1. Culturally Appropriate Interventions to Increase Adult Immunization Rates Among African American and Hispanic Seniors
J. Gabriel Rendón and Joan Clayton-Davis
Academy for Educational Development
Washington, D.C.

2. Learning Objectives Define Cultural Competency
Identify at least five culturally appropriate interventions
Present “Lessons Learned,” so far

3. In July 2002, HHS and CDC launched READII
Racial and Ethnic Disparities in Adult Immunization Initiative (READII)
In July 2002, HHS and CDC launched READII
A multi-year demonstration project
Five sites
Public & private partnerships
Culturally appropriate, community-based interventions
The Department of Health and Human Services (DHHS) made the elimination of racial and ethnic disparities in influenza and pneumococcal vaccination coverage for people 65 years of age and older a priority.
To address these disparities and assist in reaching the 2010 national health goal of 90% influenza and pneumococcal vaccination rates among people age 65 years and over.
This initiative facilitated idea and information exchange among the five health departments. The communication between and among the sites is one method of how they learned about non-traditional resources (i.e., pharmacists) and develop ideas for public and private partnerships. Sites also had the opportunity to developed new or in some cases strengthen alliances with key stakeholders, such as the local department on Aging and the Aging Services Network.
CDC’s continued long-standing relationships with CMS assisted the sites to incorporate interventions such as standing orders and take advantage of reimbursement increases for vaccines. Other key partners include: HHS, HRSA, AoA, and AHRQ
The Guide to Community Preventive Services has served as a model for evidence-based interventions, as has research done in the adult immunization field. Provider focused efforts, shown to be effective, are among the strategies each of the sites has emphasized.

4. The Five Sites and their Target Populations
Here is a map of the five sites and the target populations that each site served over the multi-year initiative.

5. Cultural Competency
“Cultural competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations.”
Health Resources and Services Administration
This definition reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups. In this presentation, we will be focusing on the African American and Hispanic senior communities.

6. Cultural Competence Pointers
There is no one way to treat any racial and ethnic group
There is great socio-cultural diversity within these broad classifications
Interventions need to be evidence-based, flexible, authentic, and ethical
Robert C. Like, MD, MS Director of the Center for Healthy Families and Cultural Diversity, UMDNJ
Robert Wood Johnson Medical School
The READII experience supports the belief and needs to have a framework of interventions that can be individualized and applied in a “target audience-centered” approach.
The following community-based interventions are examples of how the five CDC grantees appropriately tailored them to African American seniors, Hispanic seniors, or both target audiences and their families.

7. The Challenges
Raising adult influenza/pneumococcal immunization levels – particularly among minorities – is complicated and requires different partnerships and multiple, long-term strategies from those that were successful in childhood programs.
Misconceptions abound for both the public and health care providers about adult immunizations.
This Initiative was established to address the health disparities in immunization coverage. Some of you are aware of the challenges facing us; however new and different partnerships and strategies – implemented concurrently for the same population – was needed and happened with some success.

8. Chicago Intervention - Free Vaccines for Adults: A Pilot Program
Goals
Improve access to immunizations in READII neighborhoods
Aldermanic offices
Increase providers’ use of effective immunization strategies
Vaccine as an incentive
Increase minority seniors’ knowledge about influenza and pneumococcal diseases and immunizations
Community Outreach
Media Campaign
CDPH established partnership with aldermanic offices that represented the target audience. The culturally appropriateness of this intervention was how CDPH worked with and understood the target audience’s culture within the 14 READII communities
CDPH mobilized the cultural institutions, including those that respond to the social and political needs of the African American and Hispanic communities. The participating offices and the aldermen facilitated seniors’ access to influenza and pneumococcal vaccines through the offices of Alderman who serve the target community and target population
Free vaccines for providers who were located in the designated READII communities and served African American and Hispanic seniors. In addition, these providers were selected not only for their location but those providers who also look like the target audience. These providers understand and can communicate with seniors. Or example, these included bilingual providers.
The CDPH staff worked with African American and Hispanic community outreach staff from ethnic and racial CBOs that represent and serve the target audience. The two agencies responsible for community outreach and input towards the media campaign were the African American Health Care Coalition and the Chicago Hispanic Health Coalition. These partnerships ensure the culturally appropriateness of the READII messages.

9. Chicago Intervention - Free Vaccines for Adults: A pilot program
Highlights
Aldermanic offices role in improving access to vaccines
Free vaccine as an incentive for providers to join READII Quality Improvement Initiative

10. Milwaukee Intervention – Faith-based Media Campaign
Goal
Educate the African American community at-large and targeting African American seniors
Increase access to immunizations through church-based venue
The Milwaukee DOH used a cultural icon that was trusted and respected among African Americans. This trusted messenger educated the target audience on the importance of getting immunized against influenza and pneumococcal disease.

11. Milwaukee Intervention – Faith-based Media Campaign
Highlights
Engaged Ms. Cissy Houston (an African American celebrity Gospel singer) for the flu season campaign
Presentations at two large African American Church along with free, on-site immunizations
Ms. Houston further promoted the campaign by using the READII talking points
to promote on-site influenza and pneumococcal immunization
offered to church goers aged 65 years or older
during radio and TV interviews
Talking Point: An average of 36,000 people die annually due to the influenza and its complications - most are people 65 years of age and over

12. Mississippi – A Culturally Appropriate Jingle
Goal
To expand the reach of the READII message
To motivate African American seniors and the community to get immunized
Highlights
Production and distribution of the READII Jingle
Community partners provided input towards the production and broadcast of the jingle
Some Key partners included:
The MS State Department of Health
Kroger Pharmacies
Medical Mall Services
In MS to expand the READII message, the partners agreed that a musical message given the musical history in MS (R & B and Blues) that seniors would be more likely to respond positively to music and would motivate them to get immunized as they heard the jingle in places they normally go (i.e., grocery stores, the pharmacy, the health department, and even heard on the local radio stations).

13. Community based organizations
Rochester - Outreach / Education Through Trusted African American Community Organizations
Churches
Community based organizations
Action for a Better Community
Urban League of Rochester
IBERO American Action League
Neighborhood Associations
Senior housing / Nutrition centers
Non-traditional venues
All these CBOs listed on this slide were either African American and/or served the AA community
Some examples of non-traditional venues included:

14. San Antonio – Pharmacists as Public Health Extenders
“The San Antonio Model”
Approval by Texas State Board of Pharmacy
The San Antonio model was successful for three main reasons:
It’s a Community-based model
The pharmacies were located in the Hispanic communities
The pharmacists were either Hispanic or bilingual which facilitated immunizations among Hispanic seniors
Other reasons why this culturally appropriate model worked are:
Ensured pharmacists possess necessary skills,
education, and certification (i.e., bilingual pharmacist)
Ensured administration under a physician’s
written protocol
Ensured notification of all vaccinations to
‘sponsoring’ physician (SAMHD)
The model allowed participation in continuing education for current
immunization standards (CDC, ACIP, etc.)

15. Lessons Learned: Sites’ Recommendations
Establish relationships with public health providers, targeted communities, and others to foster a prevention mindset
Address what the community knows and does not know about vaccines
Adopt an “intergenerational approach” to messages and vaccination
Develop “menu” (i.e., option) approaches to flu vaccination
It helps to provide “free” vaccine

16. Thinking about the Future
Lessons Learned:
Thinking about the Future
Partners and partnerships -- need to be credible, strategic, and sustainable
“Free” is a powerful word and incentive – to both providers and targeted populations
Messengers need to be “trusted”-- and messages need to be strong, consistent, “localized,” and culturally sensitive
>Again, I’ve already mentioned a number of these new partners and new ideas being generated – they will have an impact on how future programmatic, communications and policy research takes shape around these often complicated adult immunization issues. And ultimately, I think, on how successful we are at eliminating disparities and protecting all persons from vaccine-preventable diseases.

17. What’s Next?
Programmatic activities ended December 31, 2004; Evaluation taking place through June 2005
The experiences of the multi-year initiative are being used to guide future efforts.
Sites’ experiences are/will be valuable to future efforts – both programmatic and research efforts
Dissemination of findings; Replication?
Extended from 2 years initially to a include a THIRD flu season; Process/Outcome evaluation efforts have begun but at the close of the project, will involve sites, partners (i.e., CMS), CDC/NIP staff & AED – we’ve begun discussions to ascertain the resources that will be required and the time-line expected to complete formal evaluation activities of the READII project.
A LOT of discussion/planning/ going-on; not just at Federal agencies (CDC, FDA) but among vaccine manufacturers, the insurance industry & (public & private) health providers.
New partners (Aging Services Network) are on board and many programs see the need to address adult/disparity issues in an evidence-based, cost-effective & efficient manner.
It probably goes without saying that, upon completing and evaluating READII efforts, CDC plans to share as widely as possible the results/findings in a READII Summary Report. The report will be available to the public in late summer And to the extent that resources might be identified, we would hope that successful interventions/models could be replicated in many more sites across the country.

18. Representing READII
The READII project was an important first step in identifying promising practices that could have a profound impact on leveling health inequalities among our seniors.

19. Thank You J. Gabriel Rendón Marketing and Communications Specialist
Academy for Educational Development
1825 Connecticut Avenue, N.W.
Washington, D.C
Joan Clayton-Davis
Senior Technical Advisor
1225 Ninth Avenue North
Nashville, TN
>We have truly enjoyed working with you on this important demonstration project, and are looking optimistically ahead to the rest of this year’s activities. And perhaps beyond…