Sometimes, despite the best intentions, a community benefit program fails to reach its goals. But for St. Joseph's Hospital in Tampa, FL, reassessing its approach and communicating better with the target population enabled it to turn a potential failure into a success.
A Proven Need
The low immunization rate for children under age two has been documented locally and nationally. In the United States, a country with one of the most advanced healthcare systems in the world, the immunization rate lags behind that of most of the developed world.
In Florida, Hillsborough County's immunization rates echo national findings. By age two, only 65 percent of the county's children are fully immunized (Health and Rehabilitation Services [HRS]-Hillsborough County Public Health Unit Immunization Task Force Work Plan, 1993-94). In Tampa's public housing communities, local government agencies estimate that more than 1,750 children have received few or none of the recommended vaccines.
Motivated by this documented need, St. Joseph's Hospital agreed to join the local Kiwanis Club, HRS/Public Health Unit, and the Tampa Housing Authority to expand childhood immunization efforts in low-income public housing communities.
The Program
The objective of the "Be Wise — Immunize" program is to eliminate the barriers to immunizations, such as a lack of transportation to local clinics, a lack of awareness about the importance of childhood immunizations, and long waits at clinics. The program's "mobile immunization clinic" (St. Joseph's 40-foot wellness bus) is staffed by HRS registered nurses. The bus travels to Tampa's public housing communities each month, offering immunizations against measles, mumps, rubella, pertussis, tetanus, polio, diphtheria, Haemophilus influenzae type b, and hepatitis B.
By using carefully timed direct mail pieces, flyers, and posters, Be Wise — Immunize partners believed they would encourage all residents whose children need immunizations to participate in the program. The partners hypothesized that taking immunizations directly to the doorsteps of those in need would make it so convenient that rates would dramatically improve. The goal was to immunize 480 children during the program's first year (1992).
But it was evident early in the program that Be Wise — Immunize was not reaching the vast number of children in need of immunizations. Response to the postcards sent to parents was minimal, with only 131 children receiving immunizations in the first seven months, far below the goal of 280 children. St. Joseph's efforts to fulfill its mission were in question.
Building Trust
Be Wise — Immunize partners began a detailed evaluation process by asking, Why are parents in the housing developments rejecting this program? The process began with one-on-one meetings with the resident managers, who are elected leaders within each community. Frank questions and candid answers uncovered the strong animosity and suspicion residents feel toward "outsiders," even if the outsiders are there to help.
Be Wise — Immunize was the partners' first outreach effort to the developments. Each partner brought a different view on how to work with other cultures. Although some partners were African American, none lived in the developments, making it difficult for the group to relate to the residents' needs.
"Everybody feels they know how to help us, but we're the only ones who know what we need," said Sheila Reed Palmore, resident manager, Central Park Village Housing Community. After living in the public housing development for more than 35 years, Palmore feels her views represent the entire community.
"No matter how good your intentions are, how much money you have to offer, or how helpful you try to be, you need to include the people you are serving in your decision-making process to build trust," said Palmore.
The partners began the process of gaining the community's confidence by meeting with residents on their terms. Be Wise — Immunize partners contacted resident managers on an individual basis, inviting them to share insight on their communities, endorse the program's efforts within the community, and spread the word about the program.
At first, many of the partners were reluctant to organize door-to-door efforts. Each partner had a preconceived notion about the cultural differences to be faced. No one really understood the delicate network within the community that could make or break the program. Overcoming their own personal fear, the partners began a monthly door-to-door canvasing program as a follow-up to a postcard direct mailing. At first, both the partners and the residents felt uneasy. "Residents could tell the volunteers were scared to be in a black neighborhood," said Palmore. "We needed people to feel comfortable being here if this was going to work." To accomplish this, Be Wise — Immunize partners concentrated on the greater good of the project and dismissed their preconceptions about cultural differences. After a time, living rooms became environments where volunteers and residents could work as partners.
Easing Fears
Much of residents' mistrust of the Be Wise — Immunize program stemmed from misconceptions and hidden fears brought on by government controls, often viewed as a threat to independence.
"It became clear to us that the residents were tired of being dictated to," said Denise Winter, chairperson of Young Children Priority One, Kiwanis Club of Tampa. "We learned they wanted to be a part of the decision making.
"Many of the mothers I talked to thought that we were going to take their children away from them if we knew they didn't have their children's immunizations updated," added Winter. "We had to let them know our only agenda was saving a child's life."
The fear of getting "caught in red tape" created further anxiety for residents. Understandably, HRS requires written consent from a parent or legal guardian prior to a child's immunization. Although the verification process was designed to prevent overimmunization and to comply with the law, many residents found it cumbersome and threatening. Be Wise — Immunize partners began to work together to reduce the inconveniences associated with government protocols by guiding parents through the immunization paperwork, thereby streamlining this time-consuming and confusing chore.
"I've had to drive a grandmother back to her home to get her guardianship papers because HRS needed them. We'll do whatever it takes not to lose the opportunity to immunize another child," said Winter. "We knew that if we had to turn away a mother, she wouldn't come back."
Once the partners modified their approach to the program, the results were dramatic. In the next four months, 186 children received 488 vaccinations — an average of 46 children each month. Be Wise — Immunize partners' goal for 1994 is to immunize 600 children.
Ms. Chappell is media relations coordinator, St. Joseph's Hospital, Tampa, FL.