& Ethnic Adult Disparities in Immunization
Summary of meeting held on
March 9-10, 2004 in Washington, D.C.
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.
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:
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;
To allow discussion of key issues with CDC,
partners and invited panelists; and
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
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.
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.
following sections summarize and highlight
each of the intervention-specific sessions,
as well as the March 9 panel discussion.
Tuesday, March 9th (9:30
Co-facilitators: Duane Kilgus, Health
Education Specialist, CDC and
Joan Clayton-Davis, AED
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.
Goals of grantee community outreach efforts
effective coalitions, partnerships within
target communities and with groups that
serve target communities;
target population groups and communities
about the value of adult immunization
and promote local mass immunization clinics;
local initiatives to reduce disparities
in adult immunization.
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
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.
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.
expressed on-going needs for outreach
training and spokesperson training.
Tuesday, March 9th (11:00
Co-facilitators: Glen Nowak, Associate
Director for Health Communications, NIP, CDC
and Wendy J. Mayer, AED
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.
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);
to modify, tag or adapt national materials
with local information;
Reframing of messages to reflect unique
conditions in community;
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;
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.
Tuesday, March 9th (12:30
Co-facilitators: Lance Rodewald, M.D.,
Director, Immunization Services Division, NIP,
CDC and Jim Bender, AED
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
following were cited almost universally as
major external barriers to maximizing adult
Climate of fear created by HIPAA and other
Difficult collecting needed information
to design programs
Lack of external data regarding immunization
rates for their own practices.
Lack of available funds for infrastructure
to maintain the program
Difficulty getting information from CMS
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
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.
Tuesday, March 9th (2:00
Co-facilitators: Lance Rodewald, M.D.,
Director, Immunization Services Division, NIP,
CDC and Jim Bender, AED
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.
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
restraints and practice resources are key
barriers to implementing in-office procedures
designed to maximize opportunities to provide
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.
of limited office space, patient records
are often moved off-site. As a result,
immunization history may not be in office-based
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.
concerns often inappropriately impede
implementation of standing orders, recall/reminder
Investment in/cost of vaccines is a major
barrier. Most practices cannot afford or
are reluctant to absorb the cost of unused,
nurses and other providers do not receive
recommended vaccinations themselves or have
negative personal biases, their ability to
counsel patients and encourage immunization
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.
Wednesday, March 10th (9:30
Co-facilitators: Pascal Wortley, M.D.,
READII Evaluation Lead, NIP, CDC and J. Gabriel
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.
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.
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
is often difficult or impossible to track
outreach efforts and messages.
TA and tools have assisted the sites in overcoming
programmatic hurdles. Among the examples
cited was on-site outreach worker training.
“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
evaluation TA and training needs include:.
Evaluation of communication strategies,
activities and messages
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
Tuesday, March 9th (4:00
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,
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,
Reddix, M.D., M.P.H.
Medical Director, Reddix Medical Group, Jackson,
Evans Sirois, D.O.
Internist, Alivio Medical Center, Chicago,
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
concerns (i.e., vaccine safety, HIPAA)
Lack of financial incentives (e.g., to
about financial risk (e.g., vaccine purchase)
Establish relationships among private
practitioners, public health providers,
targeted communities, and others to foster
a prevention mindset and “seamless”
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
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.