Understanding Adult Vaccination in Urban, Lower-Socioeconomic Settings: Influence of Physician and Prevention Systems

The paper by Zimmerman et. al. concerning vaccinations and urban populations with low SES is both important and timely. It is important because disparities in outcomes by race have been well documented by the Institute of Medicine and others. Such disparities are troublesome and thought to be multi-factoral. This paper documented significant differences in the rate of Pneumococcal Vaccine (PPV) and the Influenza vaccine between white and black patients. However, they demonstrated that a few simple practice characteristics and physician behaviors can improve those rates significantly. The rate of PPV vaccination increased with more structured record documentation such as EHR and the number of minutes the physician spent in the room with the patients. For the influenza vaccine, the factors were standing orders as well as the length of time of the physician in the room.

This is very good news with respect to the practice characteristics as a simple flow sheet and standing orders can both be implemented for minimal or no costs. The key physician variable, that is time of the visit, is simply good family doctoring in which the doctor-patient communication is central. Discordance between the race and ethnicity of the physician and the patient may result in cultural or linguistic barriers to communication and that may be a key factor in the different rates of vaccination in blacks and whites. However, one would surmise that any barriers related to discordance could be bridged by continuity of care and lenth of visit.

This study is timely because we are in the midst of a swine flu epidemic in many areas of the country and health officials are trying to insure that as many patients in the high risk categories are vaccinated. The November 11, 2009 edition of the Los Angeles Times has a story entitled " County's free H1N1 clinics are seeing few African Americans" which describes the different rates of receiving the H1N1 vaccine by race. The story reports that African Americans, which make up about 9% of the population, have received on 2.6% of the vaccinations distributed by the health department while Asian Americans, who account for 13% of the population have received more than 27% of the vaccines distributed.

In my 30 years of practice with low income African American patients I have found that a higher percentage refuse adult vaccinations than any other patient group. For some it has taken me more that 5 consecutive years to win them over; for others, I have never been able to convince. When the LA Times asked a black community leader what to comment on the low rates, she mentioned ongoing distrust since the Tuskegee Syphilis study. She then added "It's more than the legacy of Tuskegee--it's a whole lifetime of poor access to healthcare." Fortunately, some culturally appropriate, evidence based interventions as reference by Zimmerman et. al. in their last reference can increase these rates in this population.

Competing interests:   None declared