4/17/2014
Knowledge, Attitudes and Perceptions
of Northwest American Indian/Alaska
Native Community Members and
Medical Providers Regarding
Childhood Immunizations
CAPT Thomas Weiser, MD, MPH
Medical Epidemiologist
Portland Area Indian Health Service/
Northwest Portland Area Indian Health Board
Background
• Childhood immunizations are one of the most
effective clinical prevention interventions
• Immunization services in the US account for the
eradication of polio, the elimination of measles
and the elimination of rubella and congenital
rubella syndrome in the US
• In 2012-2013, influenza vaccination averted
79,000 hospitalization, 6.6 million cases and 3.2
million medically attended cases of influenza
Northwest Portland Area
Indian Health Board
Indian Leadership for Indian Health
Hypothesis-generating
Questions
• Is low reported immunization coverage
simply a data question?
• Are NW AI/AN communities hesitant or
resistant to immunizations like many nonAI/AN communities in the NW?
• Do elders play a supportive role in
immunizations through their experience
with vaccine-preventable diseases?
Methods
• Survey of healthcare workers in ID
• Provider Interviews: 19 questions
and OR clinics
• Interviews with healthcare workers
in ID, OR and WA clinics
• Focus groups with community
members from AI/AN communities in
OR and WA
including items specifically
identifying barriers and facilitators
of immunization
• Community Focus Groups: 6
questions to prompt discussion of
local sentiments regarding vaccines
• Analysis software: Atlas Ti v7
Results
• Interviews 33 responses
• Focus groups 3 focus groups 1 (OR), 2
(WA) with approximately 36 total
participants
Survey Instruments
Interview results
33 Healthcare providers interviewed
1. In your opinion, what are the most significant
2.
3.
4.
5.
contributors to the low rates of immunization coverage
among American Indian/Alaska Native children?
What barriers are present in the community that
inhibit children from getting recommended
immunizations on time?
What barriers within the clinic setting exist that inhibit
children from being vaccinated?
What do parents or community members say regarding
immunizations? What comments have you heard?
What strengths do you see in the community to help
address the problem of getting children immunized?
Interview Results
• Common perceived barriers identified included:
 Parents lack of knowledge or understanding of the
importance of children receiving vaccines on time
 Issues related to poverty- lack of transportation,
finances, household instability, frequent changes in
living arrangements, inaccurate contact information
making completion of immunizations difficult.
1
4/17/2014
Relationship Between Poverty
and Contacting Parents
“Distance,
combined with
socioeconomic
status and having
access to
transportation”
“… we could remind
parents but we have phone
numbers that don’t work,
we have people with cell
phones that use up their
minutes… they don’t pick
up their mail [except] once
a month at the PO Box. So
the reminders aren’t
there…”
“Those who don’t make it in
are usually hindered by
environmental circumstance,
i.e., parents are young,
multiple family members are
caring for the child”
Interview ResultsClinic “Best Practices”
• Increased use of computerized records and
systems was one of the most common
facilitators for providing better immunization
services in the clinic setting:
 Using EHR- improves forecasting, better tracking of
immunizations, clinical reminders, reports and
automatic letters to patients/families
 State Immunization Information Systems (IIS)- allow
staff to verify immunizations given outside of the
clinic, ensure IZs up to date, prevent duplicating or
over-immunizing
 Internet access to immunization information- CDC,
ACIP, state immunization websites, download VIS
handouts, etc.
“A lot of them are just
living in very chaotic
situations and kids are just
passed around and I think
there is a lack of
communication and some
disorganized homes and
dysfunctional home
situations”
Clinic Facilitators to Offer
Immunizations
Interview Results –
Community Facilitators
•
•
Advertising immunization services to the community
through local/tribal newspaper, wellness newsletters
PHNs or others attending community group events to
talk about immunizations, or provide immunizations
directly e.g.,






•
Health fairs
Early childhood development/head start
WIC
Tribal Jails
Schools
CPS/Group Home
Partner with County Health Department on outreach
Interview ResultsClinic “Best Practices” (cont.)
• Clinic efforts that help improve immunization
coverage:
 Add extra immunization clinics/venues,
especially at busy times of the year, like when
school starts in the Fall and Flu shot clinics.
 Use a standardized (CDC) immunization
schedules for routine and catch-up
immunizations
 Standing orders
 Providing transportation to the clinic
 Dedicated well child clinics, with reminder
letters sent out inviting those families with
children not up to date to attend
Focus Group Questions
• What do you think about childhood immunizations?
• Where do community members get information about
immunizations? Is this information given in ways that
people can easily understand?
• What do elders in the community say about
immunizations and the diseases they prevent?
• What do young parents say about immunizations and
the diseases they prevent?
• Do community members express doubt or distrust about
the safety or efficacy of vaccines?
• What strengths do you see in the community that can
help to address the problem of low childhood IZ rates?
Focus Group Barrier
Diagram
Focus Group Barriers
Focus Group Facilitators
• Major themes included:
 Mistrust/Fear
 Inadequate information
 Parental logistical concerns
 Poor clinic reputation
 Community and personal aversion to
immunizations
 Belief in natural immunity/natural lifestyle
2
4/17/2014
Focus Group Facilitators
• Information
 Making information understandable
 Advertising, newsletters, handouts
• Personal Experience
 Having had the disease or a child with the disease
• Community Support and Trust
• Clinic Support
 Providers with time/ability to educate in plain
language
 Having pediatricians was perceived as increasing
confidence and acceptance of immunizations
Conclusions
Limitations
• Adequate patient education about immunizations
was identified as an important concern of NW
AI/AN community members.
• First attempt at using qualitative
• Insufficient time for patient education was
identified as a barrier by medical providers
• Some focus groups included HCW
• Improving patient and provider education regarding
immunizations is needed
• Fear of vaccines (ingredients, side effects) and
mistrust of government and pharmaceutical
companies was an important concern
Next Steps
from the clinic
• None of the focus groups was from a
Tribe served directly by IHS
Acknowledgments
• Develop patient education tools endorsed
• Portland Area IHS- funding
by Tribes and Tribal organizations trusted
by community members
• Develop healthcare provider education
tools to help providers talk to patients
more effectively
• Share “Best Practice” recommendations
for improving immunizations services
• Monika Trimble- student research
assistant
• Tam Lutz- qualitative analysis
mentor
• Clarice Charging- immunizations
coordinator
Immunization Practices
Survey
Survey Results
What is your primary role in the clinic where you work?
Thank
You!
methods
12%
I offer it but I don’t push it
12%
I offer it to those who need it most
8%
16%
What do you tell your patients about the flu shot?
8%
Response Response
Percent
Count
8.0%
2
4.0%
1
88.0%
22
I recommend it for all my patients
I discourage patients from getting
0.0%
the flu shot
Other 1) Especially children due for vaccines
4%
40%
N=25
2) I use the reminder feature of the EHR to
see status and recommend based on that
0
1
1
N=25
3
4/17/2014
Where do you turn for information about
immunizations against influenza?
When a parent requests an alternative immunization
schedule for their child, what best describes your response?
100%
80%
60%
40%
20%
0%
CDC
State
Health
Jurisdiction
Dept.
IHS
Portland Local Health
(Nat’l)
Area IHS
N=25
Encourage
CDC
schedule
Provide
alternate
schedule
Warn of
risks
of
alternate
schedule
Always
follow
parents
wishes
N=25
4