Boost your immunization rates and eradicate barriers through education

First determine need, then provide targeted education

There is a simple way to prevent a multitude of life-threatening diseases in the United States. People simply need to show up at their physician’s office or a clinic for a vaccine. Yet many children and adults are not up to date on their vaccinations. Immunization coverage rates among children are at 90%; however, coverage for adolescents is only about 50%. And coverage for annual influenza immunization, which protects all age groups, is low even for at-risk populations. For example, only about 25% of adults younger than 50 who are at high risk because of medical problems such as asthma or diabetes are vaccinated for influenza, according to David Neumann, PhD, executive director of the National Partnership for Immunization in Alexandria, VA.

"The difficulty for younger adults is that many vaccines are not recommended for everyone," says Lance Rodewald, MD, director of Immunization Services Division for the Centers for Disease Control and Prevention’s (CDC) National Immunization Program (NIP) in Atlanta.

No matter the difficulty, education is an important factor to eradicating many of the barriers to immunization. However, it is important to know the issues that need to be addressed, says Rodewald. For example, studies about parents’ beliefs towards vaccination and protecting their children through vaccines reveal a strong support for immunization. Therefore, this is usually not a excuse for parents not having their children’s immunizations up to date, says Rodewald.

Another misconception is that children who are not fully vaccinated don’t have a primary care provider. Surveys have shown that 91% of undervaccinated children have a primary care provider. The problem is that physicians tend to overestimate how well they do in vaccinating children in their practice. Also parents often mistakenly believe their child is fully vaccinated, Rodewald says. The vaccination schedule is too complicated for many parents to track, and physicians frequently do not have a good tracking system, he says.

To help boost immunization rates, the Immunization Action Coalition in St. Paul, MN, takes all the complicated sets of recommendations that are issued by national advisory bodies and puts the information into easy to read, graphically attractive, one-page educational sheets. This information is then distributed to health care providers.

"We have a web site that is primarily for health care providers ( and another site that is primarily for the public ( Both have a ton of information that the public and providers can access to learn more," says Diane Peterson, associate director for immunization projects at the Immunization Action Coalition.

Education for providers and the public

Many immunization coalitions throughout the United States ensure that children and adults are fully immunized and also have programs to educate physicians, their staff, and their patients. For example, to educate staff on best practices for immunization, the Childhood Immunization Coalition of Fresno/Madera Counties in California has hosted training workshops for medical assistants for the past five years.

An expert from the California state department of health services is the featured speaker during a luncheon or dinner at the workshop. The coalition sets up informational booths at the back of the room so the medical assistants can gather additional materials to support their efforts. "All the information is geared to making sure that the medical assistants are doing the best job possible, whether storing the vaccine, administering it, or documenting it. Everything that could possibly affect the outcome is covered," says Sally Negin,RN, current treasurer and former coalition chair.

During the workshop, participants see a video on comfort measures for the baby during the immunization process. This video was produced by the California Department of Health Services to help prevent families from having a bad experience.

In an effort to increase vaccination rates among Latino children, the California Distance Learning Health Network (CDLHN) in San Diego developed a curriculum for Cultural Diversity and Customer Service workshops to educate health care providers. The effort included the video, "Immunization Techniques."

"The workshop focuses more on the interaction, like how to present information, while the video is [about] administering the shot. They complement each other. The vaccination process is a total experience, and you want it to be positive for all parties," says Rick Dailey, public health promotions manager for the CDLHN. (To learn where to obtain video and curriculum, see resources at the end of this article.) To address barriers to immunization it is important for health care providers to know their patient populations, says Dailey.

Margie Downs, BSN, RN, a parish nurse with the Harbor Hospital Parish Nurse Program in Baltimore, MD, agrees. This community outreach program has made it possible for the hospital to administer the influenza vaccine to its underinsured and uninsured patient population. When nurses are out in the community they become aware of the community’s health care needs, says Downs. Through a health ministry network, Harbor Hospital is partnered with more than 30 churches. This provides connections to patient populations that may not have an opportunity to obtain influenza vaccines through a physician’s office or clinic.

For example, many of the churches have connections to emergency relief agencies or run soup kitchens. Through these sources, patient populations that generally fall through the cracks have an opportunity to be vaccinated. "Each month, we produce a Parish Nurse note that goes into all the church bulletins. We do about 1,500 Parish Nurse notes. In September, we dedicate that note to the influenza vaccine," says Downs.

Recommendations on who should receive the first vaccines available are included in the note. In addition, literature is available at the clinic with information such as who is at highest risk of complications from influenza and the difference between a cold and the flu. The Parish Nurse program charges $10 for each vaccine, and bills Medicare for seniors. Those who cannot pay are given the vaccine free of charge.

Overcoming barriers to immunization

Often barriers to immunization are not obvious until some research is done, says Lynne Weaver, immunization outreach coordinator for Douglas County, OR. Statistics collected by the health department in her area revealed that about half the children in this rural county did not have all the immunizations required by age 2, even though walk-in clinics were available through the health department.

The Douglas County Immunization Coalition was formed to determine the barriers to immunization, and they were given a $34,000 grant from the Oregon Department of Health Services to study the problem.

To learn what prevented full immunization, the group focused on children at 2 months of age and 14 months of age using a list provided by the local health department. The coalition phoned the parents of almost 2,000 babies, and discovered that misinformation was the major factor preventing children 2 months of age from being up to date on vaccines. For example, many parents thought that, if a child was sick, he or she should not be vaccinated.

The parents felt that, after a child reached 14 months, it was the physician’s responsibility to make sure they were notified when the child was due for a vaccination. This information prompted the coalition to focus their efforts on dispelling myths about immunizations and also to work with physicians on a recall system.

The actual methods for providing education should be tailored to the community for best results, advises Marianne Pappas, coordinator of the Everybody Counts Immunization Coalition serving Chatham and Effingham counties in Georgia. For example, the Be-Wise-Immunize baby duck was created to promote the importance of immunizations. Because the residents of Savannah love to party, the duck is invited to lots of celebrations and even appears in parades. He has a different outfit for each holiday and tosses buttons with holiday appropriate slogans to the crowds. On the Fourth of July the buttons read "Conquer disease — immunize" and during Christmas they read "Give the gift of health — immunize."

To raise immunization rates among the adult population, the coalition created a calendar — something everyone could use. The calendar has health promotion and immunization messages for each month. For example, because November is national diabetes month, the messages is that people with diabetes are four times more likely to die from influenza and should be vaccinated.

Costs are kept under control by having community groups sponsor each month and, to increase demand for the calendars, older women or "grandmas" are featured. For example, a 107-year-old woman was featured on older Americans month.

Ideas from other areas can be customized to fit your patient populations, but you must know the needs of your community first, says Pappas.

To get people on board to help with efforts, it is important to understand the barriers and have the statistics at hand. Then empower members of the team with education and have them come up with ideas, she says. Every member of the Everybody Counts Immunization Coalition took a CDC video satellite course to learn all they could about immunizations. Once they passed the course, they were named immunization ambassadors, and they provided outreach education to their neighborhoods, workplace, homes, churches, and social circles, explains Pappas.


To learn more about how to overcome barriers to immunization, contact:

  • Childhood Immunization Coalition of Fresno/ Madera Counties, Isidro Fragoza, Chair, Fresno County Immunization Program, 1221 Fulton Mall, Fresno, CA 93721. Telephone: (559) 445-3550.
  • Rick Dailey, Public Health Promotions Manager, California Distance Learning Health Network, 9245 Sky Park Court, Suite 100, San Diego, CA 92123. Web-site:
  • Margie Downs, BSN, RN, Parish Nurse, Harbor Hospital Parish Nurse Program in Baltimore. Telephone: (410) 350-8227.
  • Marianne Pappas, Coordinator, Everybody Counts Immunization Coalition, Chatham County Health Department, 2011 Eisenhower Road, Savannah, GA 31406. Telephone: (912) 356-2679. E-mail:
  • Lynne Weaver, Immunization Outreach Coordinator, Douglas County, OR. Telephone: (541) 672-6631.