On March 9 and 10, 2004, the Centers for Disease Control and Prevention’s (CDC) National Immunization Program (NIP) convened a Mid-Course Review of the Racial & Ethnic Adult Disparities in Immunization Initiative (READII), a multi-year demonstration project to improve influenza and pneumococcal vaccination rates for African Americans and Hispanics age 65 or older.

Held in the Washington, DC, Conference Center of the Academy for Educational Development (AED), the meeting brought together leadership from the five READII demonstration sites – Chicago, Milwaukee, Rochester, San Antonio, and Mississippi – for a strategic session focusing on programmatic issues. The READII Mid-Course Review had three primary goals:

1. To afford an opportunity for key READII staff from each of the five sites to review and discuss with each other their successes and challenges thus far in the project;
2. To allow discussion of key issues with CDC, partners and invited panelists; and
3. To share site-specific project information with senior officials from the Department of Health and Human Services (HHS) and other partners, including the U.S. Administration on Aging (AoA), the Health Resources and Services Administration (HRSA), the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).

On March 9, eighteen grantee representatives participated in four discussion sessions encompassing Community Outreach, Communications & Media, and Provider Systems – both external and practice environments. These sessions were observed by others in attendance, including eight health providers invited by CDC and HHS. These invited guests provided their insights, observations and recommendations during an end-of-day panel discussion of program issues and challenges.

On March 10, grantees participated in a fifth session discussing Evaluation, after which Dr. Kaytura Felix-Aaron, Senior Advisor on Minority Health for AHRQ, discussed and answered questions regarding the recently-released National Healthcare Disparities Report. After the lunch break, each site took 15-minutes to highlight its programs, select interventions, challenges, lessons learned and future plans for HHS representatives.

The following sections summarize and highlight each of the intervention-specific sessions, as well as the March 9 panel discussion.

Session Summary
Co-facilitators: Duane Kilgus, Health Education Specialist, CDC and
Joan Clayton-Davis, AED

Summary: Representatives from READII sites reviewed community outreach goals, successful community outreach strategies/activities conducted through 2003; discussed challenges and barriers to community outreach; and outlined approaches or techniques that may enhance future activities.

Key Discussion Points

• Goals of grantee community outreach efforts are to:
  • Build effective coalitions, partnerships within target communities and with groups that serve target communities;
  • Educate target population groups and communities about the value of adult immunization and promote local mass immunization clinics; and
  • Promote local initiatives to reduce disparities in adult immunization.
• Strategies and activities included partnerships/coalitions/ advisory groups to develop and implement sustainable strategies; community education through trusted channels; collaboration with existing health related activities (e.g., health fairs, national efforts, etc.) and promotional tools (e.g., the Volkswagen “Flu Bug” in San Antonio, faith-based tool kits, etc.).
• Although diverse partnerships were organized or expanded at each site, challenges and barriers to effective outreach include maintaining involvement of partners/coalition members; monitoring and sustaining activities; and engaging community-based organizations and/or partners to add another project to their services or activities.
• Other challenges included: maintaining focus on target group (65+); staffing for mass immunization clinics and/or dealing with increased demand; message clarity/credibility surrounding vaccine shortages and efficacy, and Medicare coverage.
• Common threads and conclusions:
  • Trust is important; messages and messengers must address the issue.
  • Integration of READII into existing and sustainable health efforts is key.
  • Collaboration among local public health departments and buy-in from public health administration is important.
  • Sites expressed on-going needs for outreach training and spokesperson training.

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Session Summary
Co-facilitators: Glen Nowak, Associate Director for Health Communications, NIP, CDC and Wendy J. Mayer, AED

Summary: The session focused on lessons learned to date regarding mass media and other communication efforts. Grantees shared unique successes and challenges facing site-specific efforts and discussed overarching issues affecting their individual ability to maximize message delivery and effectiveness. Discussion centered on communications materials, messages, messengers and media.

Key Discussion Points

• Across the board, sites identified four crucial elements – localization, consistency, targeting and evaluation of cost-effectiveness and efficacy – as key to maximizing effectiveness of their communications materials, messages, messengers and media. Among the specifics cited were:
  • Importance of using trusted local figures versus national spokespeople (also encouraging use of models who look “real” in national materials);
  • Ability to modify, tag or adapt national materials with local information;
  • Reframing of messages to reflect unique conditions in community;
  • Maintaining message consistency from the national to the local level;
  • Receiving information and messages (e.g., vaccine shortage) in a timely manner;
  • Identifying methods to determine cost-effectiveness of these activities, similar to the standards to which intervention and other programmatic activities are held;
  • Consideration of market variables including media penetration (e.g., rural radio signal strength), available vehicles (e.g., community newspapers, ethnic radio stations, church newsletters, etc.) and unique habits of local audiences (e.g., popularity of community versus daily newspapers) to maximize message reach and effectiveness.
• Cultural competency is crucial in both materials and outreach. Materials cannot simply be translated from English into other languages, but must be rewritten and/or adapted to reflect cultural differences. Other activities (including media outreach) must be sensitive to nuances of ethnic and cultural audiences.
• Use of outside communication and marketing firms was often efficient and cost-effective and provided a degree of expertise often not available internally.
• Ongoing TA needs include communications training for partners (not just media spokespersons) and “crisis” preparation/development of contingency plans.

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Session Summary
Co-facilitators: Lance Rodewald, M.D., Director, Immunization Services Division, NIP, CDC and Jim Bender, AED

Summary: The session dealt with external factors affecting providers’ ability to maximize adult immunizations. Grantees discussed challenges to their provider-focused interventions, as well as suggestions for strategies to help overcome barriers to their provider interventions and to physician efforts to increase adult immunization rates.

Key Discussion Points
The following were cited almost universally as major external barriers to maximizing adult immunization:

• Climate of fear created by HIPAA and other privacy regulations
  • Difficult collecting needed information to design programs
  • Lack of external data regarding immunization rates for their own practices.
• Public infrastructure
  • Lack of available funds for infrastructure to maintain the program
  • Difficulty getting information from CMS and QIOs
  • Difficulty finding out who is serving the target population
  • Inflexible federal, state and local government policies hamper creative immunization (and other preventive health care) program development
• Providers are not knowledgeable about Medicare billing; pharmacists may have trouble getting reimbursed through Medicaid.
• Regulations that require doctors or RNs to administer vaccines hamper the ability to carry out standing orders; standing orders in nursing homes and hospitals are not universal, and many are not fully implemented or enforced.
• Vaccines might be delivered more widely and efficiently if public and private providers had stronger collaboration.
• There is limited recognition of the seriousness of influenza (36,000 deaths, 114,000 hospitalizations yearly) and the heightened risk factors for seniors and others.

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Session Summary
Co-facilitators: Lance Rodewald, M.D., Director, Immunization Services Division, NIP, CDC and Jim Bender, AED

Summary: The session focused on strategies for working within provider practices to maximize adult immunizations. Grantees shared experiences dealing with practice-based issues and topics including resources, standing orders, patient medical records/registries, vaccine tracking and recall systems, billing procedures and patient/provider education. Discussion centered on barriers faced by sites and their efforts to overcome them.

Key Discussion Points

• Adult provider practices are geared to handle acute and chronic, rather than preventive, care. As a result, vaccinations (and other preventive health care services) are not often a priority for the provider or the patient.
• Time restraints and practice resources are key barriers to implementing in-office procedures designed to maximize opportunities to provide immunizations.
  • Providers often do not have ready access to basic information about their patients, including how many are age 65 or older.
  • Some sites noted that even when providers know how many older adults are in their practice, they often do not know which patients have been vaccinated or believe, erroneously, that all of their patients are up-to-date with their influenza and pneumococcal vaccinations; immunization records are not well organized.
  • Because of limited office space, patient records are often moved off-site. As a result, immunization history may not be in office-based charts.
  • Tracking systems, while sometimes set up in practices, as well as immunization registries, where available to include adults, are not routinely used.
• Liability is a concern from several perspectives.
  • HIPAA and other policies have heightened concerns surrounding patient privacy; as a result, READII project staff members’ ability to work within the practice environment has been hindered.
  • Liability concerns often inappropriately impede implementation of standing orders, recall/reminder efforts, etc.
• Investment in/cost of vaccines is a major barrier. Most practices cannot afford or are reluctant to absorb the cost of unused, non-returnable vaccine.
• When nurses and other providers do not receive recommended vaccinations themselves or have negative personal biases, their ability to counsel patients and encourage immunization is compromised.
• Ordering and distribution of vaccines may sometimes be handled by sources outside the provider’s direct control. As a result, individual providers (e.g., within a larger group or system) may not have input or desired access to optimal vaccine for their patient base.

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Session Summary
Co-facilitators: Pascal Wortley, M.D., READII Evaluation Lead, NIP, CDC and J. Gabriel Rendón, AED

Summary: Participants discussed program activity successes and challenges to date at each of the five demonstration sites. Many of the site staff provided critical feedback and shared challenging questions about their ongoing process evaluation efforts. As peers, they shared strategies and possible solutions for current and planned evaluation efforts. The discussion also included examples of tailored technical assistance (TA) provided by AED and concluded with sites identifying existing and expected TA needs regarding process and outcome evaluation.

Key Discussion Points

• All sites have successfully conducted a variety of on-going process-related evaluation efforts for their program activities. Success stories ranged from efficient data collection on process management of the READII partnership to documented formative evaluation data on bilingual READII marketing materials.
• Evaluation efforts have proved to be invaluable as all five sites have made some program modifications in order to enhance their READII activities.
• Challenges were varied, however, the following common themes were identified:
  • Most sites have not analyzed their evaluation data primarily because of limited staff expertise or time constraints.
  • Sites requested modified evaluation tools to measure penetration of READII marketing and public awareness materials, and to determine cost-effectiveness.
  • It is often difficult or impossible to track outreach efforts and messages.
• Tailored TA and tools have assisted the sites in overcoming programmatic hurdles. Among the examples cited was on-site outreach worker training.
• The “SMART” framework for program planning and objective writing was identified as a useful planning and evaluation tool. Specifically, the framework assisted sites to develop and modify objectives, plan programs and activities, refocus time investments, and assess partnerships and level of community engagement.
• Ongoing evaluation TA and training needs include:.
  • Evaluation of communication strategies, activities and messages
  • Intervention Evaluation TA – e.g., a healthcare provider practice survey
  • Evaluation of seniors’ perceptions of the 12/2003 flu vaccine shortage
  • Data analysis training and TA

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Eight healthcare providers, representing diverse professional backgrounds and geographic regions, were invited by CDC and HHS to participate as observers and discussants at the READII Mid-Course Review. The invited guests included:

• Reginald Adams, D.O.
  Staff physician, Milwaukee Health Services, Milwaukee, WI
• Nate Brown, M.D.
  Medical Director, Mid-Delta Family Practice Clinic, Mound Bayou, MS
• Alicia Georges, Ed.D., R.N.
  Chairperson, Department of Nursing, Herbert H. Lehman College, City University of New York, New York City.
• Fernando Guerra, M.D., M.P.H.
  Director of Health, San Antonio Metropolitan Health District, TX
• Pradeep Kumar, M.D.
  Medical Director, Gerald Ignace Indian Health Center, Milwaukee, WI
• Kristin Nichol, M.D., M.P.H., M.B.A.
  Professor of Medicine, University of Minnesota
  Chief of Medicine Services, VA Medical Center, Minneapolis, MN
• Michael Reddix, M.D., M.P.H.
  Medical Director, Reddix Medical Group, Jackson, MS
• Evans Sirois, D.O.
  Internist, Alivio Medical Center, Chicago, IL

At the conclusion of four intervention-specific sessions on March 9, these invited guests formed a panel to discuss the information shared throughout the day; and to provide their observations, insights, thoughts and recommendations to grantees and other attendees. Facilitated by READII Program Coordinator Tamara J. Kicera, the in-depth discussion of READII challenges, barriers, and lessons learned to date yielded several noteworthy observations and recommendations:

• Barriers to greater provider participation:
  • Multiple competing prevention priorities; acute/chronic care focus; providers are “bombarded"
  • Liability concerns (i.e., vaccine safety, HIPAA)
  • Lack of financial incentives (e.g., to implement interventions)
  • Concern about financial risk (e.g., vaccine purchase) and sustainability
  • Reimbursement issues
• Recommendations:
  • Establish relationships among private practitioners, public health providers, targeted communities, and others to foster a prevention mindset and “seamless” system
  • Consider how policies at all levels may hinder effective program design (e.g., cultural competence); pursue greater cultural diversity in project staff
  • Adopt an “inter-generational approach” to messages and to vaccination
  • Develop “menu” option approaches to influenza vaccination
  • Provide “free” vaccine
• Future considerations:
  • Partners and partnerships need to be credible, strategic, and sustainable
  • “Free” is a powerful word and incentive – to both providers and targeted populations – although it may connote not billing Medicare/insurance to some individuals
  • Messengers need to be “trusted;” messages need to be strong, consistent, localized, and culturally appropriate.

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This page last modified on April 13, 2004