Family Medicine Residencies Teach Many Strategies to Boost Immunization Rates

August 04, 2009 04:50 pm Barbara Bein

Located in a state with one of the lowest immunizations rates in the country, the Oregon Health & Science University family medicine residency program in Portland has its work cut out for it. Its 36 physicians-in-training learn strategies that help them talk to parents about immunizations, educate those parents about the need for their children to be vaccinated and devise ways to make immunizations part of each visit.

Perhaps most importantly, they learn to understand the origins of parents' concerns about having their children vaccinated.

"These parents are not people who will respond to edicts," said program director Roger Garvin, M.D. Physicians "need to listen to them, understand what their concerns are, help them to see there is an ongoing need for immunizations."

Garvin told AAFP News Now that he's found it is essential to put vaccine-preventable diseases in context for parents -- and that's what residents in his program are trained to do. It's precisely because vaccines have been so successful, he said, that people don't see certain diseases.

"Some parents will ask, 'Why should my child get the polio vaccine? I've never seen polio.' I tell them we don't see this disease because we protect each other with the vaccines. We protect the child and everybody else," Garvin said.

Garvin said he tells parents about his own experiences seeing children in the hospital with Haemophilus influenzae type b, or Hib, disease who suffered terrible brain damage and died. Since the introduction of Hib vaccine, he said, "I haven't seen a case of that. It's almost eliminated as a significant problem."

The mindset of parents doesn't stem from a lack of caring, Garvin said. Instead, these parents are trying to do everything right for their children. They see forgoing immunizations, or spacing them out, as healthy choices, similar to paying careful attention to diet, he said.

Few parents, even those with exemptions from vaccinations for religious reasons, refuse all immunizations, said Garvin. They agree to some vaccines, or they want to spread the shots out. Rather than a child getting three to five shots in one day, for example, the parents agree to one immunization and come back for another later.

"There's a little bit of bargaining over which ones they want to do and when,"
Garvin said. "We have to work around that. It takes more nursing time. But we'll be flexible to get it to happen."

In the four clinics in the practice, physicians and nurses discuss immunizations at each visit. The day before appointments, nurses consult patients' charts and determine which immunizations are due. If parents want their children to be on extended schedules, nurses meet with them and set those schedules up.

"We work with them. 'Which immunizations would you like to do today?' Patients appreciate being listened to, instead of saying, 'This is the schedule and if you don’t stick to it, you're a bad parent,'" Garvin said.

Outside of Oregon, other family medicine residencies also are working to boost their immunization rates.

In Macon, Ga., a state that generally has high immunization rates, the Mercer University School of Medicine/Medical Center of Central Georgia Family Medicine Residency has more than doubled its compliance rate for the series of 15 childhood immunizations needed to start school from 42 percent in 2004 to 91 percent in 2008.

According to program director Roberta Weintraut, M.D., the residency accomplished that goal using a multifaceted approach that included joining the Vaccines for Children program; tapping into the Georgia Registry of Immunization Transactions and Services(, or GRITS, electronic tracking system; and educating parents, physicians, residents and staff.

"Some parents have resistance to having so many vaccines at once. Some babies get three, four, five immunizations in one day, and many parents will resist that. We say we'll do three today and another three in three or four weeks. GRITS tracks that for us," said Weintraut.

In addition to parents, physicians, residents and office staff members receive education and mentoring through Educating Physicians in their Communities(, or EPIC, an immunization initiative of the Georgia AFP and the Georgia Academy of Pediatrics.

Fred Girton, M.D., chair of the department of family medicine at Mercer University School of Medicine and a board member of EPIC, said physicians and other vaccine providers travel to as many as 300 physician offices and clinics each year to discuss immunization ordering, administration and storage.

Two other family medicine residencies AAFP News Now contacted -- Western Reserve Care Systems in Youngstown, Ohio, and San Joaquin General Hospital in French Camp, Calif. -- are planning to implement a number of system-wide changes to overcome barriers and boost immunization rates in their distressed communities.

At the Western Reserve Family Practice Center, a major consciousness-raising effort is under way to enlighten parents, caregivers, faculty physicians, residents and staff to boost an overall vaccination compliance rate from 77 percent to 90 percent, said program director Lisa Weiss, M.D.

The center hired a nurse educator to educate parents of children ages 3 years and younger about the importance of immunizations. Immunizations are being emphasized during both acute-care and well-child visits. At a recent health fair, the center's 13 residents shared vaccine information from the CDC, vaccine manufacturers and the AAFP Web site with community members, Weiss said.

"It helps the public and helps the residents become more aware of immunizations. It becomes part of the culture," she said.

Finally, the San Joaquin family medicine residency, located in medically underserved San Joaquin County, plans to start offering group visits for parents to counsel them on the importance of immunizations and to vaccinate their children. The residency also plans to launch a walk-in clinic and an outreach vaccination program where parents can bring their children for a vaccination day, said program director Ramiro Zuniga, M.D.

But the centerpiece of the new system will be a registry that can run regular reports to determine which children are not up-to-date on their vaccinations and provide their parents' names and contact information.

Using these measures, Zuniga said, the residency hopes to significantly raise its overall immunization compliance rate of about 54 percent, a figure that's well below the national average of about 88 percent.