Improving Immunization Rates in Underserved Neighborhoods

Background: Immunization refusal rates in the United States are increasing. Ohio is below the national average for immunization rates, with even lower rates among children who are publicly insured. Our two hospital-based pediatric primary care offices serve 25,000 children from urban, underserved neighborhoods, with 90% publicly insured and 75% Black. Our immunization refusal rate is 2%, but nearly 10% of families refuse select immunizations or request alternative schedules. The drivers of local immunization rates are unknown.

Our objective was to explore families’ immunization beliefs and perspectives through interviews to allow for development of tailored information. The secondary objective was to evaluate caregiver impression of the newly developed educational information and measure the acceptability of these materials.

Methods: This content analysis took place at a large, urban pediatric hospital’s primary care offices. Caregivers of patients were recruited for interviews. We developed semi-structured interview guides after conducting a literature review and holding informal discussions with families at community meetings. The interview script included eight questions related to educational materials, desired topics, preferred learning format and reasons for vaccine refusal. Interviews were audio recorded, transcribed, and coded by one team member, then collectively analyzed by three team members to identify initial codes. The entire team discussed codes and resolved any discrepancies and then created categories. Educational materials were created based on the results of these interviews. Finally, caregivers at well child visits were approached to review the educational materials and provide written feedback, through pre- and post-surveys, to assess acceptability and impression of the materials.

Results: Eighteen family were initially interviewed. Key educational topics identified by families included vaccine ingredients, side effects, and general benefits of immunizations. Reasons for vaccine refusal included concerns that vaccines cause disease, adverse side effects, and a fear of developing autism (Table 1). Written materials and videos were the preferred educational format, and families reported wanting these materials in conjunction with in-person discussions with the health care providers.

Several educational resources were created: 1) a timeline displaying a typical vaccine schedule with descriptions of each vaccine, 2) a brochure addressing common concerns, and 3) a testimonial video with clinicians and caregivers describing “Why I Vaccinate.” The educational information was piloted with 51 families, and the majority of caregivers reported their questions were answered and they would likely share the information with family and friends (Table 2).

Conclusion: Caregivers indicated preferences for written and digital materials to augment vaccine-related discussions with healthcare providers. Educational materials tailored to address family concerns and learning preferences may enhance quality of conversations and ultimately decrease immunization refusal in our community. Next steps include distributing educational materials more broadly within primary care and evaluating impact on immunization rates. Similar approaches could be considered for newer vaccines, including COVID-19.