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 Closing the Immunization GapImmunization levels for minority children and adults still lag behind those of the majority population. Many federally funded initiatives are working to combat this disparity—and minority nurses are fighting in the front lines. By Susan Wessling 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’s 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.
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 immunizations 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%.
Mobilize to ImmunizeMarilyn 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 Department of Health.
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:
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 takes 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 KidsIn 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.
“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 cannot 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 Retrospective 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.” Immunization as a disease prevention strategy is 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:
Immunizing Immigrant PopulationsStill 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.
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.”
Susan Wessling is a free-lance writer from central Massachusetts who specializes in health topics. Back to top of page |
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