Communitybased strategies to reduce childhood immunization disparities Sally

Community-based strategies to reduce childhood immunization disparities Sally E. Findley, Matilde Irigoyen, Martha Sanchez, Letty Guzman, Miriam Mejia, Shaofu Chen, and Frank M. Chimkin Northern Manhattan Start Right Coalition, Mailman School of Public Health, Columbia University

Two Communities of Color in Northern Manhattan, NYC • Washington Heights and Harlem • 2000 census: 421, 000 residents – Approximately 7000 births/year – Low-income, African American and Latino – 40% residents foreign born • Rich cultural heritage • Network of multi-service community organizations

The Problem: Childhood Immunization Disparities, 2000 4: 3: 1: 3: 3 series for 19 -35 month olds

Objectives • Describe a community-based immunization promotion program • Demonstrate the reduction in childhood immunization disparities • Identify the programmatic factors contributing to improved immunization coverage

Objectives • Describe a community-based immunization promotion program – Guiding principles – Implementation

Start Right • Immunization promotion program designed and implemented by a coalition of 23 community organizations • Children <5 years of age recruited from community programs for immunization education, tracking and outreach • 7, 644 children enrolled, 2002 -2005

Start Right: Guiding Principles • Community leadership • Integration with community social service programs • Peer health educators • Parental empowerment • Multiple reinforcers and feedback • Linkages with health providers

Guiding Principle: Community Leadership • Program owned by the coalition • Shared leadership: School of Public Health and 2 community organizations • Regular monthly meeting structure – Consensus decision making • Organizational accountability – Subcontracts to support organizations through community organization “hub” – Measurable outcomes: Training, enrollment and immunization targets

Guiding Principle: Integration of Programs • Immunization promotion activities embedded into major educational and social service programs working with parents of young children • No new stand-alone immunization programs created

Programs with Child Health Promotion “Windows” • Head Start and child care programs • Home visitation and Parenting programs • Faith-based educational programs • Housing advocacy and tenancy groups • SCHIP Facilitated Enrollment • Family assistance programs: WIC, Food stamps

Embedding immunization promotion w/in programs The Coalition: • Created simple guidelines for screening parents • Gave a menu of options for how/ when to convey health education messages • Created own health information materials, tailored by and for community • Linked follow-up and evaluation to routine activities

Guiding Principle: Peer Health Educator • Empower staff and organization to be competent in health education and promotion • Training developed by and for the coalition members • 900 staff trained 2001 -2005

Staff Training • Bilingual training manual: – Modules on Immunization 101, Card Reading, Parent Empowerment, Program Implementation, and Tracking • In-house training: Jointly with NYC DOH • Pre- and post-testing for each session • Feedback and course evaluation • Periodic refreshers

Guiding Principle: Parent Empowerment • Individual and group interventions • Personalized immunization calendar prepared (NIP scheduler) • Coalition developed brochures to address community concerns about immunizations

Guiding Principle: Parental Reinforcers and Reminders • Parents reminded of upcoming immunizations • Immunizations tracked to assure delivery and parents recalled as needed • Average 3 reminders per child: phone calls, postcards, or home visits • Parents receive incentives for completion of on-time immunizations

Guiding Principles: Linkages with Health Providers • Every child to have health insurance and a medical home – Referrals to SCHIP facilitated enrollment – Help parents make and keep immunization appointments • Health providers refer to Start Right

Tracking Immunizations: the Start Right Database • Three data sources: – Child’s vaccination card (NYC DOH) – Ez. VAC, the hospital network registry, where most children receive primary care in Washington Heights – NYC City. Wide Registry CIR • Data entry at each agency, with monthly updates and exchanges with central data “warehouse” with all sources

Did Start Right help reduce immunization disparities?

Methods • Selected the subgroup of children enrolled in Start Right who were 1935 month olds as of April 2004 (n=1, 502) – Calculated difference 4: 3: 1: 3: 3 coverage at enrollment and follow up. – Compared coverage against the NIS 2004 for US and NYC

Start Right Coverage for 43133 at Enrollment and Follow-up by Enrollment Cohort (Children 19 -35 months of age at April 2004 follow-up)

Immunization coverage Start Right vs US NIS 2004 % 19 -35 month olds UTD 43133 n = 1502

Immunization coverage Start Right vs NYC NIS 2004 % 19 -35 month olds UTD 43133 n = 1502

What programmatic factors contributing to improved immunization coverage?

Methods • Estimated relative contribution of program factors to immunization outcomes using logistic regression analysis

Start Right: Factors contributing to UTD • UTD at enrollment OR = 9. 8 • Latino ethnicity OR = 1. 6 • Program strategy Child care OR = 1. 9 ü WIC OR = 3. 1 ü SCHIP enrollment OR = 4. 9 ü

Conclusions • A community-based program which embedded immunization promotion into existing programs was successful in eliminating immunization disparities. • The most effective programs were those with a direct linkage to health care systems or targeting young children.

Limitations • This study is an ecological comparison • No control for other factors in the community, such as changes Medicaid managed care. • NIS sample for NYC (n<400) is small, w/out results reported for black children.