Reminder Cards and Immunization Rates Among Latinos and the Rural Poor in Northeast Colorado

Paul Hicks, MD; Gillian A. M. Tarr, MPH; Ximena Prieto Hicks, MD


J Am Board Fam Med. 2007;20(6):581-586. 

In This Article

Abstract and Introduction

Objective: Immunization rates are static in the United States. Risk factors for not being up to date (UTD) include ethnicity and lower socioeconomic status. Reminder cards increase immunization rates in urban settings. Their effect in poor, Latino, and rural children is unknown.
Background: Language-appropriate reminder cards were sent to active patients not UTD listing the vaccines missing; the card served as the physician order for the vaccine. Missed opportunities were addressed through discussion with staff and posters in patient care rooms. UTD rates before and after intervention were measured.
Results: Dual-purpose reminder/order cards increased the rate of UTD from 61.3% to 73.4%; children living near the clinic, patients who speak only Spanish, and Latinos overall showed preferential effectiveness. Children eligible to participate in the Vaccines for Children program had similar increases in UTD rates but had lower baseline and final UTD rates than did children not eligible for the Vaccines for Children program. The rate of missed opportunities did not change. The number of children to whom reminder cards needed to be sent for them to become fully immunized is 8 (number needed to treat).
Conclusions: In poor, rural, and Latino populations, language-appropriate reminder/order cards increase immunization rates.

Immunization rates in the United States have reached a plateau in the last several years; several states, including Colorado, show rates far below national averages.[1,2] After steadily rising through the 1980s, minimal improvement was seen in the 1990s. There are many theories as to why this glass ceiling exists. Among them are parental concerns about vaccine side effects and safety, the increasing complexity of the recommended immunization schedule, and competing demands in a busy office setting. Missed opportunities represent a special concern because they occur with high frequency and account for much of the immunization delay seen in practice, specifically for at-risk children.[3,4]

It is clear, however, that for some populations, the ceiling is lower than for others. Minorities and the poor have higher rates of not being up to date than do wealthier or white children.[5,6,7,8,9,10,11] The consequence of incomplete immunization is the persistent occurrence of vaccine-preventable diseases.

Many strategies have been recommended to improve immunization rates.[12,13,14,15,16,17,18,19] The Vaccine for Children (VFC) program was developed to help ameliorate the inequities in vaccinations inherent in people living in poverty and to increase minorities' access to free vaccines.[20,21] The use of computer-based vaccine registries is increasing in the United States, with over half of all children younger than 6 years of age enrolled in 2005.[22] These registries provide the benefits of accessibility in many patient care settings, thereby decreasing chances that one site will inappropriately vaccinate a child. These and other arguments in their favor have been extensively published.[12,23,24,25,26] Arguments against these registries include the large labor costs of data entry and inconsistent or incomplete data entry leading to the assessment of lower UTD rates using the registries compared with chart reviews.[27,28,29,30]

Recall and reminder cards seem to have an overall positive effect on immunization rates in both children and adults.[31,32,33] The effect is less in lower-income populations. Previous work in our institution revealed that reminder cards were ineffective in increasing the frequency of getting laboratory tests performed among adult patients with diabetes (unpublished data, Hicks, 2001). However, the effectiveness of recall and reminder cards in the immunization rates of healthy children was not evaluated in that study. Our intention with the current study was to determine whether the use of patient reminder cards and a simple office-based intervention to decrease missed opportunities would improve the number of children UTD with recommended immunizations in a low-income, rural, and Latino population.


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