INCREASING IMMUNIZATION RATES AMONG AFRICAN-AMERICAN ADULTS: E. Barriers to Adult Immunization
Several reasons have been given to explain under-utilization of vaccines among adults. First, some members of the public and health care providers do not perceive adult vaccine-preventable diseases as a significant public health problems. Second, there are unnecessary fears among patients and providers concerning adverse events following vaccination. Third, unlike childhood immunization, adult immunization indications are selective, with different target groups for different vaccines. Fourth, there are no statutory requirements for adult immunization. Fifth, there are no comprehensive vaccine-delivery systems in the public and private sectors. Sixth, there are limited reimbursement levels for vaccination services and a lack of coverage for adult immunization by third party payers. Seventh, there is a failure to establish organized vaccination programs in settings (e.g. workplace) where adults congregate. Finally, there are missed opportunities to vaccinate adults during contacts with health care providers.
Racial and ethnic disparities in adult immunization may reflect a differential effect of some or all of these factors on members of racial and ethnic minority groups, caused by underlying socioeconomic or cultural differences. These differences can create barriers to health care access and discourage appropriate use of preventive health services on the part of patients (e.g., limited access to care, lack of knowledge and negative attitude toward immunization), providers (e.g., considering immunization of adults and other preventive services as low priority within their practice, differential treatment of patients), and organizations (e.g., constraints of the practice setting, lack of organized program for delivering preventive services). buy antibiotics no prescription
Patient-related Barriers
There are a number of potential patient-related attitudinal barriers to adult immunization, which include:
♦ A general lack of awareness that vaccines are necessary (e.g., provider has not recommended vaccination);
♦ There is a feeling that there are minimal health risks from vaccine-preventable diseases;
♦ Doubts about vaccine efficacy;
♦ Misperceptions about vaccine side effects (e.g., believing influenza vaccination can cause influenza);
♦ A dislike or fear of needles;
♦ Minimal concern for preventive health measures; and
♦ A distrust of health care providers, particularly among homeless, illegal aliens, or the poor coupled with health care providers of a different racial or ethnic group.
In addition, socioeconomic conditions such as lower levels of income and education; unemployment and living in impoverished areas can also create barriers to vaccination by limiting access to quality care. When patients lack adequate health insurance; or a usual source of care; have limited transportation, and rely on hospital emergency departments for acute medical care they tend to have lower vaccination rates. These factors accentuate attitudinal barriers to vaccination.
Among Americans aged 65 years or older, Medicare has reduced many barriers to vaccination. Medicare provides influenza and pneumococcal vaccination at no cost to beneficiaries enrolled in Part В coverage. Members of racial and ethnic minority groups report contact with the health care system as often as do non-Hispanic Whites, yet African Americans have lower influenza and pneumococcal vaccination levels, even among those with more frequent contact. In 1996, a nationally representative sample of Medicare beneficiaries was asked to provide reasons for not receiving influenza and pneumococcal vaccinations. Although African Americans in the sample were less likely to report receipt of vaccination, the reasons they reported for lack of vaccination were similar to those reported by non-Hispanic Whites (Figures 3 and 4) . Among persons of all racial and ethnic groups combined, of those not receiving the pneumococcal vaccine, 57 percent reported not knowing they needed the vaccine, 13 percent stated that a doctor had not recommended the vaccine, and 11 percent did not think of it or missed it. Of those not receiving recent influenza vaccination, 19 percent reported not knowing they needed the vaccine, and 39 percent had misconceptions regarding vaccine safety or efficacy (thinking it could cause influenza or other side effects, or would not prevent influenza). Apcalis Oral Jelly
Provider-related Barriers
A doctor’s recommendation for vaccination can have a strong influence on a patient’s decision to be vaccinated, even among persons with negative attitudes toward vaccination. Recent surveys of physicians have indicated that most were aware of and agreed with vaccination recommendations, but the main reason many cited for not delivering vaccines was oversight. This indicates the need for organized programs for vaccination delivery, which would minimize missed opportunities to vaccinate when a patient visits the healthcare provider for other problems.
Primary care providers at an ambulatory careclinic serving predominantly indigent African Americans had adequate knowledge of pneumococcal vaccine overall, and over half reported that patients accepted their recommendations for vaccination most of the time. Other potential barriers to provider delivery of immunization services include: uncertainties about high risk groups that require immunization; difficulty determining a patient’s vaccination status; low priority for immunization; requirements for written consent; low reimbursement for delivery of vaccination services creating physician disincentive; fears of adverse events following vaccination and related liability concerns; and beliefs that patients should be educated by mass media campaigns. Viagra Online Canadian Pharmacy
Because older African Americans have frequent contact with health care providers, it is possible that disparities in vaccination levels could in part result from lower quality of care. For example, in one study in New York City, physicians with a predominately African American or Hispanic population were less likely to recommend influenza and pneumococcal vaccination for patients aged 65 and older compared to physicians with a predominately White patient population (47 percent vs. 74 percent for influenza; 27 percent v. 54 percent for pneumococcal). A shortage of primary care physicians resulting in higher patient loads and constraints in the practice setting, may contribute to lowered quality of care provided to African Americans living in urban or rural poverty areas. Results from a recent study of adults belonging to a managed care organization showed that African Americans were much less likely than Whites to say their doctors involve them in health care decisions. Although African Americans are much more likely to have a minority physician than Whites, the majority are treated by white physicians. Another study showing lower rates of referral for cardiac catheterization when patients were African American provides other evidence for subtle forms of racial discrimination in the health care delivery system.
F. Missed Opportunities
Adults reporting more frequent contacts with the health care system are more likely to report vaccination, reflecting increased opportunities for vaccinations to be recommended by providers or requested by patients. Williams et al. identified many opportunities to provide vaccines to adults that were being missed, despite availability of safe and effective vaccines. Health care providers often fail to take advantage of opportunities to vaccinate during office, clinic, and hospital contacts and fail to organize programs in medical settings that ensure adults are offered the vaccines they need. More than one third of persons aged 65 years or more, or younger adults at increased risk for complications from influenza or pneumococcal infection, reported five or more contacts in the past year. However, except for persons aged 65 years or more receiving influenza vaccine, the majority had not been vaccinated against influenza or pneumococcal disease. Also, influenzavac-cination levels are higher than levels of pneumococcal vaccination. These data indicate missed opportunities by providers to offer vaccination services. generic cialis uk
Because previous hospitalization is a risk factor for subsequent serious pneumococcal infection, administration of influenza and pneumococcal vaccines to inpatients has been recommended. However, among Medicare patients hospitalized for pneumonia in 12 western states in 1994, opportunities to provide pneumococcal and influenza vaccines were missed for up to 80 percent and 65 percent, respectively, of eligible persons. Among a group of primarily indigent African American adults treated for invasive pneumococcal disease at a teaching hospital, up to one third of the cases could have been prevented if the pneumococcal vaccine had been administered during previous encounters with the hospital.
Data show that opportunities to vaccinate are missed despite older African Americans having multiple doctor visits during the year. Target vaccination groups are shown to have visited the doctor five or more times during the year without receiving influenza or pneumococcal vaccines. African Americans when compared to their White counterparts were under immunized given both groups had the identical following indicators:
♦ seeing a physician a similar number of times during the year;
♦ the same educational level;
♦ had medical insurance; and
♦ had a medical home.
Missed opportunities also have been identified for administration of other vaccines, such as hepatitis B, measles, rubella, and tetanus toxoid. buy cialis soft tabs
