinical settings. Vaccinations are often skipped for plausible explanations,
3
such as individuals' forgetfulness, skipping visits, or being unfamiliar with immunization
schedules (Jacobson Vann et al., 2018). In recent years, adherence to child immunization
schedules has been identified as a crucial aspect of public health, significantly reducing
the prevalence of preventable diseases. Primary preventive healthcare focuses on
maintaining good health, avoiding illness and injury, and encouraging healthy lifestyle
choices. With children missing out on timely vaccinations, there has been a noted gap in
practice. Addressing these challenges requires innovative strategies, such as phone call
reminders, which leverage technology to enhance patient engagement and adherence.
Evidence suggests that theory-driven behavior change interventions can dramatically
improve health behaviors (Muathe et al., 2020). The project question that guided this
initiative was “Will a retrospective program evaluation of a local QI initiative at the site
demonstrate that child immunization care adherence improves with the deployment of
phone call reminders?” Experts have recommended centralized reminders from state
immunization information systems or healthcare systems as a scalable strategy (Szilagyi
et al., 2020). This quality improvement project occurred at a local pediatric primary care
health center serving a low-income, minority population. The center's historical
immunization data revealed suboptimal up-to-date vaccination rates among pediatric
patients each month. Phone call reminders are a feasible strategy to augment
immunization coverage even in low-resource settings (Brown & Oluwatosin, 2017).
Research by Gibson et al. (2017) and a systematic review by Jacobson Vann et al. (2018)
have further demonstrated the effectiveness of mobile phone-delivered reminders in
improving childhood immunization coverage and timeliness. Given the rapid
advancements in technology and increased accessibility to mobile phones, this project
4
explored the impact of phone call reminders on child immunization adherence through a
retrospective program evaluation of a local quality improvement (QI) initiative.
Project Development
I designed this initiative to implement and assess the impact of mobile text
messaging on well-child visits and immunization care adherence. I aimed to reduce
missed well-child visit appointments and increase vaccination compliance. These
outcomes were assessed by comparing the cumulative data of missed well-child
appointments and vaccine completion in 2021 to those collected on missed well-child
appointments and vaccine completion in 2022 following implementation. Obtaining de-
identified data for this retrospective project was performed by the principal owner of the
pediatric medical practice and the office manager. Successful implementation of the
initiative depended on the collaboration and participation of healthcare personnel within
the organizational structure. The office manager and staff thoroughly understood the
disparity and the proposed protocol by engaging in the early phases of the project
development. Three nurses and four administrative staff members implemented the text
messaging protocol in June 2022. Medical staff texted appointment reminders to the
patients 24 hours before scheduled appointments. Frequent progress updates and open
dialogue were crucial to maintaining worker engagement and guaranteeing the
dissemination of information. Data obtained from 2021 historical appointment attendance
and vaccination records did not contain any personally identifiable information (PII) to
maintain patient privacy. I analyzed the project's data using comparative analysis. Data
was collected from June 2021 to December 2021 before the process and from June 2022
5
to December 2022 after initiation. The comparative period spanned from June 2022 to
December 2022 post initiative launch.
Results
Historical data from June through December 2021 for well-child vaccination
appointment completion (Table 1) and postimplementation data from June through
December 2022 (Table 2) were evaluated through descriptive and correlational analysis.
The attendance rates were calculated by dividing the total number of appointment
completions by the total number of appointments scheduled. There was an overall
increase from 44.29% in 2021 to 50.71% in 2022. Correlational analysis showed a
statistically significant relationship between the passage of time (2021 to 2022) on
completed appointments (r = .710, p =.004). Thus, nearly half of the variance in
appointment completion can be explained by a comparison of 2021 to 2022 appointment
completion rates (r2 = 0.505), see Figure 1. Based on the trend analysis of the intervention
outcome, there was an increase in appointment completion for well-child vaccination
appointments beginning July 2022 that continued through December 2022 as compared
to the same timeframe in 2021. The relationship of the completed appointments to
vaccination rates was 100%. That is, when appointments were completed, vaccinations
were given 100% of the time. Cancelled or no show appointments compromise the
workflow at the site and sometimes result in delayed vaccinations, and at worst,
incomplete or lost vaccinations. Thus, the appointment completion rate in this DNP
project serves as a proxy for completed vaccinations.
6
Table 1
2021 Appointments Pediatric Primary Care
Dates Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21
Total
attendance
152 155 170 190 165 156 128
Total
appointments
scheduled
350 380 380 375 350 350 300
Total
appointment
completion rate
43.00% 40.00% 44.00% 50.00% 47.00% 44.00% 42.00%
Table 2
2022 Appointment Pediatric Primary Care
Dates Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22
Total
attendance
138 158 208 205 187 180 146
Total
appointments
scheduled
300 325 375 375 350 350 300
Total
appointment
completion rate
46.00% 48.00% 55.00% 54.00% 53.00% 51.00% 48.00%
7
Figure 1
Scatterplot: Appointment Completion Rates by Month/Year
The text messaging reminders impacted the pediatric clinic by enhancing
convenience, reducing missed appointments, and ultimately contributing to better
healthcare outcomes for children while improving overall clinic productivity. A
limitation of the effort was that the pediatric clinic treats underserved patients. The
primary challenge does not lie in providing care for this particular population but in the
relatively successful implementation of the intervention, hindered by the difficulty of
ensuring that patients attend their healthcare sessions. That is, the underserved patients
may have other factors that compromise their ability to keep appointments like
transportation issues, interruption of patient caregiver work schedules, and perhaps some
lacking technology advantages (Jacobson Vann et al., 2018). The importance of this
initiative beyond the local site where it took place was the positive social change it
8
brought. It promoted access to care, reduced disparities, and contributed to better
community health. Text messaging reminders for pediatric clinic appointments are
essential to ensure healthcare services are accessible, respectful, and inclusive to all
patients regardless of their socio-economic status or abilities (Brown & Oluwatosin,
2017). It also fostered diversity, equity, inclusion, and justice.
Conclusions
In conclusion, ensuring that children receive their vaccinations on time is crucial
for individual health, the well-being of communities, and the resilience of public health
systems. Text messaging reminders can support healthcare duties, such as illness
prevention and chronic condition management, and even bridge the gap between those
needing care and those who can provide it (Feldman et al., 2022). Evidence showed that
using mobile-delivered reminders considerably increased the rate of childhood
vaccination coverage. In particular, text messaging reminder strategies have shown
efficacy in enhancing vaccination rates and alleviating potential burdens on healthcare
systems and providers by streamlining information delivery and reminder systems
(Posadzki et al., 2016). Recommendations for this initiative focus on the disparity, which
was well defined as the need to implement an effective evidence-based intervention to
help reduce no-show appointments and increase vaccination adherence. Continued use of
the automated reminder system should remain intact for continued compliance and cost-
effectiveness improvements. Despite the hurdles introduced by the pandemic, nursing
observed a positive trend in immunization adherence rates following the implementation
of phone call reminders. Regarding the effect this initiative had on nursing practice, the
COVID-19 pandemic served as a reminder of the importance of maintaining essential
9
healthcare services, and this study reaffirms the role of evidence-based practices, such as
phone call reminders, in achieving this goal. It emphasizes the resilience of pediatric
healthcare and its capacity to overcome obstacles and continue to provide essential care
to children (see Teasdale et al., 2022).
10
References
Brown, V. B., & Oluwatosin, O. A. (2017). Feasibility of implementing a cellphone-
based reminder/recall strategy to improve childhood routine immunization in a
low-resource setting: a descriptive report. BMC Health Services Research,
17(Suppl 2), 703. https://doi.org/10.1186/s12913-017-2639-8
Feldman, A. G., Moore, S., Bull, S., Morris, M. A., Wilson, K., Bell, C., Collins, M. M.,
Denize, K. M., & Kempe, A. (2022). A smartphone app to increase
immunizations in the pediatric solid organ transplant population: Development
and initial usability study. JMIR Formative Research, 6(1), e32273.
https://doi.org/10.2196/32273
Gibson, D. G., Ochieng, B., Kagucia, E., Were, J., Hayford, K., Moulton, L. H., Levine,
O. S., Odhiambo, F., O'Brien, K. L., & Feikin, D. R. (2017). Mobile phone-
delivered reminders and incentives to improve childhood immunization coverage
and timeliness in Kenya (m-simu): A randomized controlled trial. Lancet Global
Health, 5(4), e428–e438. https://doi.org/10.1016/s2214-109x(17)30072-4
Jacobson Vann, J. C., Jacobson, R. M., Coyne-Beasley, T., Asafu-Adjei, J. K., &
Szilagyi, P. G. (2018). Patient reminder and recall interventions to improve
immunization rates. Cochrane Database of Systematic Reviews, 2018(1).
https://doi.org/10.1002/14651858.cd003941.pub3
Muathe, E., Kamau, M., & Rajula, E. (2020). Exploring strategies to improve adherence
to immunization schedule: A study among children attending maternal and child
health clinic at Kenyatta National Hospital, Nairobi, Kenya. International Journal
of Pediatrics, 2020, Article 4730205, 1–8. https://doi.org/10.1155/2020/4730205
11
Posadzki, P., Mastellos, N., Ryan, R., Gunn, L. H., Felix, L. M., Pappas, Y., Gagnon, M.-
P., Julious, S. A., Xiang, L., Oldenburg, B., & Car, J. (2016). Automated
telephone communication systems for preventive healthcare and management of
long-term conditions. Cochrane Database of Systematic Reviews, 2016(12).
https://doi.org/10.1002/14651858.cd009921.pub2
Szilagyi, P. G., Albertin, C., Casillas, A., Valderrama, R., Duru, O., Ong, M. K.,
Vangala, S., Tseng, C.-H., Rand, C. M., Humiston, S. G., Evans, S., Sloyan, M.,
& Lerner, C. (2020). Effect of patient portal reminders sent by a health care
system on influenza vaccination rates. JAMA Internal Medicine, 180(7), 962.
https://doi.org/10.1001/jamainternmed.2020.1602
Teasdale, C. A., Borrell, L. N., Shen, Y., Kimball, S., Zimba, R., Kulkarni, S., Rane, M.,
Rinke, M. L., Fleary, S. A., & Nash, D. (2022). Missed routine pediatric care and
vaccinations in us children during the first year of the COVID-19 pandemic.
Preventive Medicine, 158, 107025. https://doi.org/10.1016/j.ypmed.2022.107025
**GriefandposttraumaticStress.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/griefandposttraumaticstress-pdf)
**## WK7DIS.DATA.docx**
Self-Study: Correlation
Throughout the course, there will be a self-study Discussion pertaining to an important concept or topic covered within the assigned week. These Discussions are designed to give you the opportunity to collaborate with your peers and faculty, test your knowledge, ask questions, practice research analysis, and assist your peers.
You are not required to post to this forum; however, you are encouraged to post, review the posts of others, as well as answer questions and/or provide clarity and collaboration with your peers. Discussions will be graded as either Complete or Incomplete.
Resources
**To prepare:**
· Read and view the Learning Resources.
**Use** this Discussion to collaborate with your peers and faculty as an open office hours/ Q&A forum.
**Post** answers to the following:
· What is the relationship between correlation and causality?
· What is the role of previous research and theory with regard to causality?
· How does a scatterplot help to visualize a correlation?
· Identify and interpret the correlation used in Turgut and Yıldız (2023) and in Hazel (2023).
· Laerd Statistics
·
[Pearson Correlation in SPSSLinks to an external site.](https://statistics.laerd.com/premium/spss/pc/pearson-correlation-in-spss.php)
https://statistics.laerd.com/premium/spss/pc/pearson-correlation-in-spss.php
· Salkind, N., & Frey, B. (2019). Statistics for people who (think they) hate statistics (7th ed.). SAGE Publications.
· Chapter 6, “Computing Correlation Coefficients: Ice Cream and Crime” (pp. 119–144)
· Chapter 16, “Testing Relationships Using the Correlation Coefficient: Cousins or Just Good Friends" (pp. 303–312)
· Vigen, T. (n.d.).
[_Spurious correlation_ Links to an external site.](https://www.tylervigen.com/spurious-correlations). https://www.tylervigen.com/spurious-correlations
·
**Document:** [Correlation, Scatterplot Exercise (Excel)](https://waldenu.instructure.com/courses/157739/files/12465881?wrap=1) [Download Correlation, Scatterplot Exercise (Excel)](https://waldenu.instructure.com/courses/157739/files/12465881/download?download_frd=1)
·
**Document:** [Correlation Matrix, Data Output (Word document)](https://waldenu.instructure.com/courses/157739/files/12465955?wrap=1)
[Required Resources for Topic: Correlation](https://waldenu.instructure.com/courses/157739/pages/week-7-learning-resources?module_item_id=6373822)
· Turgut, M., & Yıldız, H. (2023).
[Investigation of grief and posttraumatic growth related to patient loss in pediatric intensive care nurses: A cross-sectional studyLinks to an external site.](https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-023-01316-z).
_BMC Palliative Care, 22_(1), 195. https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-023-01316-z
· Document: Hazel, T. (2023, November).
[_Executive summary: Quality improvement initiative pediatric vaccine appointment compliance after text messaging reminders: A retrospective program evaluation of a local quality improvement initiative_](https://waldenu.instructure.com/courses/157739/files/12465870?wrap=1) [Download Executive summary: Quality improvement initiative pediatric vaccine appointment compliance after text messaging reminders: A retrospective program evaluation of a local quality improvement initiative](https://waldenu.instructure.com/courses/157739/files/12465870/download?download_frd=1). Walden University.
**## HazelT_2023_Executive_Summary_Quality_Improvement.pdf**
Walden University
College of Nursing
This is to certify that the doctoral study by
Terrie LaVern Hazel
has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Barbara Niedz, Committee Chairperson, Nursing Faculty
Dr. Marisa Wilson, Committee Member, Nursing Faculty
Chief Academic Officer and Provost
Sue Subocz, Ph.D.
Walden University
2023
Executive Summary: Quality Improvement Initiative
Pediatric Vaccine Appointment Compliance After Text Messaging Reminders: A
Retrospective Program Evaluation of a Local Quality Improvement Initiative
by
Terrie Hazel
MS, Walden University, 2016
BS, Kaplan University, 2012
Executive Summary Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
November 2023
1
Summary
This DNP project presents an evaluation of a local quality improvement initiative
assessing whether the deployment of phone call reminders improved child immunization
appointment adherence in an underserved pediatric patient population. Childhood
immunizations are critical to preventive healthcare, reducing the burden of vaccine-
preventable diseases. Insufficient appointment completion wastes healthcare resources
and increases the frustration of personnel and clients who are forced to wait weeks for an
available visit, compromising access. Data across 12 months on appointment completion
for well-child visits were analyzed; 6 months of data were provided from 2021, prior to
the implementation of the telephone reminders. Data were also provided from an
additional 6-month period in 2022 following the telephone reminder strategy. A
comparative analysis demonstrated an increase in appointment completion from 44.29%
in 2021 to 50.71% in 2022. Correlational analyses showed a strong correlation (r = .710,
p = .004) between completed appointments and time. The proposals of this initiative
center on the need to develop an effective evidence-based intervention to help decrease
no-show appointments and boost vaccination adherence. A key recommendation from
this DNP project emerged: the pediatric practice must keep the automated reminder
system in place to maintain compliance and reduce wasteful spending. The project
confirms that the telephone reminder system is working to improve available
appointments and reduce access disparity in the patient population, a positive social
change that addresses diversity, inclusion, and equity in this underserved population.
2
Background
Primary preventive healthcare focuses on keeping people well, preventing illness
and injury, and educating people about adopting healthier behaviors (Posadzki et al.,
2016). Childhood immunizations are fundamental to preventing the spread of infectious
diseases and safeguarding public health. Despite advancements in immunization
programs, challenges related to adherence to recommended vaccine schedules persist.
The COVID pandemic exacerbated the already prevalent problem of missed
appointments. In the early phases of the global health crisis, the Centers for Disease
Control in 2020 instructed health personnel to delay nonemergency and routine medical
procedures to help maintain the healthcare system's capacity and minimize the possibility
of spread. Pediatric outpatient care visits for children under the age of 18 fell by 70% in
2021 due to parental concerns about COVID-19 exposure to their children and
themselves (Teasdale et al., 2022). Between 18.7 and 20.1 million minors failed to obtain
a final injection of diphtheria, tetanus toxoid, pertussis-containing antigens (DTP3), or
measles vaccine (Gibson et al., 2017). Child immunization is crucial in mitigating and
eradicating infectious diseases; however, adherence remains a pivotal challenge. Engaged
parental participation in immunization services is among the most significant obstacles to
achieving adequate immunization coverage (Feldman et al., 2022). A review of the local
pediatric primary care clinic discovered a 44.28% gap in patients keeping their planned
well-child immunization appointments in 2021. In a time with the growing complexity of
vaccination timelines, higher standards for healthcare provider efficiency, and mounting
requirements on medical providers, it is imperative to recognize and support effective
initiatives in clinical settings. Vaccinations are often skipped for plausible explanations,
3
such as individuals' forgetfulness, skipping visits, or being unfamiliar with immunization
schedules (Jacobson Vann et al., 2018). In recent years, adherence to child immunization
schedules has been identified as a crucial aspect of public health, significantly reducing
the prevalence of preventable diseases. Primary preventive healthcare focuses on
maintaining good health, avoiding illness and injury, and encouraging healthy lifestyle
choices. With children missing out on timely vaccinations, there has been a noted gap in
practice. Addressing these challenges requires innovative strategies, such as phone call
reminders, which leverage technology to enhance patient engagement and adherence.
Evidence suggests that theory-driven behavior change interventions can dramatically
improve health behaviors (Muathe et al., 2020). The project question that guided this
initiative was “Will a retrospective program evaluation of a local QI initiative at the site
demonstrate that child immunization care adherence improves with the deployment of
phone call reminders?” Experts have recommended centralized reminders from state
immunization information systems or healthcare systems as a scalable strategy (Szilagyi
et al., 2020). This quality improvement project occurred at a local pediatric primary care
health center serving a low-income, minority population. The center's historical
immunization data revealed suboptimal up-to-date vaccination rates among pediatric
patients each month. Phone call reminders are a feasible strategy to augment
immunization coverage even in low-resource settings (Brown & Oluwatosin, 2017).
Research by Gibson et al. (2017) and a systematic review by Jacobson Vann et al. (2018)
have further demonstrated the effectiveness of mobile phone-delivered reminders in
improving childhood immunization coverage and timeliness. Given the rapid
advancements in technology and increased accessibility to mobile phones, this project
4
explored the impact of phone call reminders on child immunization adherence through a
retrospective program evaluation of a local quality improvement (QI) initiative.
Project Development
I designed this initiative to implement and assess the impact of mobile text
messaging on well-child visits and immunization care adherence. I aimed to reduce
missed well-child visit appointments and increase vaccination compliance. These
outcomes were assessed by comparing the cumulative data of missed well-child
appointments and vaccine completion in 2021 to those collected on missed well-child
appointments and vaccine completion in 2022 following implementation. Obtaining de-
identified data for this retrospective project was performed by the principal owner of the
pediatric medical practice and the office manager. Successful implementation of the
initiative depended on the collaboration and participation of healthcare personnel within
the organizational structure. The office manager and staff thoroughly understood the
disparity and the proposed protocol by engaging in the early phases of the project
development. Three nurses and four administrative staff members implemented the text
messaging protocol in June 2022. Medical staff texted appointment reminders to the
patients 24 hours before scheduled appointments. Frequent progress updates and open
dialogue were crucial to maintaining worker engagement and guaranteeing the
dissemination of information. Data obtained from 2021 historical appointment attendance
and vaccination records did not contain any personally identifiable information (PII) to
maintain patient privacy. I analyzed the project's data using comparative analysis. Data
was collected from June 2021 to December 2021 before the process and from June 2022
5
to December 2022 after initiation. The comparative period spanned from June 2022 to
December 2022 post initiative launch.
Results
Historical data from June through December 2021 for well-child vaccination
appointment completion (Table 1) and postimplementation data from June through
December 2022 (Table 2) were evaluated through descriptive and correlational analysis.
The attendance rates were calculated by dividing the total number of appointment
completions by the total number of appointments scheduled. There was an overall
increase from 44.29% in 2021 to 50.71% in 2022. Correlational analysis showed a
statistically significant relationship between the passage of time (2021 to 2022) on
completed appointments (r = .710, p =.004). Thus, nearly half of the variance in
appointment completion can be explained by a comparison of 2021 to 2022 appointment
completion rates (r2 = 0.505), see Figure 1. Based on the trend analysis of the intervention
outcome, there was an increase in appointment completion for well-child vaccination
appointments beginning July 2022 that continued through December 2022 as compared
to the same timeframe in 2021. The relationship of the completed appointments to
vaccination rates was 100%. That is, when appointments were completed, vaccinations
were given 100% of the time. Cancelled or no show appointments compromise the
workflow at the site and sometimes result in delayed vaccinations, and at worst,
incomplete or lost vaccinations. Thus, the appointment completion rate in this DNP
project serves as a proxy for completed vaccinations.
6
Table 1
2021 Appointments Pediatric Primary Care
Dates Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21
Total
attendance
152 155 170 190 165 156 128
Total
appointments
scheduled
350 380 380 375 350 350 300
Total
appointment
completion rate
43.00% 40.00% 44.00% 50.00% 47.00% 44.00% 42.00%
Table 2
2022 Appointment Pediatric Primary Care
Dates Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22
Total
attendance
138 158 208 205 187 180 146
Total
appointments
scheduled
300 325 375 375 350 350 300
Total
appointment
completion rate
46.00% 48.00% 55.00% 54.00% 53.00% 51.00% 48.00%
7
Figure 1
Scatterplot: Appointment Completion Rates by Month/Year
The text messaging reminders impacted the pediatric clinic by enhancing
convenience, reducing missed appointments, and ultimately contributing to better
healthcare outcomes for children while improving overall clinic productivity. A
limitation of the effort was that the pediatric clinic treats underserved patients. The
primary challenge does not lie in providing care for this particular population but in the
relatively successful implementation of the intervention, hindered by the difficulty of
ensuring that patients attend their healthcare sessions. That is, the underserved patients
may have other factors that compromise their ability to keep appointments like
transportation issues, interruption of patient caregiver work schedules, and perhaps some
lacking technology advantages (Jacobson Vann et al., 2018). The importance of this
initiative beyond the local site where it took place was the positive social change it
8
brought. It promoted access to care, reduced disparities, and contributed to better
community health. Text messaging reminders for pediatric clinic appointments are
essential to ensure healthcare services are accessible, respectful, and inclusive to all
patients regardless of their socio-economic status or abilities (Brown & Oluwatosin,
2017). It also fostered diversity, equity, inclusion, and justice.
Conclusions
In conclusion, ensuring that children receive their vaccinations on time is crucial
for individual health, the well-being of communities, and the resilience of public health
systems. Text messaging reminders can support healthcare duties, such as illness
prevention and chronic condition management, and even bridge the gap between those
needing care and those who can provide it (Feldman et al., 2022). Evidence showed that
using mobile-delivered reminders considerably increased the rate of childhood
vaccination coverage. In particular, text messaging reminder strategies have shown
efficacy in enhancing vaccination rates and alleviating potential burdens on healthcare
systems and providers by streamlining information delivery and reminder systems
(Posadzki et al., 2016). Recommendations for this initiative focus on the disparity, which
was well defined as the need to implement an effective evidence-based intervention to
help reduce no-show appointments and increase vaccination adherence. Continued use of
the automated reminder system should remain intact for continued compliance and cost-
effectiveness improvements. Despite the hurdles introduced by the pandemic, nursing
observed a positive trend in immunization adherence rates following the implementation
of phone call reminders. Regarding the effect this initiative had on nursing practice, the
COVID-19 pandemic served as a reminder of the importance of maintaining essential
9
healthcare services, and this study reaffirms the role of evidence-based practices, such as
phone call reminders, in achieving this goal. It emphasizes the resilience of pediatric
healthcare and its capacity to overcome obstacles and continue to provide essential care
to children (see Teasdale et al., 2022).
10
References
Brown, V. B., & Oluwatosin, O. A. (2017). Feasibility of implementing a cellphone-
based reminder/recall strategy to improve childhood routine immunization in a
low-resource setting: a descriptive report. BMC Health Services Research,
17(Suppl 2), 703. https://doi.org/10.1186/s12913-017-2639-8
Feldman, A. G., Moore, S., Bull, S., Morris, M. A., Wilson, K., Bell, C., Collins, M. M.,
Denize, K. M., & Kempe, A. (2022). A smartphone app to increase
immunizations in the pediatric solid organ transplant population: Development
and initial usability study. JMIR Formative Research, 6(1), e32273.
https://doi.org/10.2196/32273
Gibson, D. G., Ochieng, B., Kagucia, E., Were, J., Hayford, K., Moulton, L. H., Levine,
O. S., Odhiambo, F., O'Brien, K. L., & Feikin, D. R. (2017). Mobile phone-
delivered reminders and incentives to improve childhood immunization coverage
and timeliness in Kenya (m-simu): A randomized controlled trial. Lancet Global
Health, 5(4), e428–e438. https://doi.org/10.1016/s2214-109x(17)30072-4
Jacobson Vann, J. C., Jacobson, R. M., Coyne-Beasley, T., Asafu-Adjei, J. K., &
Szilagyi, P. G. (2018). Patient reminder and recall interventions to improve
immunization rates. Cochrane Database of Systematic Reviews, 2018(1).
https://doi.org/10.1002/14651858.cd003941.pub3
Muathe, E., Kamau, M., & Rajula, E. (2020). Exploring strategies to improve adherence
to immunization schedule: A study among children attending maternal and child
health clinic at Kenyatta National Hospital, Nairobi, Kenya. International Journal
of Pediatrics, 2020, Article 4730205, 1–8. https://doi.org/10.1155/2020/4730205
11
Posadzki, P., Mastellos, N., Ryan, R., Gunn, L. H., Felix, L. M., Pappas, Y., Gagnon, M.-
P., Julious, S. A., Xiang, L., Oldenburg, B., & Car, J. (2016). Automated
telephone communication systems for preventive healthcare and management of
long-term conditions. Cochrane Database of Systematic Reviews, 2016(12).
https://doi.org/10.1002/14651858.cd009921.pub2
Szilagyi, P. G., Albertin, C., Casillas, A., Valderrama, R., Duru, O., Ong, M. K.,
Vangala, S., Tseng, C.-H., Rand, C. M., Humiston, S. G., Evans, S., Sloyan, M.,
& Lerner, C. (2020). Effect of patient portal reminders sent by a health care
system on influenza vaccination rates. JAMA Internal Medicine, 180(7), 962.
https://doi.org/10.1001/jamainternmed.2020.1602
Teasdale, C. A., Borrell, L. N., Shen, Y., Kimball, S., Zimba, R., Kulkarni, S., Rane, M.,
Rinke, M. L., Fleary, S. A., & Nash, D. (2022). Missed routine pediatric care and
vaccinations in us children during the first year of the COVID-19 pandemic.
Preventive Medicine, 158, 107025. https://doi.org/10.1016/j.ypmed.2022.107025
**GriefandposttraumaticStress.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/griefandposttraumaticstress-pdf)