Strategies to Increase Immunization Levels : The AFIX Approach
CDC, through state and other grantees, administers a program designed to move healthcare personnel from a state of unawareness about the problem of low immunization rates in their practice to one in which they are knowledgeable, concerned, motivated to change their immunization practices, and capable of sustaining new behaviors. The acronym used for this approach is AFIX: Assessment of the immunization coverage of public and private providers, Feedback of diagnostic information to improve service delivery, Incentives to motivate providers to change immunization practices or recognition of improved or high performance, and eXchange of information among providers. First conceived by the Georgia Division of Public Health, AFIX is now being used nationwide with both public and private immunization providers and is recommended by governmental and nongovernmental vaccine programs and medical professional societies.
Overview
The AFIX process consists of an assessment of an immunization provider’s coverage rates by a trained representative from the state or other immunization grantee program, feedback of the results of the assessment to provider staff, incentives to improve deficiencies and raise immunization rates, and exchange of information and ideas among healthcare providers. Some specific characteristics of this approach have made it one of the most effective for achieving high, sustainable vaccine coverage.
First, AFIX focuses on outcomes. It starts with an assessment, producing an estimate of immunization coverage levels in a provider’s office, and these data help to identify specific actions to take in order to remedy deficiencies. Outcomes are easily measurable. Second, AFIX focuses on providers, those who are key to increasing immunization rates. AFIX requires no governmental policy changes, nor does it attempt to persuade clients to be vaccinated, but instead focuses on changing healthcare provider behavior. Third, AFIX, when used successfully, is a unique blend of advanced technology and personal interaction. Much of the AFIX process can be done electronically, increasing speed and accuracy of assessment and feedback and streamlining reporting. However, the personal skills of the assessor and that person’s ability to establish rapport with and motivate a provider are critical to achieving lasting results.
Assessment
Assessment refers to the evaluation of medical records to ascertain the immunization rate for a defined group of patients, as well as to provide targeted diagnosis for improvement. This step is essential because several studies have documented that most healthcare providers, while supportive of immunizations, do not have an accurate perception of their own practice’s immunization rates. Pediatricians in these studies greatly overestimated the proportion of fully immunized children in their practices. Assessment increases awareness of a provider’s actual situation and provides a basis for subsequent actions by provider staff.
CDC has developed a software program, CoCASA, which enables assessment to be done electronically, is flexible enough to accommodate whatever assessment parameters are desired, and provides results that can be printed immediately. This program will be described further in the section titled “AFIX Tools and Resources”.
Feedback
Feedback is the process of informing immunization providers about their performance in delivering one or more vaccines to a defined client population. The work of assessment is of no use unless the results are fed back to persons who can make a change. Assessment together with feedback creates the awareness necessary for behavior change.
Feedback generally consists of the immunization program representative meeting with appropriate provider staff and discussing the results of the assessment in order to determine the next steps to be taken. This may be done at a second visit following the assessment of the provider’s records, or it may take place the same day. There are advantages and disadvantages to each approach. If CoCASA has been used, the summary report that is generated can identify specific subsets of patients (e.g., those who have not completed the series because of a missed opportunity for immunization) that, if found in substantial numbers, can provide clues to which changes in the provider’s practice would be most effective. This can save time and make the feedback session more focused.
The personal element of feedback, as mentioned, is also critical to its success. A reviewer who is involved and committed to the AFIX process, who addresses deficiencies without judgment, and who respects the confidentiality of the data and the efforts of the provider, will be likely to gain the trust of providers and motivate them to increase immunization rates in the practice.
Incentives
An incentive is defined as something that incites one to action or effort. Incentives are built into the AFIX process, recognizing that immunization providers, like everyone else, will accomplish a desired task more successfully if motivated to do so. The assessment and feedback components are not intended to be done in isolation; providers may have sufficient data about their practice’s immunization rates, but they must recognize high immunization coverage as a desirable goal and be motivated to achieve it.
Incentives are extremely variable. No one thing will be effective for every provider, and a single provider may need different types of motivation at different stages of progress. Things like small tokens of appreciation and providing resource materials at meetings have helped providers approach their task positively and create an atmosphere of teamwork, but longer-term goals must be considered as well. Since the effort to raise immunization rates may involve an increase in duties for staff, offering assistance in reviewing records or sending reminder notices might more directly address a provider’s needs. Incentives pose a challenge to the creativity of the program representative but also offer the opportunity to try new ideas.
Finally, incentives are opportunities for partnerships and collaboration. Professional organizations or businesses have been solicited to publicize the immunization efforts in a newsletter or provide funding for other rewards for provider staff. Many other types of collaboration are possible; these also have the benefit of increasing awareness of immunization among diverse groups.
eXchange of Information
The final AFIX component, eXchange of information, goes hand in hand with incentives. The more information providers have about their own practice’s immunization coverage status, how it compares with state norms and with other providers in their community, and what strategies have been successful with other providers, the more knowledgeable and motivated they will be to increase their immunization rates. It is up to the AFIX representative to provide appropriate statistical and educational information and create forums for exchange of information among providers.
Staff members at all levels can benefit from the exchange of ideas about immunization practices and increasing rates of coverage—what has worked or not worked with another provider, streamlining office procedures, or where to obtain educational or other resources. The forums for such exchanges vary widely from informal meetings on the local level to more structured meetings sponsored by government or professional organizations. Immunization training sessions can be combined with sharing of ideas regarding actual situations in which recommendations, such as those from ACIP, are applied.
With the increased use of electronic communication, this method should not be neglected in the information exchange component of AFIX. Although different from face-to-face communication, e-mail exchanges or newsletters sent electronically can be cost-saving and fast means of disseminating information.
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