Sally E. Findley, Martha Sanchez, Sergio Matos, Letty Guzman, Miriam Mejia, and Shaofu Chen

1. Implementing Health Promotion Activities through Community Partnerships The Northern Manhattan Start Right Coalition Sally E. Findley, Martha Sanchez, Sergio Matos, Letty Guzman, Miriam Mejia, and Shaofu Chen Columbia University Mailman School of Public Health Heilbrunn Department of Population and Family Health 60 Haven Avenue – B2 New York, NY 10032

2. Objectives • Describe formation of Start Right Coalition • Explore Start Right Guiding Principles • Describe how we integrated immunization promotion into community organizations and organizational culture • Document how the program built the capacity for immunization promotion w/in community organizations • Report on 2006 feed back from participating parents (n=47) and CHWs (n=30).

3. Two Communities of Color in Northern Manhattan, NYC • Washington Heights and Central Harlem • 2000 census: 421,000 residents • Approximately 7000 births/year • Low-income, African American and Latino • 40% of residents are foreign-born • Rich cultural heritage • Mini-epicenter of the 1989-91 measles epidemic • Network of multi-service community organizations

4. The Problem: Childhood Immunization Disparities4:3:1:3:3 series for 19-35 month olds Sources: National Immunization Survey, 2000 Northern Manhattan Immunization Partnerships April 2000 Chart Reviews

5. What parents are up against: 10 Antigens with 3-4 repetitions over 24 months

6. How Start Right Began • Community organizations (led by Alianza Dominicana) mobilized to improve immunization services to the community after the measles epidemic • Coalition began as two separate coalitions in Harlem and Washington Hts, supported by Children’s Defense Fund and NYCDOH • Providers established NMIP, to improve delivery of immunizations • Start Right, merger of all these efforts in 1999, with coalition members asking MSPH/Columbia University to serve as convener.

7. Start Right Coalition Partners Arthur Eugene & Thelma Adair Community Life Centers; Alianza Dominicana, Inc.; CHILD Head Start, Inc.; Riverside Center; Dominican Women's Development Center; Ecumenical Community Development Organization; Ft. George Community Enrichment Center; Harlem Children’s Zone (The Baby College); Harlem Congregations for Community Improvement; Harlem Hospital WIC Program; Mailman School of Public Health-Columbia University; Northern Manhattan Improvement Corporation; Northern Manhattan Perinatal Partnership, Inc.; Puerto Rican Family Institute /Vacunas Para la Familia; Washington Heights/Inwood Early Childhood Education Coalition; New York Presbyterian Hospital Department of Pediatrics; Northern Manhattan Community VoicesCollaborative; New York CityDepartment of Health and Mental Hygiene

8. Overview of Start Right • Immunization promotion program designed, implemented and directed by a coalition of 17 community organizations, with linkages to health care providers and the city department of health • Children <5 recruited from community programs for immunization education, tracking and outreach • 9908 children enrolled, Oct 2000-April 2007

9. Start Right: Guiding Principles • Community leadership • Integration with community social service programs • Community Health Workers • Parental empowerment • Multiple reinforcers and feedback • Linkages with health providers

10. Guiding Principle:Community Leadership • Program owned by coalition • Shared leadership: Mailman School of Public Health and 2 community organizations • Regular monthly meeting structure • Consensus decision making • Organizational accountability • Subcontracts to support organizations through community organization “hub” • Training, enrollment and outcome targets

11. Guiding Principle:Integrating Start Right Program into Community Life • Previous organization and coalition experience suggested we stay away from “stand-alone immunization programs” or programs based out of hospitals or medical systems. • Review of previous coalition activities suggested that we should design the program based on our strengths, namely the programs our organizations already offer the community. • Immunization promotion activities embedded into major educational and social service programs working with parents of young children • Community organizations were starting to strengthen CHW approaches to facilitating child health (e.g. facilitated enrollment), and the community was comfortable with this model.

13. Identifying Child Health Promotion “Windows of Opportunity” • Head Start and child care programs • Parenting programs at multi-service community organizations • Faith-based community children’s programs • Housing advocacy and tenancy groups • SCHIP Facilitated Enrollment at community organizations • Family assistance programs: WIC, Food Stamps

14. Creating an Immunization Promotion Culture in the Organization • Meet with organization leadership • Convene organization-wide meeting/forum to talk about immunization, child health and what they see themselves doing • Identify promotoras/CHW among membership, clients or staff • Incorporate the designated staff/promotoras in the Start Right program as their organizational Start Right “champion” and leader. • Include both newly recruited and internally recruited CHW in the Start Right training program

15. Guiding Principle:Community Health Worker/Promotora Model • Empower staff and organization to be competent in health education and promotion • Training developed by and for the coalition members • 938 CHW trained 2000-2007

17. Who Are the Start Right CHWs/Champions? • Mostly women and mothers • Mixture of African American and Latino, from the community • Trusted members of the community who wanted to “give back”

18. Empowering the Start Right champion/CHW for Immunization Promotion • Provide simple guidelines for screening parents for program eligibility • Give a menu of options for how and when to convey health education messages • Coalition created own health information materials, tailored by and for our community • Link follow-up and evaluation to routine activities

19. CHW Training • Bilingual, modular training manual: • Communications; Immunization 101; Card Reading; Parent Empowerment (Medical Consumerism); Program Implementation; Evaluation and Tracking • In-house training: Jointly with NYC DOH • Pre- and post-testing for each session • Feedback and course evaluation • Periodic refreshers

21. Coalition Members Trained n=938

22. Start Right Outreach Tree • Core: 2-6 CHW focusing on enrolling and working with families about immunizations • Main branches: 5-20 staff/CHW w/in the organization identifying families and referring to the “core” CHW • Outer branches: 12- 80 Promotoras talking with families in the community about SR and sending families to the organization • Leaves: 100’s of parents in SR talking about immunizations and SR with their neighbors and kin.

23. What SR CHWs say about their work • This helped me to understand things I did not know before. The information is good for informing parents. I learned how to use the calendar to make parents ready for appointments. • It helps me keep on helping the community. Many parents are not aware of the importance of vaccinations. • Learning how to read the immunization card was one of the best trainings I’ve ever gotten, because now I can tell parents if their children are up to date or not. • Now, when moms go to the doctor they know what is going on and understand what he tells them. So they come back and thank us for helping them understand. • I use positive reinforcement to turn a negative situation into a positive one by providing resources for parents that they otherwise would not have. • Our most effective work is through the activities and events that we do. We know that toddlers like to have fun and parents need things to do with their kids. We do a toddler jamboree, where kids 0-3 are invited. While the toddlers are having fun, we talk with the parents about immunizations and make sure that they are informed. Then we check their cards to see if they are up to date. If they are not, we work to get them up to date so that their kids are ready for school at 4 years old.

24. Guiding Principle:Parent Empowerment • Individual and group interventions • How to talk to parents about immunizations • How to talk to your doctor • Coalition developed brochures to address community concerns about immunizations • Personalized immunization calendar prepared at enrollment (NIP scheduler)

27. Enrollment by Start Right Strategy, Oct 2000-March 2007 N=9908 enrolled

28. Guiding Principle: Parental Reinforcers and Reminders • Parents reminded of upcoming immunizations • Immunizations tracked to assure delivery and parents recalled as needed • Average 3 reminders per child: phone calls, postcards, birthday cards or home visits • Parents receive incentives for completion of on-time immunizations (each organization can choose what they give to parents)

29. Key Messages: Parent to Parent • Sharing own experience and anxieties with the parent, giving “space” for expression of fears and doubts. • Emphasize parents’ role to protect children: The diseases are real (show pix) and children can get them. • Using the SR “PIK-PAK” materials to address concerns the parent may have. • Explaining the need for different vaccinations and repeat doses (calendar). • Give specific reminders about when to go for which shots. • Reminders: We are all very busy, and we all find it hard to get to the doctor…

30. What Parents Say about Start Right • They told me about resources available to people like me that I didn’t know about. I have passed on this information to other people about vaccines. • They put me in touch with other women and we shared opinions. That helped me to get stronger and be more independent and got my mind positive before it became negative. • I asked my doctor more. I had been anxious that the vaccine has viruses. I felt that giving the virus would be harmful. The doctor told me that it was okay because you get immune to it. • Start Right teaches people how to be up to date with immunizations. They will remind you when the next shots are due. • It is good to enroll [in Start Right], because if you are busy you may forget to vaccinate. But being in this program, you won’t forget.

31. Guiding Principles: Linkages with Health Providers • Every child to have health insurance and a medical home • Referrals to SCHIP facilitated enrollment • Help parents make and keep immunization appointments • Health providers refer to Start Right and Start Right goes to 11 clinics to follow-up with families and referrals • Retention of community base: The conversation about immunizations still takes place in the community.

32. Tracking Immunizations:the Start Right Database • Three data sources: • Child’s vaccination card (NYC DOH) • EzVAC, the hospital network registry, where most children receive primary care in Washington Heights • NYC CityWide Registry CIR • Data entry at each agency, with monthly updates and exchanges with central data “warehouse” with all sources

33. Start Right is Proud of Our Accomplishments • 9908 children enrolled to date (99% of the target) • Immunization rates were brought from 58% to 76-86% • Immunization disparities were eliminated, and the children enrolled in Start Right are now at the national average. • Parents uniformly recommend the program to others. Start Right has generated a “buzz”. • Cf. Health Promotion Practice 2006 and Ethnicity and Disease 2004 articles

35. Conclusions • We have been successful at developing a bottom-up capacity to promote immunizations in our community. • Over 900 promotoras now practice the culture of immunization promotion, with 200 actively engaged at any given time. • Almost 10,000 parents and their children have participated in the program and have been successful in obtaining vaccinations for their children. • The coalition plans to expand to address additional child health concerns with the same model.

36. The Northern Manhattan Start Right Coalition is funded by a grant from the Centers for Disease Control and Prevention, REACH 2010 (U50/CCU222197)