Transcript Impact of a Clinic Closure on Pediatric Disengagement from

Implementing Health Promotion Activities
through Community Partnerships
The Northern Manhattan
Start Right Coalition
Sally E. Findley, Martha Sanchez, Sergio Matos, Letty Guzman,
Miriam Mejia, and Shaofu Chen
Columbia University
Mailman School of Public Health
Heilbrunn Department of Population and Family Health
60 Haven Avenue – B2
New York, NY 10032
Objectives
• Describe formation of Start Right Coalition
• Explore Start Right Guiding Principles
• Describe how we integrated immunization promotion
into community organizations and organizational culture
•
Document how the program built the capacity for
immunization promotion w/in community organizations
• Report on 2006 feed back from participating parents
(n=47) and CHWs (n=30).
Two Communities of Color in Northern
Manhattan, NYC
• Washington Heights and Central Harlem
• 2000 census: 421,000 residents
– Approximately 7000 births/year
– Low-income, African American and Latino
– 40% of residents are foreign-born
• Rich cultural heritage
• Mini-epicenter of the 1989-91 measles epidemic
• Network of multi-service community organizations
The Problem: Childhood Immunization
Disparities
4:3:1:3:3 series for 19-35 month olds
100
80
60
40
20
0
US 2000
Total
NYC 2000
Hispanic
Black (NH)
N.Manhattan
White (NH)
Sources: National Immunization Survey, 2000
Northern Manhattan Immunization Partnerships April 2000 Chart Reviews
What parents are up against:
10 Antigens with 3-4 repetitions over 24 months
How Start Right Began
• Community organizations (led by Alianza Dominicana)
mobilized to improve immunization services to the community
after the measles epidemic
• Coalition began as two separate coalitions in Harlem and
Washington Hts, supported by Children’s Defense Fund and
NYCDOH
• Providers established NMIP, to improve delivery of
immunizations
• Start Right, merger of all these efforts in 1999, with
coalition members asking MSPH/Columbia University to
serve as convener.
Start Right Coalition Partners
Arthur Eugene & Thelma Adair Community Life Centers;
Alianza Dominicana, Inc.; CHILD Head Start, Inc.; Riverside
Center; Dominican Women's Development Center; Ecumenical
Community Development Organization; Ft. George
Community Enrichment Center; Harlem Children’s Zone
(The Baby College); Harlem Congregations for Community
Improvement; Harlem Hospital WIC Program; Mailman
School of Public Health-Columbia University; Northern
Manhattan Improvement Corporation; Northern Manhattan
Perinatal Partnership, Inc.; Puerto Rican Family Institute
/Vacunas Para la Familia; Washington Heights/Inwood Early
Childhood Education Coalition; New York Presbyterian
Hospital Department of Pediatrics; Northern Manhattan
Community Voices Collaborative; New York City Department
of Health and Mental Hygiene
Overview of Start Right
• Immunization promotion program designed,
implemented and directed by a coalition of 17
community organizations, with linkages to health care
providers and the city department of health
• Children <5 recruited from community programs for
immunization education, tracking and outreach
• 9908 children enrolled, Oct 2000-April 2007
Start Right: Guiding Principles
• Community leadership
• Integration with community social
service programs
• Community Health Workers
• Parental empowerment
• Multiple reinforcers and feedback
• Linkages with health providers
Guiding Principle:
Community Leadership
• Program owned by coalition
• Shared leadership: Mailman 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”
– Training, enrollment and outcome targets
Guiding Principle:
Integrating Start Right Program into
Community Life
• Previous organization and coalition experience suggested we stay
away from “stand-alone immunization programs” or programs based
out of hospitals or medical systems.
• Review of previous coalition activities suggested that we should
design the program based on our strengths, namely the programs
our organizations already offer the community.
• Immunization promotion activities embedded into major educational
and social service programs working with parents of young children
• Community organizations were starting to strengthen CHW
approaches to facilitating child health (e.g. facilitated enrollment),
and the community was comfortable with this model.
Identifying Child Health Promotion
“Windows of Opportunity”
• Head Start and child care programs
• Parenting programs at multi-service community
organizations
• Faith-based community children’s programs
• Housing advocacy and tenancy groups
• SCHIP Facilitated Enrollment at community
organizations
• Family assistance programs: WIC, Food Stamps
Creating an Immunization Promotion
Culture in the Organization
• Meet with organization leadership
• Convene organization-wide meeting/forum to talk
about immunization, child health and what they see
themselves doing
• Identify promotoras/CHW among membership,
clients or staff
• Incorporate the designated staff/promotoras in
the Start Right program as their organizational
Start Right “champion” and leader.
• Include both newly recruited and internally
recruited CHW in the Start Right training
program
Guiding Principle:
Community Health Worker/Promotora
Model
• Empower staff and organization to be competent
in health education and promotion
• Training developed by and for the coalition
members
• 938 CHW trained 2000-2007
Who Are the Start Right
CHWs/Champions?
• Mostly women and mothers
• Mixture of African American and Latino, from the
community
• Trusted members of the community who wanted to
“give back”
Empowering the Start Right
champion/CHW for Immunization
Promotion
• Provide simple guidelines for screening parents for
program eligibility
• Give a menu of options for how and when to convey
health education messages
• Coalition created own health information
materials, tailored by and for our community
• Link follow-up and evaluation to routine activities
CHW Training
• Bilingual, modular training manual:
– Communications; Immunization 101; Card Reading; Parent
Empowerment (Medical Consumerism); Program
Implementation; Evaluation and Tracking
• In-house training: Jointly with NYC DOH
• Pre- and post-testing for each session
• Feedback and course evaluation
• Periodic refreshers
Coalition Members Trained
n=938
23%
42%
35%
Basics (1&2)
Basics & Eval
All sessions
Start Right Outreach Tree
• Core: 2-6 CHW focusing on enrolling and working
with families about immunizations
• Main branches: 5-20 staff/CHW w/in the
organization identifying families and referring to
the “core” CHW
• Outer branches: 12- 80 Promotoras talking with
families in the community about SR and sending
families to the organization
• Leaves: 100’s of parents in SR talking about
immunizations and SR with their neighbors and kin.
What SR CHWs say about their work
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This helped me to understand things I did not know before. The
information is good for informing parents. I learned how to use the
calendar to make parents ready for appointments.
It helps me keep on helping the community. Many parents are not
aware of the importance of vaccinations.
Learning how to read the immunization card was one of the best
trainings I’ve ever gotten, because now I can tell parents if their
children are up to date or not.
Now, when moms go to the doctor they know what is going on and
understand what he tells them. So they come back and thank us for
helping them understand.
I use positive reinforcement to turn a negative situation into a positive
one by providing resources for parents that they otherwise would not
have.
Our most effective work is through the activities and events that we
do. We know that toddlers like to have fun and parents need things to
do with their kids. We do a toddler jamboree, where kids 0-3 are
invited. While the toddlers are having fun, we talk with the parents
about immunizations and make sure that they are informed. Then we
check their cards to see if they are up to date. If they are not, we
work to get them up to date so that their kids are ready for school at
4 years old.
Guiding Principle:
Parent Empowerment
• Individual and group interventions
• How to talk to parents about immunizations
• How to talk to your doctor
• Coalition developed brochures to address
community concerns about immunizations
• Personalized immunization calendar prepared at
enrollment (NIP scheduler)
Enrollment by Start Right Strategy,
Oct 2000-March 2007
5%
18%
Parenting
Child Care
Housing
34%
13%
5%
25%
Facilitated
Enrollment
WIC referral
Clinic/Food
Stamp
N=9908 enrolled
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, birthday cards or home visits
• Parents receive incentives for completion of ontime immunizations (each organization can choose
what they give to parents)
Key Messages: Parent to Parent
• Sharing own experience and anxieties with the
parent, giving “space” for expression of fears and
doubts.
• Emphasize parents’ role to protect children: The
diseases are real (show pix) and children can get
them.
• Using the SR “PIK-PAK” materials to address
concerns the parent may have.
• Explaining the need for different vaccinations and
repeat doses (calendar).
• Give specific reminders about when to go for
which shots.
• Reminders: We are all very busy, and we all find it
hard to get to the doctor…
What Parents Say about
Start Right
• They told me about resources available to people like
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me that I didn’t know about. I have passed on this
information to other people about vaccines.
They put me in touch with other women and we shared
opinions. That helped me to get stronger and be more
independent and got my mind positive before it became
negative.
I asked my doctor more. I had been anxious that the
vaccine has viruses. I felt that giving the virus would
be harmful. The doctor told me that it was okay
because you get immune to it.
Start Right teaches people how to be up to date with
immunizations. They will remind you when the next
shots are due.
It is good to enroll [in Start Right], because if you are
busy you may forget to vaccinate. But being in this
program, you won’t forget.
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 and Start Right
goes to 11 clinics to follow-up with families and
referrals
• Retention of community base: The conversation about
immunizations still takes place in the community.
Tracking Immunizations:
the Start Right Database
• Three data sources:
– Child’s vaccination card (NYC DOH)
– EzVAC, the hospital network registry, where
most children receive primary care in
Washington Heights
– NYC CityWide Registry CIR
• Data entry at each agency, with monthly
updates and exchanges with central data
“warehouse” with all sources
Start Right is Proud of Our
Accomplishments
• 9908 children enrolled to date (99% of the target)
• Immunization rates were brought from 58% to 76-86%
• Immunization disparities were eliminated, and the children
enrolled in Start Right are now at the national average.
• Parents uniformly recommend the program to others. Start
Right has generated a “buzz”.
• Cf. Health Promotion Practice 2006 and Ethnicity and
Disease 2004 articles
Conclusions
•We have been successful at developing a bottom-up
capacity to promote immunizations in our community.
•Over 900 promotoras now practice the culture of
immunization promotion, with 200 actively engaged at
any given time.
•Almost 10,000 parents and their children have
participated in the program and have been successful in
obtaining vaccinations for their children.
•The coalition plans to expand to address additional
child health concerns with the same model.
The Northern Manhattan Start
Right Coalition is funded by a
grant from the Centers for
Disease Control and Prevention,
REACH 2010 (U50/CCU222197)