Current federal minority health initiatives, such as the Department of Health and Human Services (HHS)’s Initiative to Eliminate Racial and Ethnic Disparities in Health, HHS’ Healthy People 2010 program and the Centers for Disease Control and Prevention (CDC)’s Racial and Ethnic Approaches to Community Health (REACH) 2010 program, have helped spark vigorous efforts to close the gap in immunization rates between minority and Caucasian populations. Immunizations, for both children and adults, have been identified as one of six key areas in which Americans of color experience serious disparities in health outcomes compared to their majority counterparts.
“In general, minority populations tend to be underserved in all areas of health care, including immunizations,” says Carolyn Montoya, RN, MSN, CPNP, the 2001-2002 president of the American College of Nurse Practitioners (ACNP) and current spokesperson for the Voices for Childhood Immunization program. (The program is a collaborative effort between ACNP, the American Nurses Association and the National Association of Pediatric Nurse Practitioners.)
The target date for eliminating disparities in all six areas–which also include infant mortality, cancer screening and management, cardiovascular disease, diabetes and HIV/AIDS–is 2010. The specific goals for immunization include increasing influenza and pneumococcal vaccinations within minority populations by 60% among all adults aged 65 years and older and achieving and maintaining childhood immunization rates at 90%.
The CDC is helping to fund two major programs aimed at achieving these standards. Racial and Ethic Adult Disparities in Immunizations (READII), a program run in collaboration with HHS’ Department of Minority Health, targets minority elders. In addition, two of the 36 REACH 2010 projects currently being funded by CDC focus on immunizations.
“We have narrowed the gap significantly when it comes to childhood immunizations, but [in adults age 65 and older] there are disparities in immunization, primarily in influenza and pneumococcal vaccinations,” says Curtis Allen, a public affairs specialist with the CDC’s National Immunization Program (NIP). “The reasons for the disparities are many and it is not necessarily a matter of access.” Even among the minority populations that are most likely to be vaccinated–those with the highest education levels and people who make frequent visits to health care providers–the disparities still exist, Allen reports.
According to the CDC’s latest statistics on immunizations:
• Pneumococcal vaccination coverage levels among Hispanics and non-Hispanic blacks were 36% and 38%, respectively, compared with 60% for non-Hispanic whites.
• Influenza vaccination coverage levels for Hispanics and non-Hispanic blacks were 49.6% and 48.5%, respectively, versus 68.6% for non-Hispanic whites.
Mobilize to Immunize
Marilyn Douglas, RN, of Ridgeland, Miss., believes nurses are a natural to lead immunization initiatives because of their role as patient educators. They can understand the process from an administrative standpoint as well as a health education perspective, says Douglas, an African-American nurse who is the program manager for a state READII project conducted through the Mississippi State Department of Health.
The Mississippi project, one of five nationwide funded by the CDC, focuses on raising immunization rates among elderly African Americans in 19 rural Delta counties by developing educational activities and increasing access to immunization services. Statewide, the difference in immunization rates between African Americans and Caucasians is much higher than the national average. Mississippi’s pneumococcal immunization rate for people 65 and older is only 27% for African Americans, compared with 61% for Caucasians. The influenza immunization rate for the same age group statewide is 43% for African Americans and 69% for Caucasians.
The READII program aims to correct that imbalance by eliminating missed opportunities for immunizations and by mobilizing community coalitions. Community-based organizations such as social service agencies, home health agencies, pharmacies, community-based educational programs and faith-based organizations are all helping with the outreach effort.
“Instead of the state and the CDC coming out into these people’s communities and telling them they need to get the flu shot, what we are doing is mobilizing the community to work in the community,” explains Douglas. “You need community-based organizations to do that and you really need to give people the information necessary to make an informed decision.”
The project, which kicked off in mid-October 2003, is working to expand accessibility of immunizations and to promote their effectiveness to the elderly population through:
• Health provider education and assessment of immunization rates.
• Regional planning meetings involving all stakeholders in targeted intervention areas.
• Communication needs assessments and provider surveys to determine perceptions of the target populations and identification of immunization barriers.
• Production of influenza and pneumococcal educational materials and public service announcements.
• Increased hiring of nurses to administer vaccinations.
• Promotional events.
It is tragic that people die of vaccine-preventable illnesses, Douglas says. In 2002, she notes, 800 individuals died of pneumonia-related illnesses in Mississippi. Nationwide, the death toll was over 36,000 people. “Most of that is the elderly population,” she adds. “This specific population is the most vulnerable because of chronic diseases, other illnesses and the age factor, which lower their resistance.”
One barrier to preventive care for older African Americans is history, Douglas feels. She points to the 1932-1972 Tuskegee Syphilis Study, which denied treatment for syphilis to 399 black sharecroppers in Alabama while actively deceiving them about their illness for 40 years. The resulting distrust of the medical system, combined with misinformation, poor access to health care in rural areas and lack of knowledge about the importance of preventive care, have all helped create Mississippi’s immunization gap.
Remoteness and lack of transportation aren’t the only health care access issues contributing to the problem in the Delta counties. Most of the physicians there have huge patient loads yet practice alone.
“They might have one nurse who is assisting them. You are talking about overloaded physicians’ practices,” Douglas explains. With such limited resources, treating acute illness and chronic disease take priority, she adds. “Some of these physicians see 70 or 80 patients a day, so preventive measures might not be on the priority list.”
Douglas believes community-based outreach will allow the READII program to achieve its goals. But if the project doesn’t succeed, she says, it will be important to find out why. “We need to measure our implementation efforts. So when we go and report [to the CDC] if this was successful or not, we need to know the ‘whys,’ so we can correct them.”
Creating long-term systems that can continue the work beyond the four-year duration of the project is key to the effort, Douglas continues. “After the grant is over, we need systems in place,” she says. “Through data collection they will be able to find out what works, what doesn’t work and why, so we can effect change for sustainability.”
A Coalition for Kids
In Los Angeles, a REACH 2010 program called Immunize LA Kids–administered by South Los Angeles Health Projects, a community-based unit of the Harbor-UCLA Research and Education Institute–is also battling the immunization gap. Its mission is to link public and private agencies, health care providers and the community to collectively develop, implement and support strategies to improve immunization up-to-date rates among Latino and African-American children in Central and South LA.
Like the Mississippi READII program, the Los Angeles project is using community outreach and education, provider education, collaboration and formation of lasting partnerships within the local minority and health care communities to create both immediate and long-term change.
“We are trying to work as a coalition with diverse segments of the community,” says Maria Fernandez, MPH, CHES, the project coordinator. “We need to link all of the coalition members’ activities to improve the immunization rate, because we can not do it alone.” The coalition includes nurses, doctors, city and state health departments, faith-based organizations and community advocacy groups,
On a national level, childhood immunization rates have risen in recent years. Figures released by HHS for the year 1996 show that non-Hispanic white children were immunized at a rate of 80% while Hispanic and black children were vaccinated at rates of 73% and 76%, respectively. For Asian American/Pacific Islander and American Indian/Alaska Native kids, the immunization rate was 81%. Most of these figures were up at least seven percentage points from 1994, with the exception of the Asian American/Pacific Islander group, whose rate fell by two percentage points.
But even though the national picture looks promising, some parts of the country are still experiencing serious disparities in childhood immunization rates. The most recent California Kindergarten Survey showed that only 64% of the state’s African-American children were up to date on their immunizations, compared with 72% for Hispanics, 73% for whites and 77% for Asians. And immunization rates in Los Angeles are significantly lower than in the rest of California. The 2001 survey found that immunization up-to-date rates for two-year-olds in Los Angeles County were 72% for Hispanics, 71% for Caucasians, 80% for Asians and a surprisingly low 52% for African Americans.
“We are now concentrating on South Central LA,” says Diane Whitfield, LVN, the project’s immunization nurse. “We are trying to reach more of the African-American community. We have more than enough data on the Latino community and their immunization rates have caught up with those for Caucasians. Now we need to find out what is really going on in the African-American community regarding the lack of immunizations.”
Like Marilyn Douglas, Whitfield also thinks the legacy of the Tuskegee study has created barriers of mistrust that need to be addressed openly. Immunize LA Kids is trying to create opportunities for honest dialogue about these issues via in-services with health care providers and health fairs in the community.
“There are actually a lot of people in the medical system who might not know about the history of the Tuskegee trials,” Whitfield explains. “On the other hand, I have met people [in the black community] who are illiterate, but they know all about it. They tell me about what goes on in prison and the different medical trials they [participated in as inmates]. The truth of the matter is there are still a lot of rumors [about medical experiments] out there.”
Immunizations as a disease prevention strategy are not taught in many medical and nursing programs, Whitfield adds. “We learn how to do injections but not immunizations,” she argues. “The immunization schedule still seems new to everybody. I have had doctors call me and ask why a child’s eyes are swollen and he is warm to the touch. Well, the answer is that he has too much diphtheria in his system.”
Whitfield works with the CDC’s Vaccines for Children program and with the leading vaccine manufacturers to get up-to-date information. “It really does help to have accurate information,” she emphasizes. Disseminating the facts–e.g., a list of contraindications–to providers and parents is important because it cuts down on missed opportunities to immunize children, such as when they have minor illnesses.
Lack of access to preventive care and California’s severe economic crisis are also issues in Los Angeles. Eleven community health centers and four school-based clinics served by the Los Angeles Department of Health Services have closed recently. Many other health care service providers are not open on Saturdays. Socioeconomic status plays a part as well. People in low-income minority communities who are working minimum wage jobs with no health insurance or sick pay can’t afford to take time off to bring their kids to the doctor for shots.
“We are pushing for health fairs on Saturdays, where we will have mobile units that come out and do everything,” Whitfield says. “Parents also need to know they don’t have to be the person to bring a child in. They can hand-write a note giving permission to give the immunizations and [stating] that is the limit to what the doctor may do.”
The REACH 2010 project is not providing vaccines directly to participants, Fernandez notes. “We believe there are other agencies that are delivering immunizations. So through community outreach, community collaboration and education, we want to teach the parents and improve the delivery of services,” she says.
Immunize LA Kids’ intervention highlights also include:
• Community health promoters from three local agencies who track and follow under-immunized children identified at public and non-profit clinics. These promoters also conduct community outreach and education and provide referrals for children who don’t have a medical provider or insurance.
• An Immunization Practices Enhancement Team that visits offices and clinics of local pediatric health providers. The team’s mission is to assess immunization records and provide recommendations and consultation for implementation of immunization best practices, including effective use of reminder-recall systems. Providers are followed for up to five years.
The ultimate goal, Whitfield concludes, is for families to have an immunization “home”–a place where they will get all their preventive care needs met. “If you have a provider home, you are more likely to have other [health care services] done,” she says. “You are more likely to take your child in when he is well, not just when he is sick.”
Immunizing Immigrant Populations
Still other efforts to close the immunization gap are targeting one of the nation’s most underserved minority populations: recent immigrants to the U.S. Back in 1994, for instance, the Charles B. Wang Community Health Center in New York City spearheaded an initiative to immunize Asian children, who are 20 times more at risk to get hepatitis B than other American children, according to Loretta Au, MD, the center’s chief of pediatrics. A local bank funded the hepatitis B immunization project as well as serology testing for the infection in an elementary school in Chinatown.
The CDC then helped the health center obtain funds from the NYC Department of Health to vaccinate children in other schools in Chinatown, and later in Queens and Brooklyn schools that had high Asian student populations. The program was discontinued after four years when the health department started its own hepatitis B vaccination program for all seventh graders.
New immigrants are often under-immunized, says Rebecca Sze, RN, FNP, director of women’s health at the Charles B. Wang Community Health Center, which has three New York sites. “Within our center,” she reports, “we have various initiatives focusing on prevention. We reach out to the schools, garment factories [where immigrant workers are employed], churches and other places where we can find the Asian population.”
As a Chinese-American nurse, Sze feels it’s important for her to take part in such efforts. “Students who were born here in the U.S. already get their immunizations from birth on,” she says. “It is the children of immigrant populations who don’t know the significance of preventive health care. That is why the nurses who are serving these populations need to be very focused and highly aware of the needs, so they can play a major role in terms of preventive care.”
Cultural competence is a key component of this awareness, adds Voices for Childhood Immunization’s Montoya, who is also coordinator of the Family Nurse Practitioner Concentration at the University of New Mexico College of Nursing. For example, she says, health care providers are required by law to give vaccination information sheets to patients before immunizations are performed. Nurses need to be aware that these sheets are available from the CDC in many different languages. Furthermore, some immigrants may be illiterate even in their native language, so having translators available is critical.
Beyond that, having more healthcare providers from diverse backgrounds would help in the effort, Montoya believes. “It isn’t just a matter of language but a matter of culture,” she explains. “For example, here in New Mexico we have a fairly large Native American population. I think it is very important to have more Native American health professionals who understand this population’s cultural beliefs and traditions, not just the language.”
Mississippi’s Douglas reiterates that the goal of creating equal immunization levels for Americans of all races must be a long-term, ongoing one. “We need to constantly teach, constantly disseminate information about this,” says. “If we can keep these projects going even after the initial grant money is gone, we can make a very big impact on eliminating the disparities.”
Closing the Immunization Gap in Your Own Community:
Resources for Nurses and Their Patients
Immunization Nursing Network Provider Outreach Web Education & Resources (INNPOWER)
An American Nurses Association initiative designed to provide nurses and other health professionals with accurate, current, scientific information on immunizations across the life span.
National Immunization Program (NIP)
The Centers for Disease Control and Prevention (CDC)’s NIP Web site contains extensive information for the planning, coordination and conduct of immunization activities nationwide. Online resources include downloadable culturally competent patient education materials targeted to specific minority populations.
Promoting Prevention for Healthy Communities: The National Asian American Immunization Project
This CDC-funded initiative of the National Asian Women’s Health Organization (NAWHO) is a multifaceted campaign of partnership building, community capacity-building and education for health care providers and the public.
Racial and Ethnic Adult Disparities in Immunization Initiative (READII)
A two-year demonstration project funded by the CDC, this initiative is being conducted in five sites to improve influenza and pneumococcal vaccination rates for African Americans and Hispanics 65 years of age and older. The Web site includes a link to a two-hour adult immunization training course, available in videotape and Web cast formats.
Vaccines for Children (VFC) Program
Part of the CDC’s National Immunization Program, VFC buys vaccines for children in certain eligibility groups–including American Indians/Alaska Natives and children with no health insurance coverage–who would otherwise be unable to afford them. Doctors can get these vaccines for their patients who qualify by joining the VFC program in their state.
Vacunas Para la Familia: Immunization for All Ages
Run by the National Alliance for Hispanic Health, this bilingual immunization awareness program offers resources for parents about infant immunization, including brochures, videos and immunization schedules. The program is part of a cooperative agreement with the CDC.
CDC National Immunization Hotline
Immunization information for patients and health professionals can be obtained by calling the toll-free hotline at (800) 232-2522 (English) or (800) 232-0233 (Spanish). The Web site offers additional resources, including information about the current flu epidemic.
Calling the Shots: Key Immunization-Preventable Diseases
• Haemophilus Influenzae type B (Hib)
• Hepatitis A
• Hepatitis B
• Lyme disease
• Meningococcal disease
• Pertussis (whooping cough)
• Pneumococcal disease
• Rubella (German measles)
• Varicella (chicken pox)
• Yellow fever
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