A Comprehensive Investigation of Barriers to Adult Immunization A Methods Paper

1. Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep 2000;49:1-38.

2. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep 1997;46:1-24.

3. Centers for Disease Control and Prevention. Active bacterial core surveillance (ABCs) report, Emerging Infections Program Network, Streptococcus pneumoniae, 1998. Atlanta, Ga: Emerging Infections Program Network; 1998.

4. Nuorti JP, Butler JC, Farley MM, et al. Cigarette smoking and invasive pneumococcal disease. N Eng J Med 2000;342:681-89.

5. Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults. Arch Intern Med 1994;154:2666-77.

6. Demicheli V, Jefferson T, Rivetti D, Deeks J. Prevention and early treatment of influenza in healthy adults. Vaccine 2000;18:957-1030.

7. Nichol KL, Margolis KL, Wuorenma J, Von Sternberg TL. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med 1994;331:778-84.

8. Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years—United States. MMWR Morbid Mortal Wkly Rep 1998;47:797-802.

9. Gyorkos TW, Tannenbaum TN, Abrahamowicz M, et al. Evaluation of the effectiveness of immunization delivery methods. Can J Public Health—Revue Canadienne De Sante Publique 1994;85(suppl):S14-30.

10. Centers for Disease Control and Prevention. Vaccine-preventable diseases: improving vaccination coverage in children, adolescents, and adults. A report on recommendations of the Task Force on Community Preventive Services. MMWR Morbid Mortal Wkly Rep 1999;48:1-33.

11. McIlvain HE, Crabtree BF, Gilbert C, Havranek R, Backer E. Current trends in tobacco prevention and cessation in Nebraska physicians’ offices. J Fam Pract 1997;44:193-202.

12. Crabtree BF, Miller WL, Aita VA, Flocke SA, Stange KC. Primary care practice organization and preventive services delivery: a qualitative analysis. J Fam Pract 1998;46:403-09.

13. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.

14. Miller, Crabtree BF, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory. J Fam Pract 1998;46:369-76.

15. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med 1993;329:1271-73.

16. Carney PA, Dietrich AJ, Keller A, Landgraf J, O’Connor GT. Tools, teamwork, and tenacity: an office system for cancer prevention. J Fam Pract 1992;35:388-94.

17. Centers for Disease Control and Prevention. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations—United States, 1996. MMWR Morbid Mortal Wkly Rep 1999;43:886-89.

18. Hutchinson HL, Norma LA. Compliance with influenza immunization: a survey of high-risk patients at a family medicine clinic. J Am Board Fam Pract 1995;8:448-51.

19. Nichol K, MacDonald R, Hauge M. Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults. J Gen Intern Med 1996;11:673-77.

20. Pregliasco F, Sodano L, Mensi C, et al. Influenza vaccination among the elderly in Italy. Bull World Health Org 1999;77:127-31.

21. Fiebach NH, Viscoli CM. Patient acceptance of influenza vaccination. Am J Med 1991;91:393-400.

22. Gene J, Espinola A, Cabezas C, et al. Do knowledge and attitude about influenza and its immunization affect the likelihood of obtaining immunization. Fam Pract Res J 1992;12:61-73.

23. van Essen GA, Kuyvenhoven MM, de Melker RA. Why do healthy elderly people fail to comply with influenza vaccination. Age Ageing 1997;26:275-79.

24. Zyzanski SJ, Stange KC, Lango D, Flocke SA. Trade-offs in high-volume primary care practice. J Fam Pract 1998;46:397-402.

25. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

26. Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-to-adherence model of the steps to clinical guideline compliance. Med Care 1996;34:873-89.

27. Prochaska JO, Redding CA, Evers K. The transitional model and stages of change. In: Glanz K, Lewis FM, Rimer BK, eds. Health behavior and health education. San Francisco, Calif: Jossey-Bass Inc; 1997;60-84.

28. Montano DE. Predicting and understanding influenza vaccination behavior: alternatives to the health belief model. Med Care 1986;24:438-53.

29. Davidson AR, Jaccard JJ, Triandis HC, Morales ML, Diaz-Guerrero R. Cross-cultural model testing: toward a solution of the etic-emic dilemma. Int J Psychol 1976;11:1-13.

30. Valois P, Desharnais R, Godin G. A comparison of the Fishbein and Ajzen and the Triandis attitudinal models for the prediction of exercise intention and behavior. J Behav Med 1988;11:459-72.

31. Landis D, Triandis HC, Adamopoulos J. Habit and behavioral intentions as predictors of social behavior. J Soc Psychol 1978;106:227-37.

32. Gielen AC, McDonald EM. The PRECEDE-PROCEED planning model. In: Glanz K, Lewis FM, Rimer BK, eds. Health behavior and health education: theory, research, and practice. San Francisco, Calif: Jossey-Bass Inc; 1997;359-83.

33. Gilchrist VJ. Key informant interviews. In: Crabtree BF, Miller WL, eds. Doing qualitative research. London, England: Sage Publications; 1992;70-89.

34. Aday LA. Designing and conducting health surveys. San Francisco, Calif: Jossey-Bass Inc; 1989.

35. Silverman M, Ricci EM, Guntinas MJ. Strategies for increasing the rigor of qualitative methods in the evaluation of health care programs. Eval Rev 1990;14:57-74.

36. Crabtree BF, Miller WL. Doing qualitative research. Newbury Park, Calif: Sage Publications, Inc; 1992.

37. Shah BV, Barnwell BG, Bieler GS. SUDAAN user’s manual. Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.

ABSTRACT

OBJECTIVES: Immunization rates for influenza and pneumococcal vaccines among the elderly (especially minority elderly) are below desired levels. We sought to answer the following 4 questions: (1) What factors explain most missed immunizations? (2) How are patient beliefs and practices regarding adult immunization affected by racial or cultural factors? (3) How are immunizations and patient beliefs affected by physician, organizational, and operational factors? and (4) Based on the relationships identified, can typologies be created that foster the tailoring of interventions to improve immunization rates?

STUDY DESIGN: A multidisciplinary team chose the PRECEDE-PROCEED framework, the Awareness to Adherence model of clinician response to guidelines, and the Triandis model of consumer decision making as the best models to assess barriers to and facilitators of immunization. Our data collection methods included focus groups, face-to-face and telephone interviews, self-administered surveys, site visits, participant observation, and medical record review.

POPULATION: To encounter a broad spectrum of patients, facilities, systems, and interventions, we sampled from 4 strata: (1) inner-city neighborhood health centers, (2) clinics in Veterans Administration facilities, (3) rural practices in a network, and (4) urban/suburban practices in a network. In stage 1, a stratified random cluster sample of 60 primary care clinicians was selected, 15 in each of the strata. In stage 2, a random sample of 15 patients was selected from each clinician’s list of patients, aiming for 900 total interviews.

CONCLUSION: This multicomponent approach is well suited to identifying barriers to and facilitators of adult immunizations among a variety of populations, including the disadvantaged.

KEY POINTS

An increase in adult immunization rates requires individualized interventions that account for the organization and culture of each family medicine practice.
Assessment of the characteristics of a practice depends on a thorough investigation of provider and patient knowledge, attitudes, beliefs and practices regarding immunization.
The PRECEDE-PROCEED framework using the Awareness to Adherence and Triandis models creates useful theoretical models for evaluating the characteristics of family medicine practices.
Typologies developed from this procedure may help to simplify the process of characterizing practices and developing individualized immunization interventions.

Together, influenza and pneumonia are the sixth leading cause of death. Each year, influenza causes approximately 20,000 deaths, and pneumococcus causes approximately 500,000 cases of pneumonia, 50,000 cases of bacteremia, and 3000 cases of meningitis.^1,2 African Americans experience approximately twice the rate of invasive pneumococcal disease as whites.^3,4

Despite the burden of disease and the availability of vaccine guidelines,^1,2,5-7 vaccination rates are only modest, though they are slowly rising. In 1997, only 65% and 45% of persons 65 years or older reported receiving influenza and pneumococcal vaccines, respectively.⁸ Influenza vaccination rates were lower for persons of Hispanic (58%) and non-Hispanic black (50%) origin than for non-Hispanic whites (67%). Pneumococcal vaccination rates were 34% for Hispanics, 30% for non-Hispanic blacks, and 47% for non-Hispanic whites.⁸

The low rates are surprising, given that there is an abundance of literature reporting successful interventions for increasing immunization rates.^9,10 In a meta-analysis, system-oriented interventions (eg, standing orders for nurses) resulted in pooled rate increases of 39% and 45% for influenza and pneumococcal vaccines, respectively.⁹ Patient-oriented strategies (eg, postcard reminders that influenza or pneumococcal vaccine was due) resulted in increases of 12% and 75%, respectively. Provider-oriented strategies (eg, chart reminders) resulted in increases of 18% and 8%, respectively, for influenza and pneumococcal vaccines.⁹

Causes of low immunization rates

Although immunization rates are slowly increasing, why have they not risen more, given the evidence of effective interventions? We believe that there are 4 primary reasons why many clinical practices have not successfully applied research findings to improve adult vaccination rates.

First, offices are complex systems with idiosyncratic organization structures and values. They tend to accept changes when they are congruent with the organization’s goals and culture. Most previous efforts at intervention treated practices uniformly, with a “one size fits all” approach.^2,11 However, data from the Direct Observation of Primary Care Study reveals a wide variety of patients and problems.^12-14 Several authors have recommended tailoring interventions to match the organizational structure, office culture, and individual physician philosophies and practices as a means of increasing the likelihood of success.^11,12,15,16

Also, patient beliefs about adult vaccination are varied and include racial and ethnic diversity as well. Significant percentages of the elderly report lack of awareness of the need for immunizations (19% for influenza vaccination and 57% for pneumococcal vaccination).^17-19 Among racial groups, non-Hispanic blacks were least aware of the need for these vaccines, followed by Hispanics and non-Hispanic whites.¹⁷ Concern that vaccination may actually cause disease^17,20 and fear of the pain of injection and/or needles^17,21,22 lead many to decline vaccination. Although serious adverse events due to vaccination are rare, media attention to them increases public awareness of their occurrence and may contribute to fear of adverse reactions.^17,20-23