Max The Vax

Sherese M. Brooks Rodriguez

L26557877

Health Communication and Advocacy

HLTH 634-D01

November 15, 2015

Introduction
The purpose in writing this review is to share more insight into the importance of
immunizations and how to increase vaccination rates. The life expectancy has vastly improved
during the last century due largely to immunizations. Immunizations in the United States target
17 identifiable vaccine-preventable diseases according to Healthy People 2020.1 Childhood
immunization is one of the most cost-effective and beneficial public health programs. According
to Healthy People 2020, despite the availability of vaccine-preventative measures approximately
42,000 adults and 300 children die each year in the United States from these diseases.1 Among
the leading causes of death and illness are tuberculosis (TB), influenza, and viral hepatitis.1
These infectious diseases cause havoc among our population through illness, disability, and
death.
According to the CDC Hispanics have lower mortality rates than the overall population
but are at greater risk for chronic illness and diseases.2 One factor that is affecting them
negatively is the low immunization rates linked to low-economic status and fear of authority
among new immigrants. Hispanics had the lowest percentage (among all racial/ethnic groups) of
adults aged 18 and older who are vaccinated against seasonal influenza from 2010-2013, rates
respectively 28.8, 28.3, and 30.5.1
Max The Vax is a multi-step approach intervention which highlights some of the most
effective, evidence-based strategies for increasing immunization rates. We will connect and
partner with primary care physicians (public and private sectors) and community programs to
incorporate health education information in Spanish. We highly recommend bi-lingual health
professionals in medical clinics within high Latino populations of the various identified
communities. Likewise, another component is the use of reminders for upcoming vaccinations,
recalls for missed vaccinations, immunization-only visits, and utilizing visual aids such as
posters in the clinics to further remind parents and individuals about the importance of
vaccinations; all of which will be in Spanish. There will be a variety of delivery methods for
reminders and recalls including letters, postcards, telephone, and text messages. The patient
education will inform them what could happen if they dont get vaccinated. Bi-lingual
immunization records will be provided. The fear of deportation, stigma, and misconceptions will
be addressed in the educational material to help with barriers for undocumented Latinos. In
addition, we plan to use an incentive rewards component, in which Latinos will receive rewards
for getting vaccinated, completing a booster series, etc. Overall, these culturally appropriate
strategies will help to increase immunization rates among Latinos.
The layout of this literature review is provided in three parts including the introduction,
body of evidence, and summary and conclusions. This review includes numerous references that
are peer-reviewed journal articles, government reports, and professional reports. In addition, the
sources describe the problem, population epidemiological and the probability of using my
planned intervention approach. All journal articles have sufficient or substantial evidence-based
literature to support their findings and recommendations.

Body of Evidence
Reports were the first to be reviewed to gain insight on the social profile, barriers and
strategies to improve immunization rates for the Latino population. The Cultural Insights report
was conducted by the CDC and it focused on bringing research into practice to build a better
understanding of the Latino population.2 It concentrated on helping to communicate more
effectively with specific cultures in order to influence their behavior. The report emphasized
health communication and marketing practices to guide communities in making environmental
changes to support healthy lifestyles. Two other similar reports were produced by the National
Foundation of Infectious Disease (NFID); one focuses on pediatrics and the other on adolescents
and adults.3,4 Latino socio-economic profile typically consists of lack of insurance, low
educational level, high proportion of female heads of households, and high rates of
underemployment which negatively impact their healthcare status. The pediatric report
specifically additional immunization barriers for Latinos including: lack of Spanish-speaking
workers at healthcare facilities, complexity of todays immunization schedule, immigration
issues, etc.3 The adolescent/adult report suggested strategies with 3 focuses: increase community
awareness and demand for immunizations, increase accessed to vaccines, and reducing health
system barriers.4
Next, various reviews were assessed including systematic reviews and journal reviews.
The two systematic reviews are evidenced-based interventions that were provided by The
Community Guide and both are supported by the Community Prevention Services Task Force.5,6
Both reviews (interventions) had initial numerous systematic studies, then years later were
updated with several more studies to conclude a more recent report and findings. Likewise, there
was sufficient and strong evidence of effectiveness in increasing vaccination rates for children
and adults.5 The first review introduced the client or family incentive rewards intervention.
These rewards are used to motivate people to obtain recommended vaccinations. The rewards
may be given when the client and/or family receive a vaccination, for keeping an appointment, or
when they complete a vaccination series.5 The rewards may be monetary or non-monetary such
as gift cards, baby products, food vouchers, etc. The other systematic review introduced client
reminder and recall systems as their intervention. The reminder and recall intervention was used
to remind patients that vaccinations are due and recalls were provided when they were late. The
intervention could differ in delivery methods such as: postcards, letter, telephone, text messages,
etc. The content was specific and used Spanish. The AOA journal article identifies there are
many barriers as to why we (U.S.) falls short in our goals of vaccinating children, adolescents,
and adults. These barriers can be classified into three categories: health care system barriers,
health care provider barriers, and patient barriers.7 This article emphasis the importance of
reducing patient barriers such as misconceptions, miseducation, lack of access (perceived and
real), etc. Lack of access is a major barrier to immunizations. Typically these low-income
families are at a greater risk for incomplete immunizations, particularly Hispanics and those in
urban communities are at the greatest risk.7 Another journal article provided statistics on the
prevalence of influenza vaccination coverage for all racial/ethnic groups. Latinos ranked the
lowest in all categories including: 11% for age 18-49, 25% for age 50-64, and 45% for age older
than 65.8 This is similar to the data presented earlier by Healthy People 2020.

Lastly, studies were evaluated for the literature review that highlighted various
approaches and strategies for increasing immunizations especially enhancing the delivery. The
first study utilized mailed or online surveys (20 questions) to gather data on primary care
physicians on their perceptions of potential strategies for increasing adolescent immunizations
rates. Notably adolescent immunization rates havent reached the levels of children vaccines nor
U.S. goals.9 The merit contribution of this study is that it used data from a literature review (The
Task Force on Community Prevention Services) to provide a list of 9 groups of potential
strategies. They also agreed with the recommendation of a patient reminder/recall system
presented earlier. Another survey based study (52 questions) focused on Latino mothers
perceived barriers to immunization. New data presented implicated that the mothers perception
of their childrens up-to-date status was a contributing factor for their children being
underimmunized. One interesting set of data found that over 92% of the women believed their
childrens vaccines were up-to-date, however documentation proved only 42% were found to be
up-to-date.10
The Findley et al study discussed effective strategies for immunization promotion while
focusing on integration into community programs. The Start Right Coalition was formed by 23
organizations to provide a community-driven immunization program in a low-income
community in New York City. This sustainable approach is being regarded as a merit based on
immunization rates that improved and were maintained for a 5-year period.11 Likewise, another
contribution of this study is the community setting, specifically the location, in which majority of
the participants were African-American or Latino. The coalition implemented principles
including evidenced-based immunization promotion activities such as reminders and recalls.11
This study was the biggest among all data presented in this literature review; it was comprised of
more than 31,000 parents who received outreach and over 10,000 children that were enrolled.11
Hispanics/Latinos are least likely to receive an influenza vaccine that any other
racial/ethnic group in the U.S. as reported by a Phippard et al study.12 This compares with the
statistics provided by another resource. Overall there is a high awareness of the influenza
vaccine, however only 36% reported vaccination.12 Misconceptions about influenza risk,
prevention and treatment were common in this Hispanic border population; improved
educational efforts and reminder systems could impact vaccination behaviors. Latino residents
living near the Mexico border have differing health beliefs and behaviors which impacts
infectious diseases. They are at more risk because of the travel from one country to another and
the rapid spread of influenza.
Summary and Conclusions
Vaccines are unique in that they protect both individuals and communities. In general,
one study reported 77.0% of Hispanic children were immunized, compared with 82.5% of nonHispanic White children.10 When comparing the references there is consensus that vaccination
gaps in adults in the U.S. are much wider than gaps among children, with the overall adult
vaccination rate under 70.10 There are gaps that persist typically in urban areas and with large
minority and ethnic populations like Latinos. Based on the data presented, there is a true need

for better education about the importance and benefits of immunizations, reducing
misconceptions, providing culturally appropriate interventions, and reducing barriers to access.
There are limited Task Force recommendations for adolescents because their evidence
isnt uniformly based on adolescent vaccination studies.9 Therefore, there is a need for more
studies and reviews on strategies emphasizes how to improve adolescent immunization rates.
Likewise, due to little findings on improving adult immunization rates, there is also a need to
develop culturally specific ways to reach adults, particularly undocumented & recent Latino
immigrants. There were no major differences in the results of my studies. However, one study
attested to more distinct attitudes and behaviors for Latino residents living along the
U.S./Mexico border and the need for education around the use of antibiotics and risk beliefs.
Max The Vaxs goal is to increase immunization rates and encourage strategies that
providers, clinics, and community programs can reach the Latino population. My program is
supported by the literature findings presented above. The program has components such as client
reminder/recall system, client and/or family incentive program, immunization-only visits, which
have strong evidence supported by The Community Prevention Services Task Force findings and
other journal articles. Likewise, working with community programs has been established as a
sustainable intervention that is critical when forming relationships with primary care clinics and
educational centers. Culturally appropriate interventions and strategies that uniquely impact the
Latino population is a common theme. The reminder/recall cards, posters, immunization record,
and patient educational materials will all be provided in Spanish. The research findings strongly
emphasize the need for more patient education and improved delivery of immunizations, both of
which are key components in the Max The Vax program.

References
1. Immunization and Infectious Diseases. Healthy People 2020 website.
http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectiousdiseases. Update November 13, 2015. Accessed November 13, 2015.
2. Building Our Understanding: Cultural Insights. Communicating with Hispanic/Latinos. Center
for Disease Control and Prevention website.
http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/hispanic_latin
os_insight.pdf. Updated November 4, 2014. Accessed November 13, 2015.
3. A Report on Reaching Ethnic and Minority Populations to Improve Pediatric Immunization
Rates. National Foundation for Infectious Diseases website.
http://www.nfid.org/publications/reports/pediatricwhitepaper.pdf. Updated October 2012.
Accessed November 12, 2015.
4. A Report on Reaching Ethnic and Minority Populations to Improve Adolescents and Adult
Immunization Rates. National Foundation for Infectious Diseases website.
http://www.nfid.org/publications/reports/adolescent-adult-white-paper.pdf. Updated October
2012. Accessed November 12, 2015.
5. Increasing Appropriate Vaccinations: Client or Family Incentive Rewards. Community
Preventive Services website.
http://www.thecommunityguide.org/vaccines/IncentiveRewards_archive.html. Published April
2011. Updated July 14, 2015. Accessed November 12, 2015.
6. Increasing Appropriate Vaccinations: Client Reminder and Recall Systems. Community
Prevention Services website. http://www.thecommunityguide.org/vaccines/clientreminder.html.
Published May 2015. Updated July 14, 2015. Accessed November 12, 2015.
7. Hendriksz T, Malouf PJ, Sarmiento S, Foy JE. Overcoming Patient Barriers To
Immunizations. AOA Health Watch. 2013; 3: 9-14.
8. Hutchins SS, Fiscella K, Levine RS, Ompad DC, McDonald M. Protection of Racial/Ethnic
Minority Populations During an Influenza Pandemic. American Journal of Public Health. 2009;
99 (2): S261-S270. doi: 10.2105/AJPH.2009.161505.
9. Humiston SG, Serwint JR, Szilagyi PG, Vincelli PA, Dhepyasuwan N, Rand CM, Schaffer SJ,
Blumkin AK,Curtis CR. Increasing Adolescent Immunization Rates In Primary Care: Strategies
Physicians Use And Would Consider Implementing. Clinical Pediatrics. 2013;52(8):710-720.
10. Adorador A, McNulty R, Hart D, Fitzpatrick JJ. Perceived Barriers To Immunizations As
Identified By Latino Mothers. Journal of the American Academy of Nurse Practitioners. 2011;
23 (9):501508. doi: 10.1111/j.1745-7599.2011.00632.x
11. Findley SE, Sanchez M, Mejia M, Ferreira R, Pena O, Matos S, Stockwell MS, Irogoyen M.
REACH 2010: New York City. Effective Strategies for Integrating Immunization Promotion Into
Community Programs. Health Promot Pract. 2009; 10(2):128S-137S.

12. Phippard AE, Kimura AC, Lopez K, Kriner P. Understanding Knowledge, Attitudes, and
Behaviors Related to Influenza and the Influenza Vaccine in US-Mexico Border Communities.
Journal of Immigrant and Minority Health. 2013; 15 (4): 741.746.