Improving immunization rates in the clinic and in the community

Over the past decade, the United States has had tremendous success in achieving very high immunization compliance rates among children,¹ sometimes as high as 91%.² However, despite progress toward controlling the spread of communicable disease through immunizations, more than 2.1 million children nationwide are not adequately immunized.³ Even among US children who are adequately immunized, only about half of them actually received their immunizations on time.^4-7

Although immunization education can be a community-based effort, the improvement of childhood immunization rates in any community can begin with the involvement of a single clinical practice site that enacts interventions. Although parents of children seen in that clinic may be surveyed in order to use data to formulate specific interventions, a more immediate approach can be taken and interventions implemented based on the common concerns of parents and/or the barriers to the timely immunization of children. Some of the interventions that can be implemented on the clinical level include: instituting a reminder program; coaching parents in how to respond to their child's pain, crying, or anxiety when receiving an immunization; and allowing time to adequately address parental concerns regarding immunizations during office visits.

Some populations have high immunization rates, whereas other communities continue to struggle with maintaining immunization completion among community members.³ Communities in Utah traditionally have been such communities. States such as Utah with high birth rates typically have low infant vaccination rates, and conversely, states with low birth rates have high vaccination rates.⁸ However, in 2006, a coalition was established to improve childhood immunization rates in Utah County. Collaborating with several pediatricians' offices, family practice offices, and the local health department, the Immun-wize Project was implemented, which ultimately improved the childhood immunization rates in the area by 11% to 87.8%.⁹

The results of the survey demonstrated that immunization concerns of parents in Utah County differed somewhat from the concerns of parents nationwide. Nationally, parents who procrastinated in obtaining their children's immunizations did so because they had limited access to immunizations, were unable to pay for immunizations, or were unaware that their children were overdue for the next immunization.¹¹ Congruent with national findings, it was discovered that in Utah County parental confusion regarding the immunization schedule contributed to the overall problem of underimmunized children. It also was discovered that one-third of parents delayed immunizing their children because they were worried about the child's pain, crying, or anxiety. In addition, approximately 25% of parents delayed immunizations because they had concerns about immunization safety.^10,12 After identifying these 3 primary parental concerns, program interventions were designed to address them.

The Immun-wize Project interventions included advertising on local television programs and banners on local news station Web sites advising when children should return for their next set of immunizations. Posters were placed in area hospitals, clinics, stores, and preschools, encouraging parents to contact their healthcare providers to see whether their child's immunizations were up-to-date. Articles regarding immunization schedules also were published in city newsletters and in local newspapers.

For parents who worried about their child's pain, crying, or anxiety, local Mom-n-Me playgroups held classes on how to help prepare a child for an immunization visit. They recommended books, such as The Berenstain Bears Go to the Doctor, for parents to read with their child before the office visit and for healthcare providers to keep in the waiting room that would help children understand why they need immunizations and what to expect during the shots.

Because immunization safety was a concern for parents, a different immunization question or concern was highlighted each month and discussed on the Immun-wize Web site ( http://www.immun-wize.org/) and blog (http://immun-wize.blogspot.com/). School nurses inserted the project's monthly immunization article into school newsletters in Utah County, thereby sending educational messages directly home with school-aged children and successfully reaching their parents, even those who were not actively pursuing information, at no cost to the Immun-wize Project. In addition, the monthly immunization messages were distributed via wellness newsletters sponsored by various businesses. Immunizations were promoted with advertisements on public transportation and through various community events.