title: A comprehensive investigation of barriers to adult immunization: a methods paper.
abstract: OBJECTIVE
  Immunization rates for influenza and pneumococcal vaccines among the elderly (especially minority elderly) are below desired levels. We sought to answer 4 questions: (1) What factors explain most missed immunizations? (2) How are patient beliefs and practices regarding adult immunization affected by racial or cultural factors? (3) How are immunizations and patient beliefs affected by physician, organizational, and operational factors? and (4) Based on the relationships identified, can typologies be created that foster the tailoring of interventions to improve immunization rates?
  
  
  METHODS
  A multidisciplinary team chose the PRECEDE-PROCEED framework, the Awareness-to-Adherence model of clinician response to guidelines, and the Triandis model of consumer decision making as the best models to assess barriers to and facilitators of immunization. Our data collection methods included focus groups, face-to-face and telephone interviews, self-administered surveys, site visits, participant observation, and medical record review.
  
  
  METHODS
  To encounter a broad spectrum of patients, facilities, systems, and interventions, we sampled from 4 strata: inner-city neighborhood health centers, clinics in Veterans Administration facilities, rural practices in a network, and urban/suburban practices in a network. In stage 1, a stratified random cluster sample of 60 primary care clinicians was selected, 15 in each of the strata. In stage 2, a random sample of 15 patients was selected from each clinician's list of patients, aiming for 900 total interviews.
  
  
  CONCLUSIONS
  This multicomponent approach is well suited to identifying barriers to and facilitators of adult immunizations among a variety of populations, including the disadvantaged.
authors.affiliation: Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, M-200 Scaife Hall, Pittsburgh, PA 15261, USA. Zimmer+@pitt.edu.
authors.forename: R K
authors.initials: RK
authors.lastname: Zimmerman
authors.forename: M
authors.initials: M
authors.lastname: Silverman
authors.forename: J E
authors.initials: JE
authors.lastname: Janosky
authors.forename: T A
authors.initials: TA
authors.lastname: Mieczkowski
authors.forename: S A
authors.initials: SA
authors.lastname: Wilson
authors.forename: I J
authors.initials: IJ
authors.lastname: Bardella
authors.forename: A R
authors.initials: AR
authors.lastname: Medsger
authors.forename: M A
authors.initials: MA
authors.lastname: Terry
authors.forename: J A
authors.initials: JA
authors.lastname: Ball
authors.forename: M P
authors.initials: MP
authors.lastname: Nowalk
mesh_terms: D000368:Aged; D005194:Family Practice / Q000458:organization & administration*; D005260:Female; D017144:Focus Groups; D019983:Guideline Adherence / Q000592:standards / Q000706:statistics & numerical data; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D007114:Immunization / Q000523:psychology* / Q000706:statistics & numerical data*; D007252:Influenza Vaccines; D008297:Male; D008913:Minority Groups / Q000193:education / Q000523:psychology; D008960:Models, Psychological; D015279:Organizational Culture; D010342:Patient Acceptance of Health Care / Q000523:psychology* / Q000706:statistics & numerical data; D010414:Pennsylvania; D022242:Pneumococcal Vaccines; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012044:Regression Analysis; D011795:Surveys and Questionnaires
chemical_list: D007252:Influenza Vaccines; D022242:Pneumococcal Vaccines