Strategies for improving influenza immunization rates among hard-to-reach populations

With some exceptions, influenza immunization rates in the U.S. are low overall. This problem is particularly acute among underserved racial/ethnic minority groups and other hard-to-reach (HTR) populations living in urban areas, such as substance users, undocumented immigrants, and homebound elderly. These groups may be less likely than those receiving routine health care to be immunized. Additionally, in the event of an influenza pandemic, gaining access to and delivering vaccine to these groups would be particularly problematic. In September, 2006, community health administrators and researchers, national vaccine policy makers, vaccine manufacturing executives, local department of health representatives and community members attended a day-long meeting to discuss challenges and develop strategies for immunizing the general and HTR populations on the individual, provider and structural level. A guided review of the literature was also conducted to provide additional information on each of these levels. Challenges in delivering vaccine to the general and HTR populations at the individual level include distrust of the government and health care system, lack of education leading to misconceptions about vaccine risks and benefits, and difficulties in negotiating the health care system. At the provider level, challenges are lack of clear, strong recommendations from health care providers, cost, and legal or regulatory barriers to broadening the provider base to include nurses or pharmacists. At the structural level, challenges include balancing the vaccine supply with the demand, poor access to immunization services and difficulties in locating or engaging HTR populations. Strategies for increasing immunization coverage at the individual level include developing community-based educational campaigns to change attitudes and increase motivation for receiving vaccine; at the provider level, improving vaccination practices (adopting standing orders and instituting mailings/reminders), and broadening the provider base; and at the structural level, partnering with community-based organizations, and promoting social mobilization and immunization in non-traditional settings and at convenient times for HTR populations. In the event of a pandemic, effective strategies include involving community-based organizations in planning exercises, distributing vaccine in non-traditional settings, and including HTR populations in statewide preparedness plans. These observations provide a first step toward optimizing strategies for immunizing HTR populations.