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July 2003, Vol 93, No. 7 | American Journal of Public Health 1041-1044
© 2003 American Public Health Association

FIELD ACTION REPORT

Community-Provider Partnerships to Reduce Immunization Disparities: Field Report From Northern Manhattan

Sally E. Findley, PhD, Matilde Irigoyen, MD, Donna See, MPH, MBA, Martha Sanchez, BA, Shaofu Chen, MD, PhD, Pamela Sternfels, MS and Arturo Caesar, MD, MPH

Sally E. Findley and Martha Sanchez are with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City. Matilde Irigoyen, Donna See, Shaofu Chen, and Pamela Sternfels are with the Department of Pediatrics, College of Physicians and Surgeons, Columbia University. Arturo Caesar is with Harlem Renaissance Healthcare Network, Health and Hospitals Corporation, New York City, and the Department of Medicine, College of Physicians and Surgeons, Columbia University.

Correspondence: Requests for reprints should be sent to Sally E. Findley, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, 60 Haven Ave, B–2, New York, NY 10032.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PROGRAM ELEMENTS
 EVALUATION
 DISCUSSION
 References
 

In 1996 we launched a community–provider partnership to raise immunization coverage for children aged younger than 3 years in Northern Manhattan, New York City. The partnership was aimed at fostering provider knowledge and accountability, practice improvements, and community outreach. By 1999 the partnership included 26 practices and 20 community groups. Between 1996 and 1999, immunization coverage rates increased in Northern Manhattan 5 times faster than in New York City and 8 times faster than in the United States (respectively, 3.4% vs 0.4% [t = 6.05, p < 0.001] and vs 0.6% [t = 5.65, p < 0.001]). The coverage rate for Northern Manhattan stayed constant through 2000, although it declined during this period for the United States and New York City. We attribute the success at reducing the gap to the effectiveness of our partnership.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PROGRAM ELEMENTS
 EVALUATION
 DISCUSSION
 References
 
WE CONDUCTED A STUDY TO assess the effectiveness of our community–provider partnership in reducing immunization disparities among the disadvantaged communities of Harlem and Washington Heights in Northern Manhattan, New York City. Previous studies showed that interventions by either health providers or community organizations alone had limited impact on immunization coverage.1–4 Our partnership combined the efforts of health providers and community organizations.


   PROGRAM ELEMENTS
TOP
 ABSTRACT
 INTRODUCTION
 PROGRAM ELEMENTS
EVALUATION
 DISCUSSION
 References
 
Starting in 1997, the Northern Manhattan Immunization Partnership targeted 3 broad programmatic areas: provider knowledge and accountability, practice improvements, and community outreach (Table 1Go). This partnership has involved up to 20 community programs and 26 private and public practices serving virtually all children aged younger than 3 years in Northern Manhattan (n = 19 800). Half of the children (52%) are Latino, 32% are African American, and 44% receive government assistance.5 This study reports on the 8 practices, both public and private, consistently involved in the program between 1996 and 2001, serving annually 11 712 children aged younger than 3 years (range = 167–4682). Four practices served the African American community of Harlem and 4 served the Latino community of Washington Heights. These 8 practices also had more complete integration of provider and community-based initiatives.


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  		TABLE 1—— Northern Manhattan Immunization Partnership (NMIP) Interventions by Program Area and Year
 
From the start, provider knowledge and accountability were facilitated through practice assessments and feedback, using Centers for Disease Control and Prevention methodology.6 Practice-specific report cards integrated coverage, documentation, and disengagement from care. Beginning in 1998, we initiated system-wide improvements in immunization delivery: flow sheets summarizing information about all immunizations ever given to a child, reminder/recall, standing orders, centralized immunization policies, and parent vaccination cards. We also organized educational programs for providers, nurses, and office staff. In 2000, we launched a Web-based immunization registry at the hospital-affiliated practices, and in 2001 we extended the registry to community provider offices.

Simultaneously, we collaborated with community organizations to expand outreach. We developed bilingual immunization outreach materials, expanded our linkages with the Special Supplemental Nutrition Program for Women, Infants, and Children, and contracted with selected community organizations for targeted outreach. In 1999, the Northern Manhattan Start Right Coalition was launched to promote immunization at ongoing service programs. Regular process evaluation with feedback from community partners and providers has helped to improve these community-based programs (Table 2Go).


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  		TABLE 2—— Feedback From Community Partners and Providers of the Northern Manhattan Immunization Partnership (NMIP)
 

   EVALUATION
TOP
 ABSTRACT
 INTRODUCTION
 PROGRAM ELEMENTS
 EVALUATION
DISCUSSION
 References
 
We conducted semiannual chart audits of randomly sampled children aged 6 to 35 months with at least one visit to the practice. These were compared with the National Immunization Survey (NIS) coverage rates for US and New York City children. We limited our analyses to children aged 19 to 35 months so that our data would be comparable to those of the NIS. After excluding our 1998 data, which only included children aged 6 to 24 months, we reassembled our semiannual audit data into birth cohorts comparable to the NIS cohorts (n = 852, 1503, 2111, and 2177 for 1996, 1997, 1999, and 2000, respectively; mean age = 27.7 months).

The NIS immunization coverage rates are population-based rates obtained through a random-digit-dialed telephone survey.7 The NIS US sample included 22 521 to 33 305 children per year (mean age = 27.0 months8–11), and the New York City subsample ranged from 211 to 274 children per year (mean age = 27.1 months) (L. Barker, written communication, March 25, 2002).

Up-to-date immunization coverage was defined as 4 injections for diphtheria-tetanus-pertussis, 3 for polio, 1 for measles, and 3 for Haemophilus influenzae type b—the 4:3:1:3 series. We calculated annual coverage, coverage differences for Northern Manhattan versus New York City and the United States, and rates of change in coverage. One-sample t tests and {chi}2 tests were used to assess significant differences.

In 1996, before the Northern Manhattan Immunization Partnership was launched, immunization coverage in Northern Manhattan was 45.8%, 30.7 percentage points lower than in the United States as a whole (t = -18.0, P < .001) and 29.2 percentage points lower than in New York City (t = -17.11, P < .001) (Figure 1Go). By 2000, the disparities had been significantly reduced—immunization rates in Northern Manhattan were 18.8 percentage points lower than in the United States (t = -17.6, P < .001) and 10.7 percentage points lower than in New York City (t = -10.8, P < .001). The annual rate of increase in coverage between 1996 and 1999 was greater in Northern Manhattan than in the United States or New York City: 3.4% versus 0.4% and 0.6%, respectively (t = 6.05, P < .001 for Northern Manhattan vs United States; t = 5.65, P < .001 for Northern Manhattan vs New York City). Coverage in Northern Manhattan declined from 1999 to 2000 by 0.2%, significantly less than the 2.2% decline in the United States ({chi}2 = 16.87, P < .001) and the 10.2% decline in New York City ({chi}2 = 101.43, P < .001).



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  		FIGURE 1—— Immunization coverage rates (4:3:1:3 series) for children aged 19 to 35 months in Northern Manhattan, New York City, and the United States, 1996 to 2000.

Note. The 4:3:1:3 series is 4 injections for diphtheria-tetanus-pertussis, 3 for polio, 1 for measles, and 3 for Haemophilus influenzae type b. Excludes data for 1998.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PROGRAM ELEMENTS
 EVALUATION
 DISCUSSION
References
 
Between 1996 and 1999, immunization coverage in Northern Manhattan increased 8 times faster than in the United States and 5 times faster than in New York City, enabling a significant narrowing of disparities. While rates declined from 1999 to 2000 in the United States and New York City, Northern Manhattan maintained its coverage, further narrowing the gap. While the changes may not seem large, these gains are robust and compare quite favorably to the achievements of other community immunization programs.1,3,12

While we cannot attribute direct causality, we associate this sustained increase in coverage to the effectiveness of our partnership at mobilizing both providers and communities. Specifically, the increase in coverage observed in 1997 was probably attributable to improvements in immunization delivery, especially documentation. Although the practice improvements continued, their impact from 1997 to 2000 was offset by increased complexity of the immunization schedule, which resulted in a doubling of the vaccines required. The community interventions appear to have sustained the coverage rate improvements, but these were not fully expanded until 1999, when the Start Right Coalition launched its program of immunization outreach and promotion.

Despite these improvements, the Northern Manhattan practice coverage still lags behind the US and New York City rates. Recently released 2001 NIS estimates show an increase of 7% for New York City and 1% for the United States.13 We stopped chart audits in 2001, but the trial registry–based audits for 2002 show an additional increase for the Washington Heights practices, to 64%. Thus, it appears that we are continuing to make improvements in coverage.

The difference between our coverage rates and those of the NIS may reflect different assessment methodologies.14 Practice-based assessments tend to underestimate coverage because immunizations given by other providers may not be documented in the record.15 The difference may also reflect the high rates of disengagement from care at these practices.16 Ongoing efforts by community outreach workers of the Start Right Coalition, provider reminder/recall efforts, and registry uptake are expected to further reduce disparities in immunization coverage.


   Acknowledgments
 
This study was supported by grant U66/CCU212961 from the National Immunization Program, Centers for Disease Control and Prevention, and grant U50/CCU217475 from the Reach 2010 program, Office of Minority Health, Centers for Disease Control and Prevention.


   Footnotes
 
Note. The contents of this report are solely the responsibility of the authors and do not necessarily represent the official views of the funding agency.

Contributors

S. E. Findley, M. Irigoyen, D. See, and A. Caesar developed the Northern Manhattan Immunization Partnership (NMIP) program interventions and supervised data collection. S. E. Findley, M. Irigoyen, and M. Sanchez developed the Start Right interventions. S. E. Findley and M. Irigoyen conceived of the comparative study, conceptualized the ideas, interpreted findings, and led the writing. D. See and M. Sanchez coordinated the NMIP and Start Right program interventions, respectively. S. E. Findley, S. Chen, and P. Sternfels conducted the statistical analysis.

Peer Reviewed

Accepted for publication December 9, 2002.


   References
TOP
 ABSTRACT
 INTRODUCTION
 PROGRAM ELEMENTS
 EVALUATION
 DISCUSSION
 References
 
1. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents and adults. Am J Prev Med.2000;18:S97–S140.

2. Szilagyi PG, Roghmann KJ, Campbell JR, et al. Immunization practices of primary care practitioners and their relation to immunization levels. Arch Pediatr Adolesc Med.1994;148:158–166.[Abstract/Free Full Text]

3. LeBaron CW, Starnes D, Dini EF, Chambliss JW, Chaney M. The impact of interventions by a community-based organization on inner-city vaccination coverage. Fulton County, Georgia, 1992–1993. Arch Pediatr Adolesc Med.1998;152:327–332.[Abstract/Free Full Text]

4. Irigoyen M, Findley SE. Methodological difficulties in assessing contributions by community-based organizations to improving child health. Arch Pediatr Adolesc Med.1998;152:318–320.[Free Full Text]

5. United States Census of Population, 2000. Washington, DC: US Bureau of the Census; 2001.

6. Centers for Disease Control and Prevention. Clinic assessment software application. 2000. Available at: http://www.cdc.gov/nip/casa. Accessed May 6, 2003.

7. Zell ER, Ezzati Rice TM, Battaglia MP, Wright RA. National Immunization Survey: the methodology of a vaccination surveillance system. Public Health Rep.2000;115:65–77.[Web of Science][Medline]

8. Centers for Disease Control and Prevention. 1996: estimated vaccination coverage with individual vaccines and selected vaccination series by 19 months of age by state and immunization action plan area US, National Immunization Survey, Q1/1996-Q4/1996. Available at: http://www.cdc.gov/nip/coverage/NIS/96/toc-96.htm. Accessed May 6, 2003.

9. Centers for Disease Control and Prevention. 1997: estimated vaccination coverage with individual vaccines and selected vaccination series by 19 months of age by state and immunization action plan area US, National Immunization Survey, Q1/1997-Q4/1997. Available at: http://www.cdc.gov/nip/coverage/NIS/97/toc-97.htm. Accessed May 6, 2003.

10. Centers for Disease Control and Prevention. 1999: estimated vaccination coverage with individual vaccines and selected vaccination series by 19 months of age by state and immunization action plan area US, National Immunization Survey, Q1/1999-Q4/1999. Available at: http://www.cdc.gov/nip/coverage/NIS/99/toc-99.htm. Accessed May 6, 2003.

11. Centers for Disease Control and Prevention. 2000: estimated vaccination coverage with individual vaccines and selected vaccination series by 19 months of age by state and immunization action plan area US, National Immunization Survey, Q1/2000-Q4/ 2000. Available at: http://www.cdc.gov/nip/coverage/NIS/00/toc-00.htm. Accessed May 6, 2003.

12. Barnes K, Friedman SM, Namerow PB, Honig J. Impact of community volunteers on immunization rates of children younger than 2 years. Arch Pediatr Adolesc Med.1999;153:518–524.[Abstract/Free Full Text]

13. Centers for Disease Control and Prevention. National, state, and urban area vaccination coverage levels among children aged 19-35 months-United States 2001. MMWR Morb Mortal Wkly Rep.2001;51:664–666.

14. Fairbrother G, Freed GL, Thompson JW. Measuring immunization coverage. Am J Prev Med.2000;19(3 suppl 1):78–88.[Web of Science][Medline]

15. Rodewald L, Maes E, Stevenson J, Lyons B, Stokley S, Szilagyi P. Immunization performance measurement in a changing immunization environment. Pediatrics.1999;103:889–897.[Abstract/Free Full Text]

16. Irigoyen M, See D, Findley SE. Children’s disengagement from medical homes-a neglected public health imperative. Am J Public Health.1999;89:157–159.[Free Full Text]




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This Article
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