Raising Patient Awareness, Immunization Coverage in the Community

October 2015, Vol 3, No 10 - Inside Influenza Readiness
Krissy K Moehling, MPH
Jonathan M Raviotta, MPH
Michael Susick, MPH
Mary Patricia Nowalk, PhD, RD
Richard K Zimmerman, MD, MPH

Despite the vast public health impact and individual benefit of immunizations, vaccine uptake among adults and certain population subgroups in the United States is suboptimal.1 The Centers for Disease Control and Prevention (CDC) reported that influenza vaccine coverage during the 2012-2013 flu season for adults was 41.5% and adolescents, 42.5%.2 Although there are well-known patient barriers to vaccine acceptance, such as patient refusal to get the vaccine, other contributing factors exist that fall within the purview of healthcare systems and providers, including choice of vaccines, reimbursement, and timing of vaccine distribution.

Low vaccination coverage is a complex interplay of patient-, provider-, and system-level factors that vary from setting to setting. This leads to a significant challenge in improving immunization rates across the diverse healthcare landscape. A successful intervention should be broad enough to apply to a number of vaccines and population groups, nimble enough to adjust to changes in recommendations, and adaptable enough to suit an array of practice settings. It should also address all of the intertwined systems and behaviors that contribute to vaccination success.

As part of The Pittsburgh Vaccination Research Group (PittVax), we have spent more than 2 decades researching patient-, provider, and system-level barriers and facilitators of immunizations. In addition, we have researched methods to increase vaccination rates in hospital and primary care settings, the effects of vaccine policy on vaccination rates, patient perceptions of vaccine policy, comparative cost-effectiveness of vaccine policies, vaccine effective­ness, and immune respons­es to vaccination. Based on research and other data to increase vaccination rates, we developed a practice improvement toolkit called the 4 Pillars Immunization Tool­kit that includes evidence-based strategies for increasing immunization rates.

The following strategies outline ways pharmacists and other healthcare providers can raise patient awareness using the tool we developed, and increase immunization rates in the community setting.

The 4 Pillars Immunization Toolkit

As their role in preventive care grows to include services like immunization, it is important for pharmacists and other healthcare providers to develop their own strategy to raise awareness among patients and customers in their community. Pharmacists and retail clinicians are well-positioned to educate, make strong recommendations, and address misconceptions patients may have about vaccinations during visits.

The 4 Pillars Immunization Toolkit is an interactive website application with an evidence-based, quality-improvement intervention and education program.3,4 The toolkit was developed and tested in community primary care settings. It was sub­sequently updated and broadened to include a larger number of vaccines and applicable populations. It has been used as part of interventions to increase immunization rates of children, teens, and adults.5-7

The purpose of the toolkit is to address known barriers to vaccination by providing evidence-based facilitator strategies that have been shown to increase immunization across practice types (eg, pediatric, family medicine, geriatric).5-10 The 4 Pillars were derived from findings of the Community Preventive Services Task Force8 and research emphasizing the importance of sustained motivation in immunization efforts.6,11-13

The 4 Pillars of the toolkit are: (1) convenient and easy access to vaccines; (2) patient notification of the importance of vaccination and availability of vaccination services; (3) enhanced vaccination systems within the healthcare setting; and (4) motivation of healthcare staff through an onsite immunization champion.5-7 The toolkit encourages collaboration through cooperation and teamwork, and the immunization champion serves as the key driver of the practice change plan through innovative thinking and motivation.

Practical Tool for Pharmacists, Healthcare Providers

Although the toolkit was designed for primary care offices, it can serve as a valuable tool in other settings where immunizations are administered such as community pharmacies and clinics. Pharmacies that offer on-site vaccinations can increase access to vaccines by allowing patients to take advantage of quick service, convenience, and low vaccination costs.

Successfully addressing patient concerns related to vaccinations requires an understanding of their source. Sometimes communication is stymied because of unrecognized differences between patients and healthcare providers, such as health literacy; ethnic, religious, or cultural background; and native language. The toolkit provides suggestions for healthcare professionals to effectively communicate and overcome communication barriers. It also includes links to trusted vaccination resources, such as the CDC, Immunization Action Coalition, and the National Foundation for Infectious Diseases.

Pharmacists’ role as a trusted clinical educator with a thorough knowledge of vaccine drug components allows them to discuss potential side effects, benefits of vaccination, and address misconceptions of the vaccine in a way that can lessen patient concerns. Ideally, raising patient awareness about vaccination services should go beyond advertising that vaccines are available, and include active outreach to customers who may not normally get vaccinated. A simple statement, such as “While you are here picking up your prescription, we can offer you a flu vaccine,” can begin a conversation.

During the influenza season, any time a pharmacist interacts with a customer should be considered an opportunity to provide a vaccination. This year, in particular, patients may be less willing to get vaccinated because of widespread media coverage on the low effectiveness rate of vaccinations this past influenza season. Pharmacists and healthcare providers in the community are uniquely positioned to help ensure that patients continue to receive influenza vaccines and other vaccines needed.

Pharmacists can also assume a leadership role among their healthcare colleagues by getting vaccinated themselves and encouraging their coworkers to do the same. Healthcare professionals often believe they are better able to avoid infection despite their high likelihood of exposure and ignore the fact that they can serve as vectors for infection. As a matter of patient safety, healthcare professionals should receive the recommended vaccines. Vaccinated providers are better advocates for vaccination among patients.


Providing convenient access to vaccines; educating and encouraging patients and other healthcare professionals to receive annual influenza vaccines; and working together with other healthcare providers to increase immunization rates are just a few ways to better protect the community against vaccine-preventable diseases, and improve health outcomes.


The 4 Pillars Immunization Toolkit implementation trials were supported by CDC grant 1U01lP000662-01 and Pfizer Inc grant 8201807.


Ms Moehling and Dr Zimmerman received a grant from Pfizer Pharmaceuticals, Merck & Co, and Sanofi Pasteur; Mr Raviotta and Dr Nowalk received a research grant from Pfizer Pharmaceuticals and Merck & Co; and Mr Susick received a research grant from Sanofi Pasteur.


  1. Centers for Disease Control and Prevention. Adult vaccination coverage—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:66-72.
  2. Santibanez TA, Yusheng Z, O’Halloran A, et al. Flu vaccination coverage, United States, 2012-13 influenza season. www.cdc.gov/flu/fluvaxview/coverage-1213estimates.htm. Updated September 25, 2013. Accessed August 10, 2015.
  3. The Pittsburgh Vaccination Research Group. The Pittsburgh Vaccination Research Group website. PittVax overview. www.pittvax.pitt.edu/pittvax-overview. Accessed August 14, 2015.
  4. The Pittsburgh Vaccination Re­search Group. The 4 Pillars™ Immunization Toolkit website. www.4pillarstoolkit.pitt.edu/. Accessed August 14, 2015.
  5. Nowalk MP, Lin CJ, Hannibal K, et al. Increasing childhood influenza vaccination: a cluster randomized trial. Am J Prev Med. 2014;47:435-443.
  6. Nowalk MP, Nolan BA, Nutini J, et al. Success of the 4 pillars toolkit for influenza and pneumococcal vaccination in adults. J Healthc Qual. 2014;36:5-15.
  7. Zimmerman RK, Nowalk MP, Lin CJ, et al. Cluster randomized trial of a toolkit and early vaccine delivery to improve childhood influenza vaccination rates in primary care. Vaccine. 2014;32:3656-3663.
  8. Community Preventive Services Task Force. The community guide: increasing appropriate vaccination. www.thecommunityguide.org/vaccines/index.html. Accessed September 16, 2015.
  9. Zimmerman RK, Nowalk MP, Raymund M, et al. Tailored interventions to increase influenza vaccination in neighborhood health centers serving the disadvantaged. Am J Pub Hlth. 2003;93:1699-1705.
  10. Nowalk MP, Nutini J, Raymund M, et al. Evaluation of a toolkit to introduce standing orders for influenza and pneumococcal vaccination in adults: a multimodal pilot project. Vaccine. 2012;30:5978-5982.
  11. Slaunwhite JM, Smith SM, Fleming MT, et al. Increasing vaccination rates among health care workers using unit “champions” as a motivator. Can J Infect Control. 2009;24:159-164.
  12. Westrick SC, Breland ML. Sustainability of pharmacy-based innovations: the case of in-house immunization services. J Am Pharm Assoc. 2009;49:500-508.
  13. Zimmerman RK. Increasing engagement of clinicians in adult immunizations: reflections on a decade and a half of research. Vaccine. 2014;32:7040-7042.

A Note from the Editor-in-Chief

Retail pharmacies and the clinics inside pharmacies are seeking to expand their immunization services to patients. This is a value-added service that frees up physicians to provide more in-depth services. Pharmacies have evolved to an “anytime” provision of immunizations as most pharmacists are now trained and able to provide immunizations. Pharmacies are improving their support systems for billing and reporting to state registry programs. As immunizations grow within pharmacy walls, there are a number of strategies on how to reach out to patients and advise them of the benefits of immunization and the services that can be offered at your location. This article describes one of many opportunities for healthcare practitioners to consider when seeking to expand immunization services. We welcome your insight on this approach as well as any other strategies and tactics used to grow immunizations at your pharmacies. Please send your ideas to This email address is being protected from spambots. You need JavaScript enabled to view it..

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Last modified: October 29, 2015
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