NIAM Blog Series: Breaking Down Barriers to Access to Increase Immunization Rates

Every August, local health departments throughout the country participate in National Immunization Awareness Month (NIAM) to spread awareness of the importance of vaccines across the lifespan. Throughout this month, NACCHO’s NIAM Blog Series will highlight local health department efforts to improve immunization rates in their communities. This week, we spoke with Patricia Hall, BSN, RN, DN/CM, Program Supervisor of Infectious Disease at St. Mary’s County Health Department (SMCHD), to learn more about the Amish Mobile Immunization Clinic Project, a 2017 NACCHO Model Practice.

This week’s National Immunization Awareness Month theme focuses on babies and young children. Why was it important to connect with St. Mary’s County’s Amish community to reinforce that a healthy start begins with on-time vaccinations?

In 2013, the St. Mary’s County (MD) pertussis rate was 3.0 (per 100,000) and continued to rise to an alarming rate of 6.4. After further investigation, it was determined that the majority of the pertussis cases resided within our county’s large Amish community. With an estimated population of over 1,400, the Amish are active members of the community and provide many goods and services to the residents of Southern Maryland. To them, someone is healthy if they “look well, maintain a good appetite, and can function physically,” while an unhealthy person is “unable to perform daily work and contribute to their family and community.” The Amish believe that childhood diseases, such as chicken pox and pertussis, provide natural herd and lifelong immunity. The community traditionally uses holistic and alternative medicine and, as devout Christians, believes in the power of prayer for healing.

Implementing public health interventions in hard-to-reach communities often means overcoming cultural barriers. Tell us about the cultural barriers you faced and how you overcame them.

Historically, the Amish do not vaccinate their children, but some members of the community have begun to do so. Recent events, including a measles outbreak in 2014, have resulted in members of the community approaching St. Mary’s County Health Department for preventive services. While cases typically go unreported, a recent case of pertussis within the community resulted in lifelong health complications for the patient, triggering concern. In addition, an annual school immunization survey submitted to Amish Elders indicated high percentages of non- or under-vaccinated children. While limited, community members may use the larger healthcare system under certain circumstances after consultation and approval by Amish Elders. But similar to the general population, Amish people who pursue healthcare services face many barriers: culture and beliefs, language and communication, health literacy, lack of insurance, high costs, and access to care. As such, SMCHD sought to cut out some of those barriers by bringing clinical services directly to the community.

How did you bring those clinical services directly to the community, what did you hope to achieve, and what was required to ensure the initiative was successful?

To reduce barriers to access and expand outreach to underserved populations within the county, SMCHD developed a mobile, home-based clinic model for implementation in the Amish community. The primary objective of the clinic was to provide community-wide immunizations for infants, children, and adults in a manner that was sensitive to the cultural identity of the Amish community and delivered at no cost. To achieve this goal, SMCHD:

  • Worked collaboratively with the Amish holistic health worker and Amish Elders;
  • Contracted a local pediatrician that was known to and trusted by the Amish community to staff the mobile clinic;
  • Offered health department staff to operate the clinic, maintain records, and complete immunization record books;
  • Provided all supplies, including vaccines; and
  • Delivered on-going follow-up and health promotion services.

How did you evaluate the success of the mobile immunization clinic?

In regards to the ongoing evaluation process, the Infectious Disease Program completes a summary at the end of each mobile clinic that addresses what went well and what can be improved. Numerous items were evaluated, including communication, supplies, storage of the vaccine, man power hours devoted to the clinic, check-in and check-out process, and time management. It is imperative to evaluate all of these factors. In addition, the Amish continue to request that SMCHD return to do more clinics, which lets us know that the community has found these clinics beneficial.

What efforts are in place to continue strengthening relationships within the Amish community to ensure sustainability of the mobile clinic and increase immunization rates?

In an effort to continue to enhance the relationship between the Amish community and the health department, we used several performance measures to gauge patient experience feedback, cost of healthcare services, and disparities on performance. For example, the Infectious Disease Program nurse spoke directly to the elder Amish woman in charge to get specific feedback on any questions and/or concerns that she observed or was made aware of. By demonstrating that we want to take their concerns into consideration to improve the services, we were able to increase trust between the Amish and the health department, which has resulted in the community’s openness to more clinics.

What recommendations do you have for communities interested in implementing a vaccination program for a hard-to-reach population?

When considering implementing this type of outreach, health departments should consider the need to have buy-in from stakeholders, as well as think outside of the box on how to reach goals with limited funds since there is a cost to initiate and maintain this type of outreach. Our health department is able to utilize Vaccines for Children (VFC) immunizations from the State of Maryland for this program due to the fact that the Amish families do not have health insurance. Physicians agreed to payment of $575 for every four hours, and the supply cost is $450. SMCHD has been able to keep the staffing cost to $500 by utilizing Nursing Student Interns.

It took approximately four months for SMCHD to put the mobile clinic into active practice. This involved writing and obtaining approval protocol, signing a contract with the physician, securing extra supplies, scheduling dates and times, and developing advertisements. Developing and implementing these clinics required a great deal of planning and coordination, but the end result has been one we are very proud of and we hope to continue to bring our services to this community to ensure access to vaccines.

NACCHO is pleased to support local health departments in their participation of NIAM. Learn more about how your local health department can get involved, and be sure to check out our other posts in the NIAM Blog Series throughout the month of August.

About Kim Rodgers

Kim Rodgers serves as a Communications Specialist at NACCHO. Her work includes promoting local health departments' best practices, as well as partner tools and resources, in infectious disease and preparedness through NACCHO's communications channels, storytelling, and outreach to various audiences.

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