Despite efforts to increase rates of immunization among Medicare patients, especially racial and ethnic minorities, these rates remain well below Healthy People 2020 targets . It is not difficult to conclude that we need to learn more about how and why people choose to receive or not receive immunizations. In 2017, the Roundtable on Health Literacy at the National Academies of Sciences, Engineering, and Medicine commissioned a project taking a qualitative approach to this complex issue .
The goal of the project was to step outside the published literature and population-level data and speak to those with on-the-ground experience in promoting and administering immunizations to people over 65. We were interested in learning about the experiences of immunizers in a variety of settings and in identifying what medical, public health, and pharmaceutical health professionals considered their most successful strategies for immunizing their patients and customers. Specifically, we were interested in whether strategies were being undertaken in accordance with the principles of organizational health literacy—that is, that immunizations are convenient and accessible; that patients are given useful, easy-to-understand information; and that impact and outcomes of the strategy are reviewed. To do this, we conducted telephone interviews with 23 health care professionals in 11 states. We identified interviewees by contacting the American Pharmacists Association, the American College of Physicians, the National Association of Community Health Clinics, colleges of pharmacy and medicine, departments of public health, and nonprofits serving seniors.
Health care professionals we interviewed believed that immunization was part of their mission and that it was important to reach out, connect, and communicate with their patients. Most providers said the key to immunizing patients is genuinely caring for them, knowing current guidelines, and being confident in informing them. The health professionals also shared the view that most adults 65 and older were receptive to influenza (flu) and pneumococcal (pneumonia) immunizations. The interviewees all believed that most resistance to immunization could be overcome with clear, respectful explanations of the vaccines and how they work. With regard to population-level differences in vaccine resistance, several interviewees told us that in their view, it is a myth that African Americans are particularly resistant to receiving vaccines. Everyone we spoke with emphasized the importance of earning the trust of patients and customers and being considered members of the communities they served.
Although many of our interviewees emphasized the importance of building a personal relationship with patients and customers, they also spoke of the importance of a well-designed workflow that promotes and supports immunization. Successful strategies for pharmacies, clinics, and community agencies were driven by senior leadership and tailored to fit the needs of the site and the patients they served. In these organizations, leadership set immunization as a priority, promoted up-to-date training on current guidelines, and viewed staff as key in recommending vaccines. The people we interviewed believed that the most effective systems provide all staff with training based on the recommendations of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Tracking progress and providing incentives were also hallmarks of successful systems, according to the providers we interviewed. Tracking and incentivizing success not only promoted teamwork but also showed the organizational leadership’s commitment to immunizations.
The providers we interviewed also spoke of many challenges. Clinics found that tracking of immunizations was often problematic if patients did not receive immunizations on-site. Commonly used tracking systems do not allow pharmacies and clinics to easily share information. All states have immunization registries, but they are not commonly used for adult vaccines, except in public health clinics. Smaller clinics struggled to keep enough vaccines in stock without over-ordering. In addition, providers who served largely low-income populations told us that even when immunizations are covered by Medicare, patients often experience barriers that prevent immunization. For example, several rural providers noted that transportation and the distance patients had to travel to reach the clinic were barriers to receiving immunizations.
This project has a number of limitations. We asked our interviewees to relate their experiences and personal views. Thus, the information we gathered is entirely anecdotal. In addition, due to time constraints, we were limited in the number of people we could interview. We tried to mitigate this by interviewing a diverse group in terms of the type of provider, organization, and geographic location. In spite of these limitations, however, we believe that this project has much to offer to others engaged in immunizing adult populations. The people whom we interviewed were dedicated and knowledgeable and shared valuable insights into their work.
This paper provides an opportunity to address the issues surrounding low immunization rates among older adults, particularly in areas where immunization rates still fall short of national goals and disparities between different groups remain. This project may help us move closer to achieving national immunization goals for seniors and to eliminating disparities. The providers interviewed saw immunizing adults over 65 as part of their mission and viewed the provision of flu and pneumonia immunizations as a process rather than a discrete task on a checklist. Successful immunizers were patient- and community-centered and had taken steps to gain the trust of people they served. Every provider we spoke with viewed trust as a key component of successful immunization efforts. They adopted a systems approach that aligned closely with the attributes of a health-literate organization. Although not all used the words “health literate” to describe their approach to immunizations, they were, in fact, following the principles of health literacy in their day-to-day work by meeting people where they are, streamlining the process within the organization, addressing concerns in everyday language, and confirming individuals’ understanding.
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Tweet this! In our newest NAM Perspectives Commentary, authors conducted interviews with immunization providers across the country to investigate why vaccination levels remain well below Healthy People 2020 targets: http://ow.ly/88cS30kyglL
Tweet this! Health care professionals working to ensure that America’s aging population is appropriately vaccinated must be supported by well-designed workflows and robust data-sharing systems: http://ow.ly/88cS30kyglL
Tweet this! “Successful immunizers were patient- and community-centered and had taken steps to gain the trust of people they served.” Learn more about immunization strategies based on organizational health literacy in our newest NAM Perspectives: http://ow.ly/88cS30kyglL
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- Williams, W. W., P. J. Lu, A. O’Halloran, D. K. Kim, L. A. Grohskopf, T. Pilishvili, T. H. Skoff, N. P. Nelson, R. Harpaz, L. E. Markowitz, A. Rodriguez-Lainz, and A. P. Fiebelkorn. 2017. Surveillance of vaccination coverage among adult populations—United States, 2015. Morbidity and Mortality Weekly Surveillance Summary 66(SS-11):1–28. https://www.cdc.gov/mmwr/volumes/66/ss/ss6611a1.htm (accessed May 9, 2018).
- Davis, T. C., C. Arnold, and J. A. Dillaha. 2018. Can the attributes and practices of immunization providers successfully address racial and ethnic disparities in immunization rates among Medicare patients? Lessons learned from conversations with providers. Washington, DC: Roundtable on Health Literacy, The National Academies of Sciences, Engineering, and Medicine. http://nationalacademies.org/hmd/~/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/Commissioned%20Papers%20-Updated%202017/Davis%20et%20al%202018%20Can%20the%20Health%20Literacy%20Attributes%20and%20Practices%20of%20Immunization%20Providers%20Successfully%20Address%20Disparities.pdf (accessed May 9, 2018).