Effectiveness of Individually Tailored Calendars in Promoting Childhood Immunization in Urban Public Health Centers

Childhood immunization rates are low in many large US cities.1 In general, rates are lowest in inner-city areas,2 among minorities,1–3 in families with lower incomes,3–8 in single-parent families,6,9 in larger families,5,10 and in families with less educated parents.6 The major barriers to childhood immunization are well established and include parentrelated factors (e.g., lack of knowledge of immunization schedule,10–15 perceptions that vaccination is relatively unimportant10,14,16), factors associated with the social or physical environment (e.g., limited availability or high cost of transportation and child care, work conflicts, family circumstances8,14), and factors associated with the health care delivery system (e.g., restrictive appointment and immunization policies, limited operating hours, insufficient personnel, excessive waiting time, missed opportunities to immunize3,5–7,11,13,14,16–19). To date, knowledge of the characteristics of high-risk populations has not always resulted in provision of unique or effective immunization programs for their members. Strategies such as mailed or telephone reminders, shown to be effective in general population samples,20,21 may have only nominal effects among high-risk populations.22 For example, in 2 Atlanta public health clinics, modest improvement in immunization rates was found among families who received a telephone reminder, but because 20% of the sample could not be reached by telephone, the overall effect of the intervention did not achieve significance.23 Immunization guidelines and recommendations indicate that providers should use more “patient-oriented” approaches,24 communicate more effectively with families and communities,25 and increase the demand for immunizations through health education.7 These recommendations are consistent with a social marketing approach to planning public health interventions—namely, an app