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September 3, 1997, Vol 278, No. 9 >
ARTICLE | September 3, 1997

Developing Curricula to Promote Preventive Medicine Skills: Title and subTitle BreakThe Teaching Immunization for Medical Education (TIME) Project FREE

Richard Kent Zimmerman, MD, MPH; William H. Barker, MD; Raymond A. Strikas, MD; Ellen R. Ahwesh, MA; Tammy A. Mieczkowski, MA; Janine E. Janosky, PhD; Steven L. Kanter, MD
[+] Author Affiliations

Members and organizations of the TIME committees are listed at the end of this article. Dr Barker is chair of the Association of Teachers of Preventive Medicine Advisory Committee for the TIME Project.

This work was presented in part at the 30th National Immunization Conference, Washington, DC, April 9, 1996; Prevention 97, Atlanta, Ga, March 22, 1997; and the 30th Annual Spring Conference of the Society of Teachers of Family Medicine, Boston, Mass, May 5, 1997.

Reprints: Richard Kent Zimmerman, MD, MPH, Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, M-200 Scaife Hall, Pittsburgh, PA 15261 (e-mail: zimmer+@pitt.edu).


JAMA. 1997;278(9):705-711. doi:10.1001/jama.1997.03550090029028
Text Size: A A A
Published online
Article
References

Context.  —Vaccines are underused in the United States, resulting in needless morbidity. Many experts have concluded that clinician education is critical to increasing the nation's vaccination rates.

Objective.  —To develop and evaluate case-based curricular materials on immunizations that promote preventive medicine skills.

Design.  —Before-and-after trial of an educational intervention.

Setting and Participanst.  —Medical schools and primary care residency programs from 20 institutions across the United States participated in the Teaching Immunization for Medical Education (TIME) project.

Intervention.  —A multidisciplinary team developed learning objectives, abstracted clinical cases, and created case-based modules that use contextual learning and small-group interaction to solve clinical and public health problems. The case-based methods are multistation clinical teaching scenarios (MCTS) and problem-based learning (PBL).

Main Outcome Measures.  —Knowledge gained by learners from pretest to posttest and the overall ratings of the sessions by learners and facilitators based on evaluation questionnaires.

Results.  —Pretest and posttest results were obtained on a total of 1122 learners for all modules combined. For the MCTS method, mean scores increased from the 10-item pretest to the posttest by 3.1 items for measles, 3.8 for influenza, 1.8 for hepatitis B, 3.9 for pertussis, 1.9 for adult vaccination, 1.9 for childhood vaccination, and 2.6 for Haemophilus influenzae type b (P<.01 for each). For the PBL method, mean scores increased by 3.4 items for measles, 3.3 for influenza, 2.6 for hepatitis B, and 2.5 for pertussis (P<.01 for each). Most learners (MCTS, 98%; PBL, 89%) and most facilitators (MCTS, 97%; PBL, 100%) rated the sessions overall as very good or good.

Conclusions.  —Use of TIME modules increases knowledge about immunizations, an essential step to improving vaccination practices of future clinicians. Given the realities of decreased faculty time and budgets, educators face major challenges in developing case-based curricula that prepare learners for the 21st century. Nationally tested libraries of cases such as the TIME modules address this dilemma.

REFERENCES

1 +
Fedson DS, for the National Vaccine Advisory Committee.  Adult immunization: summary of the National Vaccine Advisory Committee report . JAMA . 1994;;272:1133-1137.
2 +
Centers for Disease Control and Prevention.  Pneumococcal and influenza vaccination levels among adults aged ≥65 years—United States, 1993 . MMWR Morb Mortal Wkly Rep . 1996;;45:853-859.
3 +
LeBaron CW, Birkhead GS, Parsons P, et al.  Measles vaccination levels of children enrolled in WIC during the 1991 measles epidemic in New York City . Am J Public Health . 1996;;86:1551-1556.
4 +
Atkinson WL, Orenstein WA, Krugman S.  The resurgence of measles in the United States, 1989-1990 . Annu Rev Med . 1992;;43:451-463.
5 +
National Vaccine Advisory Committee.  The measles epidemic: the problems, barriers, and recommendations . JAMA . 1991;;266:1547-1552.
6 +
Centers for Disease Control.  Measles—United States, 1990 . MMWR Morb Mortal Wkly Rep . 1991;;40:p-372.
7 +
Cutts FT, Orenstein WA, Bernier RH.  Causes of low preschool immunization coverage in the United States . Annu Rev Public Health . 1992;;13:385-398.
8 +
Williams WW, Hickson MA, Kane MA, et al.  Immunization policies and vaccine coverage among adults: the risk for missed opportunities . Ann Intern Med . 1988;;108:616-625.
9 +
 Correction : Ann Intern Med . 1988;;109:348.
10 +
United States General Accounting Office. Vaccines for Children: Reexamination of Program Goals and Implementation Needed to Ensure Vaccination . Washington, DC: US General Accounting Office; 1995;.
11 +
Rodewald L, Peak R, Ezzati-Rice T, et al.  Who are the immunization providers for US children: findings from the 1994 National Health Interview Survey (NHIS) Provider Record Check (PRC) . Ambul Child Health . 1997;;3:168.
12 +
US Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . Washington, DC: US Public Health Service; 1991;.
13 +
Barker WH.  Overview: the ATPM-CDC Immunization in Medical Education Project . Am J Prev Med . 1994;;10( (suppl) ):1-3.
14 +
Falter KH, Strikas RA, Barker WH, et al.  Curriculum content on vaccine-preventable diseases in US medical schools . Am J Prev Med . 1994;;10( (suppl) ):4-10.
15 +
Strikas RA, Falter KH, Barker WH, et al.  Curriculum content on vaccine-preventable diseases in primary care and preventive medicine residency programs in the United States . Am J Prev Med . 1994;;10( (suppl) ):11-17.
16 +
Barrows HS, Tamblyn R. Problem-Based Learning: An Approach to Medical Education . New York, NY: Springer-Verlag; 1980;.
17 +
Kaufman A. Lessons From Successful Innovations: Implementing Problem-Based Medical Education . New York, NY: Springer Publishing Co; 1985;.
18 +
Barrows HS. How to Design a Problem-Based Curriculum for Preclinical Years . New York, NY: Springer Publishing Co; 1985;.
19 +
Albanese MA, Mitchell S.  Problem-based learning: a review of literature on its outcomes and implementation issues . Acad Med . 1993;;68:52-81.
20 +
Wetzel M, Reid L. The Multistation Exercise: Accessible, Adaptable, Active-Learning . Washington, DC: Association of American Medical Colleges; 1991;.
21 +
Zimmerman RK, Janosky JE, Wald ER, et al.  Development and multicenter evaluation of Multistation Clinical Teaching Scenarios on immunization: the ATPM-CDC Teaching Immunization for Medical Education (TIME) project . Am J Prev Med . 1997;;13:78-83.
22 +
Bloom BS, Engelhart MD, Furst EJ, et al. Taxonomy of Educational Objectives: The Classification of Educational Goals. Handbook 1: Cognitive Domain . New York, NY: David McKay Co; 1956;.
23 +
Stufflebeam DL.  The relevance of the CIPP evaluation model for educational accountability . J Res Dev Educ . 1971;;5:19-25.
24 +
Scriven M.  The methodology of evaluation . In: Perspectives of Curricular Evaluation: AERA Monograph Series in Curriculum Evaluation . Chicago, Ill: Rand McNally; 1967;;1.
25 +
Cooley WW, Bickel WE. Decision-Oriented Educational Research . Boston, Mass: Kluwer Nijhoff Publishing; 1986;.
26 +
Maguire T, Skakun E, Harley C.  Setting standards for multiple-choice items in clinical reasoning . Eval Health Prof . 1992;;15( (4) ):434-452.
27 +
Gross LJ.  Setting cutoff scores on credentialing examinations: a refinement of the Nedelsky procedure . Eval Health Prof . 1985;;8:469-493.
28 +
Zimmerman RK, Giebink GS, Street HB, Janosky JE.  The knowledge and attitudes of Minnesota primary care physicians about barriers to measles and pertussis immunization . J Am Board Fam Pract . 1995;;8:270-277.
29 +
Markland RE, Durand DE.  An investigation of socio-psychological factors affecting infant immunization . Am J Public Health . 1976;;66:168-170.
30 +
Rundall TG, Wheeler JR.  Factors associated with utilization of the swine flu vaccination program among senior citizens in Tompkins County . Med Care . 1979;;17:191-200.
31 +
Aho WR.  Participation of senior citizens in the swine flu inoculation program: an analysis of Health Belief Model variables in preventive health behavior . J Gerontology . 1979;;34:201-208.
32 +
Centers for Disease Control and Prevention.  Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) . MMWR Morb Mortal Wkly Rep . 1997;;46( (RR-7) ):1-25.
33 +
Taylor JA, Darden PM, Slora E, et al.  The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from pediatric research in office settings . Pediatrics . 1997;;99:209-215.
34 +
Stevens D, Baker R, Hands S.  Failure to vaccinate against whooping cough . Arch Dis Child . 1986;;61:p-387.
35 +
Peckham C. The Peckham Report: National Immunisation Study: Factors Influencing Immunisation Uptake in Childhood . London, England: Action for the Crippled Child; 1989;.
36 +
Zimmerman RK, Bradford BJ, Janosky JE, et al.  Barriers to measles and pertussis immunization: the knowledge and attitudes of Pennsylvania primary care physicians . Am J Prev Med . 1997;;13:89-97.
37 +
Zimmerman RK, Schlesselman JJ, Baird AL, Mieczkowski TA.  A national survey to understand why physicians limit childhood immunizations . Arch Pediatr Adolesc Med . 1997;;151:657-664.
38 +
Szilagyi PG, Rodewald LE, Humiston SG, et al.  Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status . Pediatrics . 1993;;91:1-7.
39 +
Gamertsfelder DA, Zimmerman RK, DeSensi EG.  Immunization barriers in a family practice residency clinic . J Am Board Fam Pract . 1994;;7:100-104.
40 +
Wood D, Pereyra M, Halfon N, Hamlin J, Grabowsky M.  Vaccination levels in Los Angeles public health centers: the contribution of missed opportunities to vaccinate and other factors . Am J Public Health . 1995;;85:850-853.
41 +
Hutchins SS, Escolan J, Markowitz LE, et al.  Measles outbreak among unvaccinated preschoolaged children: opportunities missed by health care providers to administer measles vaccine . Pediatrics . 1989;;83:369-374.
42 +
Reiser SJ.  Medicine and public health: pursuing a common destiny . JAMA . 1996;;276:1429-1430.
43 +
Jonas HS, Etzel SI, Barzansky B.  Educational programs in US medical schools, 1993-1994 . JAMA . 1994;;272:694-701.
44 +
Association of American Medical Colleges. Physicians for the Twenty-first Century: The GPEP Report . Washington, DC: Association of American Medical Colleges; 1984;.
45 +
Accreditation and the Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree . Chicago, Ill: Association of American Medical Colleges and the American Medical Association; 1993;.
46 +
The Immunization in Medical Education Advisory Committee.  Vaccine-preventable diseases core curriculum objectives . Am J Prev Med . 1994;;10 ( (suppl) ):18-21.
47 +
Atkinson WL, Kaplan JM, Clover R.  Measles: virology, epidemiology, disease, and prevention . Am J Prev Med . 1994;;10( (suppl) ):22-30.
48 +
LaForce FM, Nichol KL, Cox NJ.  Influenza: virology, epidemiology, disease, and prevention . Am J Prev Med . 1994;;10( (suppl) ):31-44.
49 +
Moyer LA, Mast EE.  Hepatitis B: virology, epidemiology, disease, and prevention, and an overview of viral hepatitis . Am J Prev Med . 1994;;10 ( (suppl) ):45-55.
50 +
Tyler CW, Granoff BR.  Cooperative agreements between academic professional associations and the Centers for Disease Control and Prevention . Am J Prev Med . 1996;;12( (suppl to No. 4) ):6-7.

Figures

Tables

Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Fedson DS, for the National Vaccine Advisory Committee.  Adult immunization: summary of the National Vaccine Advisory Committee report . JAMA . 1994;;272:1133-1137.
2 +
Centers for Disease Control and Prevention.  Pneumococcal and influenza vaccination levels among adults aged ≥65 years—United States, 1993 . MMWR Morb Mortal Wkly Rep . 1996;;45:853-859.
3 +
LeBaron CW, Birkhead GS, Parsons P, et al.  Measles vaccination levels of children enrolled in WIC during the 1991 measles epidemic in New York City . Am J Public Health . 1996;;86:1551-1556.
4 +
Atkinson WL, Orenstein WA, Krugman S.  The resurgence of measles in the United States, 1989-1990 . Annu Rev Med . 1992;;43:451-463.
5 +
National Vaccine Advisory Committee.  The measles epidemic: the problems, barriers, and recommendations . JAMA . 1991;;266:1547-1552.
6 +
Centers for Disease Control.  Measles—United States, 1990 . MMWR Morb Mortal Wkly Rep . 1991;;40:p-372.
7 +
Cutts FT, Orenstein WA, Bernier RH.  Causes of low preschool immunization coverage in the United States . Annu Rev Public Health . 1992;;13:385-398.
8 +
Williams WW, Hickson MA, Kane MA, et al.  Immunization policies and vaccine coverage among adults: the risk for missed opportunities . Ann Intern Med . 1988;;108:616-625.
9 +
 Correction : Ann Intern Med . 1988;;109:348.
10 +
United States General Accounting Office. Vaccines for Children: Reexamination of Program Goals and Implementation Needed to Ensure Vaccination . Washington, DC: US General Accounting Office; 1995;.
11 +
Rodewald L, Peak R, Ezzati-Rice T, et al.  Who are the immunization providers for US children: findings from the 1994 National Health Interview Survey (NHIS) Provider Record Check (PRC) . Ambul Child Health . 1997;;3:168.
12 +
US Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . Washington, DC: US Public Health Service; 1991;.
13 +
Barker WH.  Overview: the ATPM-CDC Immunization in Medical Education Project . Am J Prev Med . 1994;;10( (suppl) ):1-3.
14 +
Falter KH, Strikas RA, Barker WH, et al.  Curriculum content on vaccine-preventable diseases in US medical schools . Am J Prev Med . 1994;;10( (suppl) ):4-10.
15 +
Strikas RA, Falter KH, Barker WH, et al.  Curriculum content on vaccine-preventable diseases in primary care and preventive medicine residency programs in the United States . Am J Prev Med . 1994;;10( (suppl) ):11-17.
16 +
Barrows HS, Tamblyn R. Problem-Based Learning: An Approach to Medical Education . New York, NY: Springer-Verlag; 1980;.
17 +
Kaufman A. Lessons From Successful Innovations: Implementing Problem-Based Medical Education . New York, NY: Springer Publishing Co; 1985;.
18 +
Barrows HS. How to Design a Problem-Based Curriculum for Preclinical Years . New York, NY: Springer Publishing Co; 1985;.
19 +
Albanese MA, Mitchell S.  Problem-based learning: a review of literature on its outcomes and implementation issues . Acad Med . 1993;;68:52-81.
20 +
Wetzel M, Reid L. The Multistation Exercise: Accessible, Adaptable, Active-Learning . Washington, DC: Association of American Medical Colleges; 1991;.
21 +
Zimmerman RK, Janosky JE, Wald ER, et al.  Development and multicenter evaluation of Multistation Clinical Teaching Scenarios on immunization: the ATPM-CDC Teaching Immunization for Medical Education (TIME) project . Am J Prev Med . 1997;;13:78-83.
22 +
Bloom BS, Engelhart MD, Furst EJ, et al. Taxonomy of Educational Objectives: The Classification of Educational Goals. Handbook 1: Cognitive Domain . New York, NY: David McKay Co; 1956;.
23 +
Stufflebeam DL.  The relevance of the CIPP evaluation model for educational accountability . J Res Dev Educ . 1971;;5:19-25.
24 +
Scriven M.  The methodology of evaluation . In: Perspectives of Curricular Evaluation: AERA Monograph Series in Curriculum Evaluation . Chicago, Ill: Rand McNally; 1967;;1.
25 +
Cooley WW, Bickel WE. Decision-Oriented Educational Research . Boston, Mass: Kluwer Nijhoff Publishing; 1986;.
26 +
Maguire T, Skakun E, Harley C.  Setting standards for multiple-choice items in clinical reasoning . Eval Health Prof . 1992;;15( (4) ):434-452.
27 +
Gross LJ.  Setting cutoff scores on credentialing examinations: a refinement of the Nedelsky procedure . Eval Health Prof . 1985;;8:469-493.
28 +
Zimmerman RK, Giebink GS, Street HB, Janosky JE.  The knowledge and attitudes of Minnesota primary care physicians about barriers to measles and pertussis immunization . J Am Board Fam Pract . 1995;;8:270-277.
29 +
Markland RE, Durand DE.  An investigation of socio-psychological factors affecting infant immunization . Am J Public Health . 1976;;66:168-170.
30 +
Rundall TG, Wheeler JR.  Factors associated with utilization of the swine flu vaccination program among senior citizens in Tompkins County . Med Care . 1979;;17:191-200.
31 +
Aho WR.  Participation of senior citizens in the swine flu inoculation program: an analysis of Health Belief Model variables in preventive health behavior . J Gerontology . 1979;;34:201-208.
32 +
Centers for Disease Control and Prevention.  Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) . MMWR Morb Mortal Wkly Rep . 1997;;46( (RR-7) ):1-25.
33 +
Taylor JA, Darden PM, Slora E, et al.  The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from pediatric research in office settings . Pediatrics . 1997;;99:209-215.
34 +
Stevens D, Baker R, Hands S.  Failure to vaccinate against whooping cough . Arch Dis Child . 1986;;61:p-387.
35 +
Peckham C. The Peckham Report: National Immunisation Study: Factors Influencing Immunisation Uptake in Childhood . London, England: Action for the Crippled Child; 1989;.
36 +
Zimmerman RK, Bradford BJ, Janosky JE, et al.  Barriers to measles and pertussis immunization: the knowledge and attitudes of Pennsylvania primary care physicians . Am J Prev Med . 1997;;13:89-97.
37 +
Zimmerman RK, Schlesselman JJ, Baird AL, Mieczkowski TA.  A national survey to understand why physicians limit childhood immunizations . Arch Pediatr Adolesc Med . 1997;;151:657-664.
38 +
Szilagyi PG, Rodewald LE, Humiston SG, et al.  Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status . Pediatrics . 1993;;91:1-7.
39 +
Gamertsfelder DA, Zimmerman RK, DeSensi EG.  Immunization barriers in a family practice residency clinic . J Am Board Fam Pract . 1994;;7:100-104.
40 +
Wood D, Pereyra M, Halfon N, Hamlin J, Grabowsky M.  Vaccination levels in Los Angeles public health centers: the contribution of missed opportunities to vaccinate and other factors . Am J Public Health . 1995;;85:850-853.
41 +
Hutchins SS, Escolan J, Markowitz LE, et al.  Measles outbreak among unvaccinated preschoolaged children: opportunities missed by health care providers to administer measles vaccine . Pediatrics . 1989;;83:369-374.
42 +
Reiser SJ.  Medicine and public health: pursuing a common destiny . JAMA . 1996;;276:1429-1430.
43 +
Jonas HS, Etzel SI, Barzansky B.  Educational programs in US medical schools, 1993-1994 . JAMA . 1994;;272:694-701.
44 +
Association of American Medical Colleges. Physicians for the Twenty-first Century: The GPEP Report . Washington, DC: Association of American Medical Colleges; 1984;.
45 +
Accreditation and the Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree . Chicago, Ill: Association of American Medical Colleges and the American Medical Association; 1993;.
46 +
The Immunization in Medical Education Advisory Committee.  Vaccine-preventable diseases core curriculum objectives . Am J Prev Med . 1994;;10 ( (suppl) ):18-21.
47 +
Atkinson WL, Kaplan JM, Clover R.  Measles: virology, epidemiology, disease, and prevention . Am J Prev Med . 1994;;10( (suppl) ):22-30.
48 +
LaForce FM, Nichol KL, Cox NJ.  Influenza: virology, epidemiology, disease, and prevention . Am J Prev Med . 1994;;10( (suppl) ):31-44.
49 +
Moyer LA, Mast EE.  Hepatitis B: virology, epidemiology, disease, and prevention, and an overview of viral hepatitis . Am J Prev Med . 1994;;10 ( (suppl) ):45-55.
50 +
Tyler CW, Granoff BR.  Cooperative agreements between academic professional associations and the Centers for Disease Control and Prevention . Am J Prev Med . 1996;;12( (suppl to No. 4) ):6-7.

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