Innovative Immunizations Initiative The national Healthy People 2020 initiative has a vision of building "a society in which all people live long, healthy lives" ("Healthy People," 2011). The purpose of the Healthy People 2020 initiative is to identify and support the actions that must be taken for the people of the United States to achieve better health by 2020. The Healthy People 2020 initiative, developed under the aegis of the Federal Interagency Workgroup (FIW), will bring about collaboration among a wealth of federal agencies, community stakeholders, a professional advisory committee, and the U.S. Department of Health and Human Services (HHS). As such, the Healthy People 2020 initiative serves as a model for health-focused innovative programs. An important health issue has been identified by the Healthy People 2020 initiative: Low compliance to immunization.

The Problem

Even though the United States has an ambitious ongoing program of immunization for its citizens, approximately 42,000 adults and 300 children die every year from diseases that can be prevented by vaccination. Where pockets of under-vaccinated and unvaccinated people reside, entire communities are put at increased risk for outbreaks of vaccine-preventable disease. Disease does not respect national boundaries, and global travel and commerce can expose populations to new or replacement disease strains that greatly increase the risk that there will be outbreaks of serious illnesses and increased death rates.

Childhood vaccination rates are lower in some minority populations, particularly where there is a correlation with poverty. Approximately 33% of U.S. citizens -- that is more than 100 million people -- report that they belong to an ethnic or racial minority population. According the Office of Health and Human Services, Office of Minority Health, as a population, the Hispanics in the United States are proportionately poorer and less likely to have health insurance than non-Hispanics. In 1996, 80% of non-Hispanic white children had been immunized while only 73% of Hispanic children and 76% of black children were vaccinated. By 2005, at the national level, the percentage of children 19 to 35 months of age receiving recommended vaccinations had increased notably. Yet, the percentages of children who received some or all of the recommended vaccinations differed significantly from state to state. Estimates by the National Institute of Science (NIS) indicated that the percentage of children who had received all of their vaccinations was 83.6% in Massachusetts and 59.5% in Nevada. A city by city comparison showed 81.4% of the children in Boston, Massachusetts, receiving all of their vaccinations compared to 65.2% of the children in Detroit, Michigan.

Differences in socioeconomic status and the earned income of households are considered to be the key variables in immunization rates for children. Where children remain under-vaccinated in urban areas with high rates of social commerce and lower economic status, there is substantive opportunity for outbreaks of preventable disease. The increase in immunization rates over the past several decades clearly indicates that these situations are amenable to intervention. While many initiatives aimed at continuing the rising trend in immunization rates for the general population, neighborhood-specific programs hold the most promise of penetrating the barriers to a successful immunization program that targets impoverished Hispanic children.

The Proposal

The Vital Information Vaccination Agreement (VIVA!) program will capitalize on the inherent leadership and cultural wisdom of marginalized Hispanic communities to implement an informational and vaccination support program. The VIVA! Program will be funded through a $500,000 grant from the Health Care Reform initiative. The main components of the program are: Community Health Workers recruited from native populations, recall card notifications for identification and tracking of children who are recorded as not UTD on immunizations, and a Photovoice club for primary grade through high school students.

VIVA! CHW. Healthcare challenges in developing countries are being met in culturally sensitive ways that are relevant to the immunization problem in urban and rural America. Patients who have been...

These CHW are usually women who reside in or near the village or community in which the patient receives care. The CHW know the barriers and the concerns of patients and can act as information resources, as well as provide moral support for long-term in-home treatment. The World Health Organization (WHO) argues that, "There is robust evidence that CHWs can undertake actions that lead to improved health outcomes, especially, but not exclusively, in the field of child health (Who Are CHWs, 2007). Further, WHO data indicates that CHW initiatives are "vulnerable unless they are driven, owned by and firmly embedded in communities themselves" (Who Are CHWs, 2007).
VIVA! Recall & Identification. Hicks, et al. (2007) found that reminder cards sent to the families of children who were not up-to-date (UTD) on their immunizations resulted in an absolute increase of 12.1% and a relative increase of 73.4% UTD at termination of the series window. However, the study concluded that for one child to become fully immunized, recall cards would need to be sent to eight children. The information gained from this study indicates that contact with Hispanic families about the need to immunize their children does garner some responses. The results also indicate that a card arriving in the mail is insufficient to maximize the opportunities children have to receive UTD vaccinations. The proposed program will utilize the CHW model in conjunction with the reminder card model provided to Latinos living in rural Colorado.

VIVA! Photovoice Club. A special version of action research, Photovoice is a practice in which "native and naive" photographers are given cameras, photography training, and turned loose -- with guidance -- in their communities. Initially conceived of as a means to inform policymakers, Photovoice has evolved a second purpose as a technique to inform the population employing it. The fundamental goals of Photovoice are as follows: (a) To enable a community to see their joys and their pain points reflected; (b) to share knowledge about important issues and to foster critical dialogue through group meetings and discussions centered around the photographs; and (c) to inform those who can create and change policy. Wang et al. (1998) have used Photovoice to promote public health and as a means of participatory needs assessment.

VIVA! Program Evaluation.

Measuring the Impact of the CHWs. The primary measure of program effectiveness in the VIVA! Program is immunization uptake. Other measures will include satisfaction with the program components, levels of trust, and contribution to community / public health clinic relations. Face-to-face interviews and questionnaires will be used to gather information about the deployment and training of CHWs in Hispanic neighborhoods.

Measuring the Impact of Identification & Recall. The methodology used by Hicks, et al. () will be applied to the VIVA! Program. This is possible because the procedures from the Hicks, et al. study will be replicated in order to contribute to the literature and add quantitative measures to the evaluation of this program. As in Hicks, et al., a Fisher exact test will be used to determine if the recall card method impacted the overall and individual UTD rates. The Fisher exact test will also be used to compare the pre-intervention and post-intervention groups. The test will further be applied to stratify any changes in UTD rates that might result from potential confounders. Since the program is community-based and not clinic-based (as in the Hicks, et al. study) missed opportunities for UTD completion will not be assessed.

Measuring the Influence of Photovoice. Participants in the Photovoice component of VIVA! Are expected to enhance their community standing and contribute to increased local control and autonomy for addressing their own public health issues. Participants will be interviewed regarding these outcomes. The Community Health Workers are expected to gain increased credibility among those community members they serve by virtue of their affiliation with the Photovoice participants. Community members -- both those who responded to the VIVA! Initiative and had their children vaccinated and…