Ethan Taylor PUBH 6500 Assignment 4

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CityLink Center Immunization Program

A Grant Proposal

Christine Hanahan Leah Palmer Ethan TaylorThe George Washington University

Public Health 6500: Planning and Implementing Health Promotion ProgramsSpring I 2015

C. Hanahan, L. Palmer, E. Taylor 1

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Part I: Introduction and Needs Assessment

1.1 Introduction to the Request

CityLink Center is a private non-profit organization committed to addressing the

challenges facing Greater Cincinnati’s low-income adults and their families through an

integrated approach that includes health and wellness services. Opening in 2013, CityLink

Center utilizes a bundled services model, developed by the Annie E. Casey Foundation and

considered the best-in-class method for systemically fighting poverty, with proven success in

Chicago, New York, and Atlanta (CityLink, 2013). CityLink is seeking a grant of $61,100 from

the Greater Cincinnati Foundation (GCF) to fund a health intervention that will reduce the

incidence of vaccine-preventable diseases (VPDs) by achieving age-appropriate immunization

compliance for children less than 18 years of age from the families served by the center. This

program will consist of parental education and counseling, on-site vaccination clinics, and

immunization tracking and reminders. As a result, children will get a healthy start to life and

future generations of Cincinnatians will be able to thrive, a shared goal of CityLink and the GCF.

1.2 Background: Suboptimal Immunization for Vaccine-Preventable Diseases (VPDs)

Immunization has been widely publicized as one of the ten greatest achievements in

public health in the 20th century and Siddiqui, Salmon and Omer (2013) credited vaccines as,

“among the most effective public health interventions against infectious diseases”. The World

Health Organization (WHO) reports that worldwide, immunizations prevent an estimated 2-3

million deaths each year and has established a Global Vaccine Action Plan with a goal of

achieving >90% vaccine coverage across all countries (World Health Organization [WHO],

2013). In the early 1900’s, cases of infectious diseases were commonly reported in the U.S. and

there were few treatment or preventive measures (Center for Disease Control and Prevention


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[CDC], 1999). Between 1900 and 1999, two dozen vaccines were either developed or licensed

and nine VPDs (e.g. polio, measles and smallpox) were eradicated, eliminated or greatly reduced

in the U.S. due to national efforts focused on promoting vaccine use among all children and the

development of a vaccine-delivery system (CDC, 1999). The CDC reports that for children born

in the U.S. between 1994 and 2013, “vaccination will prevent an estimated 322 million illnesses,

21 million hospitalizations, and 732,000 deaths during their lifetimes” (Elam-Evans, Yankey,

Singleton, & Kolas, 2014).

However, there remain significant gaps in vaccination coverage for the recommended

schedule among children (see Attachment 1). Healthy People (HP) 2020 has ten specific

vaccination objectives for the percentage of children at birth or at ages 19 – 35 months who will

receive the recommended dosages by 2020 (Health People 2020, 2015). Data from various

national surveys in 2008-2009 suggested that four of the vaccine target objectives had been met

and need to be maintained (i.e., Hepatitis B, measles-mumps-rubella [MMR], varicella, polio).

The target was about 10-15 percentage points below the target for two vaccines (i.e., a

combination of diphtheria, tetanus, and acellular pertussis antigens [DTaP] and pneumococcal

conjugate vaccine). For four others (i.e., Hib antigen, Hepatitis A, birth dose of Hepatitis B, and

rotovirus), the coverage was about 30-40 percentage points below the target (Health People

2020, 2015). The goals for four out of five of the vaccines targeted for coverage among children

in kindergarten had been met by 2009-2010; varicella vaccine coverage was a few percentage

points below the 2020 target. In addition, all of the recommended vaccinations for adolescents

were well below the HP 2020 target in 2008; most notably, human papillomavirus (HPV) for

females, and HPV for males in 2012 (Health People 2020, 2015).


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The literature suggests that there are two groups of children who do not meet the

recommended immunizations: 1) children of parents who refuse or delay vaccinations; and 2)

children living in poverty (Falagas & Zarkadoulia, 2008). The former group tends to be higher

socioeconomic status (SES), well educated, and highly concerned with their children’s health

(Gilkey, McRee & Brewer, 2013). The latter tends to be lower SES, non-white, less well

educated and lack health insurance (Falagas & Zarkadoulia, 2008). Since CityLink focuses

primarily on low-income families, our proposed program aims to address those unique needs.

1.3 Social Assessment of the Problem

Children of impoverished families are at a distinct disadvantage for optimal

immunization coverage levels and have been especially prone to VPD outbreaks in previous

decades (Klevens & Luman, 2001). Using National Immunization data from 1996 to 1999,

Klevens & Luman (2001) noted that those living above the poverty line had the best rates of

vaccine compliance for U.S. children aged 19 to 35 months, while those at or near the poverty

line had lower compliance, and those in severe poverty ranked the lowest. Furthermore, under-

immunized children are disproportionately more likely to reside in urban areas and to be

minorities (Smith, Lindley & Rodewald, 2011). Despite national and state programs providing

free or discounted childhood vaccines, the threat of VPDs remains, as poor families continue to

under-immunize their children (Smith, Lindley, & Rodewald, 2011).

A variety of factors that affect immunization status afflict low-income families. Mothers

with low educational attainment are more likely to have low health literacy, which is associated

with lower immunization rates (Pati et al, 2014). Prior immunization status and the use of

electronic medical records influence the continuation of scheduled immunization for infants and

children. A child with up-to-date immunizations at three months of age was more likely to be


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immunized on time at seven months, yet children in poverty frequently do not have a consistent

medical provider to provide for such tracking (Pati et al, 2014). Poor health outcomes are linked

to the age and marital status of the mother, along with family size, and the child’s birth order. In

particular, a single, young mother having three or more children is least likely to have her

children fully vaccinated (Pati et al, 2014).

To pull themselves out of poverty, adults must have full-time work, opportunities for

education and training, remain healthy, and be able to attend to their family needs (Shore &

Shore, 2009). Nearly half of working mothers must take time off without pay to care for sick

children, often jeopardizing job stability and limiting career advancement (Kaiser Family

Foundation, 2003). Solving the problem of under-immunization will further reduce the barriers

to moving out of poverty by keeping children healthy and free from VPDs. This will decrease the

number of days parents must care for sick children and allow them to focus on the personal,

professional and educational development required for stable employment.

1.4 Epidemiologic Assessment of the Problem

The U.S. faces a high incidence of vaccine preventable diseases, with approximately

3,400 children contracting VPDs in 2007 (Health Resources and Services Administration, 2010).

Vaccinations prevent 14 million disease cases and 33,000 deaths annually; they also save 9.9

billion dollars in direct medical costs and an estimated 33.4 billion dollars in indirect costs

(Healthy People 2020, 2015). Chart 1 summarizes the key factors associated with VPDs,

highlighting the critical role of improved vaccine compliance to maintain and reduce the

incidence.

1.4.1 Genetics: Although genetics are not a cause for VPDs, they may play a role in

adverse vaccine reactions, which could contribute to parental non-compliance. Allergic reactions


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to vaccines may be genetically based and represent a fear for many parents (Falagas &

Zarkadoulia, 2008). However, most allergic reactions from vaccinations are local, non-

immediate skin reactions, and 10% do not reoccur upon re-exposure (Gold et al, 2000).

1.4.2 Behavioral Factors: Parent behavior has a direct effect on vaccination compliance.

Childhood immunizations have markedly reduced an increasing number of vaccine-preventable

diseases. However, vaccination rates among children remain less than optimal, with 30% of

children failing to receive all recommended vaccines by 2 years of age according to the CDC’s

2013 data (CDC, 2013). Approximately 20% of parents miss immunization appointments for

their children (Stockwell et al, 2014). The top three causes of missed appointments reported by

parents were competing priorities (i.e. work, childcare, and other appointments), forgetfulness,

and problems with insurance (Stockwell et al, 2014).

1.4.3 Environmental: Living within a population with a sufficient percentage of

vaccinated individuals, known as “herd immunity”, protects unvaccinated individuals from

disease by (Fine, Eames & Heymann, 2011). Herd-immunity thresholds, “the population

immunity level needed to interrupt transmission,” are established based upon the contagiousness

of VPD’s; for measles, a population vaccination rate of 92-94% is required to prevent sustained

spread of the virus (Orenstein & Seib, 2014). As of 2013, the U.S. lagged behind CDC

recommendations with an MMR vaccination rate of 91.9% among 19-35 month olds (CDC,

2013). Individuals who are un- or under-vaccinated are at increased risk, as was evidenced by the

recent measles outbreak in California in December 2014 when at least 40 confirmed cases were

identified, most of who appear to be insufficiently vaccinated (California Department of Public

Health, 2015). The number of cases in this outbreak subsequently rose to 173 cases by mid-

March 2015 (CDC, 2015a).


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Chart 1: Conceptual Model of Risk Factors Leading to Vaccine Preventable DiseasesUnderlying Factors Risk Factors Health Problem

Predisposing Factors (Intrapersonal)· Knowledge/Perceptions regarding susceptibility,

severity, transmission routes, and limited or no experience with VPDs

· Knowledge/Perceptions of vaccine safety, side effects, efficacy & benefits

· Health literacy or having limited capability to track and/or maintain complex schedules

Reinforcing Factors (Interpersonal/Cultural)· Inaccurate or anti-vaccine messaging from peers,

family, and the media· Lack of a relationship with a provider who

communicates about immunization needs and safety· Religious or cultural influencesEnabling Factors (Systems influences)· Accessibility to provider office (hours, cost,

transportation)· Availability/supply of vaccines in region· Variable public school immunization requirements

or exemptions

Genetic Risks· Allergies to vaccines

or components

Behavioral Risks· Parents fail to comply

with CDC recommended vaccination schedules

· Parents fail to make or keep appointments

Environmental Risks· Lack of herd

immunity due to under vaccination

· VPD rates in community

Incidence of Vaccine

Preventable Diseases (VPDs)

1.5 Assessment of Educational and Ecological Factors

This section further reviews the underlying factors in chart 1.

1.5.1 Predisposing: Knowledge and perceptions regarding susceptibility and transmission

routes are limited for parents with little or no experience with VPDs and the perceived severity

of VPDs is often underestimated (Falagas & Zarkadoulia, 2008). A major factor affecting

knowledge of immunizations is parental health literacy and poor educational attainment is

associated with lower immunization rates (Pati et al, 2011). Health literacy also has an impact on

the ability of parents to track children’s medical records and understand complex vaccine

schedules (Pati et al, 2011). In multiple studies, low vaccine compliance was found to be the

result of parental beliefs that vaccines are unsafe and that the consequences were worse than the

disease itself (Falagas & Zarkadoulia, 2008).


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1.5.2 Reinforcing: The influence of significant others plays a role in a parent’s decision to

vaccinate their children (Siddiqui, Salmon & Omer, 2013). In one study of source credibility,

Freed and colleagues found that, while 15% of parents reported valuing the views of family and

friends and 26% placed some trust in celebrities, the majority trust the opinions of pediatricians

(76%), follow by other trained medical professionals (26%) or government vaccine experts

(23%) in order to make informed decisions regarding vaccine safety and immunizations (as cited

in Siddiqui, Salmon & Omer, 2013, p. 2644). However, many families living in poverty lack a

consistent and strong relationship with a provider (Falagas & Zarkadoulia, 2008). The now

infamous Dr. Andrew Wakefield’s 1998 paper incorrectly linking the MMR vaccination to

Autism continues to affect parental decision-making on immunizations (Saint-Victor & Omer,

2013). Finally, some parents may object to immunizations because of their religious or cultural

beliefs, which have been shown to put them at 6-35 times the risk for infectious diseases than the

general population (Grabenstein, 2013).

1.5.3 Enabling: Public educational systems have varying legal requirements for vaccine

exemptions by state (CDC, 2015b). Most states allow for medical exemptions from school

vaccination requirements, but some states permit religious and personal belief exemptions; the

state of Ohio permits both personal and religious exemptions (CDC, 2015b). Immunization

compliance is dependent on availability of vaccines in the region, cost of vaccines to parents, and

accessibility to provider offices (Falagas & Zarkadoulia, 2008). Programs are currently

established to aid in the vaccination of underserved populations, but often struggle with vaccine

availability. For example, the U.S Vaccines for Children (VFC) had vaccines arriving

significantly later than non-VFC vaccines from 2007-2009 and as a result, compliance decreased

(Ambrose & Toback, 2012). The cost of paying for immunizations with or without insurance was


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associated with decreased compliance in families with low socioeconomic status (Falagas &

Zarkadoulia, 2008). Availability of immunizations based on clinic hours of operation are an

additional concern, as parents cite problems scheduling appointments with competing priorities

for time and experienced long wait times at these clinics (Stockwell et al, 2014).

We conclude by summarizes the most important underlying factors associated with the

incidence of VPDs in chart 2, which our proposed intervention addresses.

Chart 2: Most Important Educational & Ecological FactorsHealth Problem: Children are susceptible and acquiring vaccine preventable diseases

Health Behavior/Environmental Risk Factor(s): Parents are not vaccinating children according to the CDC recommended schedule

Underlying Factors Item 1 Item 2

Predisposing Factors Knowledge/Perceptions of vaccine safety, side effects, efficacy & benefits

Health literacy or having limited capability to track and/or maintain complex vaccine schedules

Reinforcing Factors Lack of a relationship with a provider who communicates about immunization needs and safety

Inaccurate or anti-vaccine messaging from peers, family, and the media

Enabling Factors Accessibility to provider services (hours, cost, transportation)

Availability/supply of vaccines in region

1.6 Identification of Needs

Sperling’s Healthiest Cities Study ranked Cincinnati 48 out of 50 cities, making it one of

the least healthy cities in the nation based on an analysis of health, nutrition, lifestyle and

physical activity factors (Sperling, 2014). Mortality rates for all ten of the leading causes of

death are higher in Cincinnati as compared to the state of Ohio (Cincinnati Health Department,

2011). With an estimated population of nearly 300,000 residents, 30.4% of Cincinnatians live

below the poverty line. Most single head of household families are poor (70%) and African-

Americans are disproportionately represented with an estimated 60% living in poverty (U.S.


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Census Bureau, 2014). Within the Cincinnati’s inner city area, only 70% of adults have a high

school education, the median family income is less than $12,000, 77% work in blue-collar or

service jobs, and only one in four children live in two-parent homes (Maloney & Auffrey, 2013).

The Cincinnati Health Disparity Reduction Plan identified the need for additional services in

high need areas, a focus on health education, the establishment of free clinics, and additional

support and funding for minority health care that is culturally sensitive in order to address

preventive healthcare, covering all aspects of health (City of Cincinnati Health Department,

2011).

The status of children in Cincinnati is particularly concerning, with over 50% of the

city’s children living in poverty (U.S. Census Bureau, 2014). The city ranks third, behind Detroit

and Cleveland, for child poverty, nearly twice the national rate. Cincinnati’s inner city

neighborhoods fit the criteria for “severely distressed” as defined by the Annie E. Casey

Foundation, concentrating a large segment of African-American and Hispanic children in

disadvantaged neighborhoods, undermining both the quality of daily life and significantly

increasing the risk of disease and mortality among both children and adults (Turner et al, 2014).

Pulling families out of poverty through better-paying jobs and career advancement is the single

most important road to improving future success for children and breaking the persistence of

intergenerational poverty (Turner et al, 2014).

There has been a recent decrease in the vaccination rates among children aged 19-35

months and in 2013, Ohio ranked in the bottom three states for MMR coverage (Elam-Evans et

al, 2014). Although the immunization rates for Hamilton County show good progress across all

recommended vaccines for children in this age group, the CDC data is not categorized by city or

neighborhood. The predictors of low vaccine coverage are housing stress, percentage of African-


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American children under the age of five, and percentage of children under the age of 18 living in

poverty (Smith & Singleton, 2011). These are all common characteristics of the clients of

CityLink. Compliance with the CDC-recommended schedules is at risk, with a clear gap between

the Healthy People 2020 immunization objectives and the stark reality of Cincinnati’s inner city.

1.7 Community Analysis

The city of Cincinnati has implemented several solutions to address immunization rates

and reduce the incidence or risk of VPDs. The Hamilton County Health Department offers

immunizations at a central location for county residents with Medicare, Medicaid, or no

insurance (Hamilton County Public Health Department, 2015). However, this clinic is open only

one day per week during the day and by appointment only, making it inaccessible for many

working parents (Hamilton County Public Health Department, 2015). The City of Cincinnati

Health Department operates five primary care centers that provide a range of medical services to

uninsured and underinsured residents (City of Cincinnati Health Department, 2015). While the

services include immunizations through the CDC’s Vaccines for Children (VFC) program, most

are open only 40 hours/week and transportation issues add to the challenges for those living in

poverty (City of Cincinnati Health Department, 2015). In response to cutting the school nurse

program, grants were awarded and 18 of the 55 Cincinnati Public Schools have established

school-based health centers (SBHCs) (Interact for Health, 2014). These centers are primarily

focused on the needs of school-age children suffering from chronic health conditions in an effort

to reduce absenteeism, but are now expanding to cover dental care, vision care and

immunizations (Interact for Health, 2014). However, young children remain without access to

these services and, with only 30% of the schools having an SBHC, not all school age children are

covered.


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CityLink’s mission is to provide on-site services, customized to create a seamless path

out of poverty for each client. Increasing health prevention services to include immunization will

ensure that children living in poverty are adequately protected against VPDs and further reduce

potential barriers for parent employment and education. CityLink Center is centrally located in

the heart of the ten poorest Cincinnati neighborhoods where the need is greatest. The facility is

easily accessible on the bus route and physically large enough to accommodate an immunization

clinic. The Health & Wellness Center is already established and provides a range of education

and direct-delivered health education and prevention services (CityLink, 2013). Identification of

immunization needs is a natural extension that can be easily integrated into the client action

plans. In the first year of operation, CityLink reported operating expenses of $1.322M and has a

professional staff of fourteen, augmented by a well-trained and passionate volunteer force. While

CityLink does not have medical staff or an existing partner agency to deliver immunizations, the

model was designed to expand, as it has recently done so to deliver dental and vision services on-

site (CityLink, 2013). Offering vaccinations is a natural extension of our programs and can be

met through contracted public health clinicians.

1.8 Proposed Solutions to Meet the Needs

As previously noted, health literacy and knowledge of vaccine schedules, as well as

access, is lacking in impoverished and underserved communities (Klevens & Luman, 2001). The

most important and changeable factors that this new program will address are outlined in chart 3,

with a focus on those factors which are either more important, more easily changeable or both.

The holistic approach will focus on improving awareness, knowledge and beliefs to change

perceptions about the importance of immunizations. In turn, this will motivate parents to take


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action. When combined with improving access to and provider relationships, immunization

compliance levels are expected to improve, reducing the incidence of VPDs.

The CityLink program will involve Service Coordinators discussing vaccination benefits,

as well as assessing the immunization status of the client’s children. This personalized

interaction has proven instrumental in developing trust in vaccinations by tailoring the message

in a structured approach and addressing parental concerns through a respectful interaction (Leask

et al, 2012). Since transportation and scheduling remain major barriers to adequate immunization

with existing health services, CityLink intends to expand the current health and wellness center

programs to provide an on-site public health nurse with full immunization capacity for clients’

children. The expanded center will provide immunization services during times when clients are

already onsite at CityLink, further minimizing the likelihood of competing priorities. This

program will also include the capability to assess and track vaccine compliance for clients’

children, ensuring the scheduling of appointments to adhere to the complex vaccine schedules.

Chart 3: Changeability/Importance MatrixMore Important Less Important

MoreImmediatelyChangeable

● Knowledge/Perceptions of vaccine safety, side effects, efficacy & benefits

● Lack of a relationship with a provider who communicates about immunization needs and safety

● Health literacy or having limited capability to track and/or maintain complex vaccine schedules

LessImmediatelyChangeable

● Accessibility to provider services (hours, cost, transportation)

● Availability/Supply of vaccines in the region


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Part II: Design of Intervention

2.1 Purpose, Goals & Specific Objectives

The purpose, or health objective, of the CityLink Immunization Program is to reduce the

incidence of vaccine-preventable diseases (VPDs) among children under the age of 18 from

participating families by 15%, within 24 months of program implementation, using the state of

Ohio’s rate of 39.9 per 100,000 as the baseline (Ohio Department of Health, 2014). Within 12

months of implementation, the first intermediate outcome is to achieve compliance with the

Center for Disease Control and Prevention (CDC) recommended age-specific immunization

schedules for 70% of the children under 18 years of age participating in the CityLink

Immunization Program. A second intermediate outcome is to have 90% of participating families

maintain 100% of their scheduled immunization appointment(s).

The program will be “rolling” in nature, allowing new CityLink clients to enroll at any

time, concurrent with the start of receiving services from the center. There are three immediate

outcomes after six months of participation. First, parents will understand the CDC recommended

immunization schedule for their child’s age group and perceive the benefits to be worth the

effort. Secondly, parents will understand the safety and benefits of CDC recommended

immunizations for their child’s age group and perceive the risks and potential side effects of the

immunizations to be acceptable in comparison to the disease. Third, parents will understand the

transmission routes, symptoms, and health effects of vaccine preventable diseases and perceive

their children to be susceptible.

The detailed inputs, activities and outputs are thoroughly described in the Logic Model in

section 2.4 and Attachment 2.


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2.2 Theoretical Basis for Intervention

Many preventive health interventions and research utilize the HBM. A study of the HBM

constructs in relation to college-aged males and their uptake of the Human Papilloma Virus

(HPV) vaccine showed significant lack of perceived susceptibility, severity, and self-efficacy

(Mehta, Sharma, & Lee, 2012). Focus groups discussed barriers and addressed cues to action in

male uptake of the vaccine to prevent HPV infection in themselves, as well as passing it to

partners (Mehta, Sharma, & Lee, 2012).

Further applications of the HBM in immunizations programs include a program targeting

preschool staff members to receive a pertussis vaccination (Dardis, Koharchik, & Dukes, 2015).

Following an educational campaign based on the HBM constructs in conjunction with two

immunization clinics, 80% of staff members received pertussis boosters (Dardis, Koharchik, &

Dukes, 2015). An additional study found that application of the cues to action construct was

more effective at improving vaccination rates in children than focusing solely on increasing

perceived susceptibility and severity (Hilyard et al, 2014).

The HBM model was originally developed by psychologists Irwin M. Rosenstock,

Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal in the early 1950’s as a way

to provide a systematic, theory-based approach for public health researchers to understand

behaviors associated with people failing to adopt preventative health measures and target future

programs to generate more positive outcomes (Carpenter, 2010). The basic constructs of this

model are that if individuals perceive themselves to be susceptible to a negative health condition,

perceive that health condition to be severe, perceive the benefits of the behaviors to reduce the

likelihood or severity of that condition to be high, and perceive the barriers to adopting the

behavior low, then they are more likely to perform the behavior. In addition to the constructs


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associated with perception, HBM also includes “cues to action”, which serve as an internal or

external prompt for an individual to perform the behavior and self-efficacy was added to the

model in 1988 (Carpenter, 2010). HBM is well established and has been applied to all types of

health behavior, including preventive programs.

The CityLink Immunization Program will apply the HBM. Through education, parents

will improve their perceptions of VPD susceptibility and severity, along with increasing positive

perceptions of vaccine benefits and the reduction of perceived barriers. This education will

contain reliable information, which parents are not often exposed to through non-medical sources

such as friends, celebrities and the media. Cues to action will be accomplished through

counseling from the CityLink Service Coordinators, through repeated appointment reminders,

and via visual posters onsite. The program will eventually lead to self-efficacy for parents to

reach and maintain compliance with the CDC recommended schedules based upon the easily

accessible center offering convenient and flexible appointments, immunization record tracking,

and a text messaging reminder system.

2.3 Theory of Action

The CityLink Immunization Program has three proposed components: 1) education and

counseling to increase awareness of severity, susceptibility and perceived risks of VPDs and the

benefits of vaccinations in reducing VPDs, 2) on-site vaccination clinics to improve access, and

3) immunization tracking and reminders to improve self-efficacy. The expanded Theory of

Action statements related to each component are outlined below. All three components focus on

increasing immunization rates, under the indication that if parents immunize their children, then

VPDs will be lowered.

Component 1: Education and Counseling. If parents receive education regarding the

transmission routes and severity of VPD’s, then the parents will have a better understanding of


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the risks and susceptibility for their child contracting a VPD. If parents perceive the risk of their

child’s susceptibility to VPDs to be high, then they will be more likely to immunize their

children. If parents receive education about vaccine efficacy, then they will have a better

understanding of the benefits of immunizations. If parents perceive that vaccines will reduce the

incidence of VPDs in their child, then they will be more likely to immunize their children.

Component 2: On-site immunization clinics. If parents have free and easy access to

CityLink’s immunization clinics, then several of the common physical and financial barriers to

immunization schedule adherence will be lessened. If parents perceive the barriers to vaccinating

their children are alleviated, then parents will be more likely to immunize their children.

Component 3: Immunization record keeping and reminders. If children’s immunization

status is assessed and tracked by CityLink Center, then parents will be better prepared and

capable of maintaining their child’s immunization schedule. If parents are better prepared and

capable of maintaining their child’s immunization schedule, then parents will have greater self-

efficacy in their ability to take action. If parents have greater self-efficacy in their ability to take

action, then they will be more likely to attend immunization appointments. If parents are given

multiple reminders as cues to action for immunization appointments, then they will be more

likely to attend their child’s next immunization appointment. If parents attend their next

immunization appointment, then their child will be more likely to be up-to-date on the

recommended CDC vaccination schedule.

2.4 Intervention Description & Logic Model

a. Intervention Literature Summary

Briss et al (2000) conducted a systematic review of population-based interventions

intended to improve vaccination coverage, focusing on three categories of interventions: 1)

increasing demand; 2) enhancing access; and 3) provider-based interventions. The first category


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included interventions with client reminder/recall, multicomponent interventions with education,

vaccination requirements for school attendance, community-wide education only interventions,

incentive-based interventions, and client-held medical records (Briss et al, 2000). The

researchers concluded that there was sufficient evidence of effectiveness only for interventions

that included client reminder/recall and multicomponent interventions with education, as well as

policies that require vaccinations for school attendance (Briss et al, 2000).

The second category of interventions seeks to enhance access by reducing costs and/or

increasing the convenience of obtaining vaccinations through existing health care settings or

non-medical settings (Briss et al, 2000). After evaluating 19 studies, the researchers found strong

evidence to conclude that reducing out-of-pocket costs improves vaccination coverage (Briss et

al, 2000). Interventions seeking to expand access explored establishing vaccination programs as

part of Women, Infants, and Children (WIC) settings, providing home visits, and on-site school

and day care center vaccination programs (Briss et al, 2000). However, they noted that providing

home visits is resource-intensive and vaccination programs in schools and day care centers

lacked sufficient evidence to assess effectiveness (Briss et al, 2000). The research team

concluded, “as part of multicomponent interventions, expanding access improves vaccination

coverage among children…in a range of contexts” (Briss et al, 2000).

The final category evaluated by Briss et al (2000) included provider recall/reminders,

provider assessment of vaccination status, standing orders to deliver vaccines without direct

physician involvement, and provider education-only interventions. While there is strong

evidence to support the role of providers in improving vaccination coverage, the lack of easy and

consistent access to a convenient provider remains a barrier for those living in poverty (Lannon

et al, 1995).


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The intervention literature suggests that the HBM will be effective to increase

compliance with immunization recommendations. One recently published study using data from

2009 demonstrated the importance of the HBM in promoting immunizations using the 2009

National Immunization Survey (NIS) data to examine parent’s beliefs and to identify barriers

that might lead to immunization delay or refusal (Smith et al, 2011). Four psychosocial domains

reflective of the HBM constructs were utilized (i.e., susceptibility, seriousness, efficacy and

safety, social pressures and convenience). The investigators generally found that parents’

perceived susceptibility and severity, as well as the perceived benefits of vaccinations, were

significantly associated with vaccine coverage within the group delaying or refusing vaccines by

24 months (Smith et al, 2011). Parents who delayed or refused childhood immunizations had

more vaccine safety concerns, held more negative beliefs towards the protection offered by

immunizations, and had lower vaccination coverage for 9 of the 10 recommended vaccines. In

contrast, those who neither delayed nor refused held more positive beliefs towards

immunizations and had significantly higher immunization rates (Smith et al, 2011).

b. Intervention & Logic Model Description

The proposed CityLink Immunization Program is a multicomponent intervention that

brings together personalized parent education and easily accessible vaccines with record keeping

and reminders for the CityLink clients. The TaskForce on Community Preventive Services

evaluated interventions and concluded that multicomponent interventions involving education

are effective at improving vaccination coverage by making the community aware, not only of

vaccination services, but also of their relevance and importance, as well as the information

necessary to utilize them (Briss et al, 2000). Furthermore, collaboration between local resources

and an existing community-based organization effectively increases immunization coverage rates


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in low-income, resource-poor children, consistent with our target population served by CityLink

(Suryadevara, Bonville, Ferraioli, & Domachowske, 2013).

The program logic model is shown in Attachment 2 and further described in this section.

Inputs: The inputs for the CityLink Immunization Program consist of funding, staff,

vaccine-related supplies, materials for education, and an IT-system capable of record tracking

and reminders. Funding of $61,100 is required for this one-year program, primarily to cover the

required human resources consisting of a public health nurse, an immunization specialist,

CityLink Service Coordinators, a program director, and a program evaluator. Immunization

schedules, information about vaccines and VPDs, and various forms from the CDC will serve as

reference materials. The existing CityLink Wellness Center will be used for this program and

equipped with an immunization storage unit and appropriate vaccination and emergency medical

supplies. The existing IT system will be augmented with an immunization records tracker and

appointment reminder module.

Activities: The program will consist of three components, each with associated activities.

The first component is education and counseling. The immunization specialist will deliver

education on immunizations and VPDs in a seminar format and prepare the Service Coordinators

to conduct client counseling. The immunization specialist will also create marketing materials in

the form of posters, parent brochures and informational packets, which will be distributed to

CityLink clients by the Service Coordinators. In one-on-one sessions, the Service Coordinators

will conduct immunization counseling with their clients, focusing on the needs of the children

under the age of 18. CityLink forecasts the capacity of the Service Coordinators to handle up to

200 clients each to address all their service needs, including immunizations for their children.


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The second component is on-site immunization clinics. The administrative assistant will

purchase a vaccination storage unit as well as the necessary medical supplies and vaccines for

the monthly clinics. The administrative assistant will also collect and print all of the necessary

immunization forms and waivers required for vaccinations. During the monthly clinics, the

service coordinators will check-in clients while the public health nurse administers the

immunizations to the children.

The third component is record keeping and reminders. The IT consultant will configure

the records tracking and reminder module. Service Coordinators will capture and record the

immunization status of participating children. The administrative assistant will set up

appointments for the immunizations at the monthly clinics and trigger appointment reminders

(two per appointment) to remind the parents of the upcoming clinic.

Outputs: In preparation for the intervention, one staff seminar will be conducted and three

CityLink Service Coordinators educated on immunizations, VPDs, and parental counseling

techniques. To market the program, 25 posters will hang at CityLink Center and CityLink

Service Coordinators will distribute 300 information packets to clients as they counsel them on

childhood immunizations. With an average of 1.5 children per parent, the program will obtain

and store immunization status records on 450 children. There will be 450 immunization

appointments made throughout the program and, with two reminders per appointment, 900

immunization reminders will be sent to parents of participating children. With the help of the

administrative assistant checking in the children and completing initial paperwork, the public

health nurse will be able to administer 20 immunizations per hour during the two-and-a-half hour

clinic for a total of 50 immunizations per clinic. The program output goal is to administer a total

450 immunizations to children at nine monthly clinics.


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Immediate Outcomes: The program will be “rolling” in nature, allowing new CityLink

clients to enroll at any time, with three immediate outcomes after 6 months of participation. First,

they will understand the CDC recommended immunization schedule for their child’s age group

and perceive the benefits to be worth the effort. Secondly, they will understand the safety and

benefits of CDC recommended immunizations for their child’s age group and perceive the risks

and side effects of immunization to be acceptable in comparison to the disease. Third, they will

understand the transmission routes, symptoms, and health effects of vaccine preventable diseases

and perceive their children to be susceptible to these diseases.

Intermediate Outcomes: After 12 months of program implementation, 70% of the

participating children will be compliant with the CDC recommended age-specific immunization

guidelines and 90% of participating families will maintain 100% of their scheduled

immunization appointments.

Long-range (Health) Outcomes: Within 24 months of program implementation,

CityLink’s Immunization Program will reduce the incidence of VPDs among children in

participating families by 15 percent, using the state of Ohio’s rate of 39.9 per 100,000 as the

baseline.


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Part III: Implementation

3.1 Intervention Implementation

In preparation for delivery of the program, CityLink Service Coordinators will be

educated on immunizations through reading materials and instruction booklets from the CDC. A

seminar, delivered by an immunization specialist, will include role-playing activities so that

counselors can learn to respond appropriately to potential concerns or objections raised by

clients. Utilizing material from the CDC’s Vaccines For Children program, targeted marketing

materials will be developed in the form of a parent brochure and posters to advertise the onsite

immunization clinics. A vaccine storage unit will be purchased and the Health & Wellness

Center will be stocked with appropriate supplies (e.g. alcohol wipes, syringes, needles, Band-

Aids). All necessary clinic documentation including waivers, protocols, Vaccine Adverse Events

Reporting (VAERS) forms, will be assembled in advance of implementation. CityLink will

purchase vaccines from the Hamilton County Health Department and will contract with a public

health nurse for immunization delivery.

The first component of the intervention program, education and counseling, will focus on

educating parents about vaccine-preventable diseases, the benefits of vaccines, and the CDC-

recommended immunization schedule. While community-wide education alone has not been

proven to improve immunization rates, there has been success with using a comprehensive and

personalized case-management approach (Wood et al, 1998). The CityLink Immunization

Program will expand the existing client-based needs assessment and goal setting to include their

children’s immunization needs by improving awareness and providing counseling to understand

and address the family’s concerns and perceived barriers to vaccination. It is well known that the

CDC schedule for childhood immunizations is becoming increasingly long and complex and if a


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child falls behind, the catch-up schedule may appear insurmountable. With their CityLink

Service Coordinator’s help, clients can more effectively navigate this complexity and create an

individualized plan to bring their child(ren) up to date. Clients will be given a take-home

brochure using content available from CDC’s Vaccines For Children program. During regularly

scheduled visits to CityLink Center, clients will have an ongoing opportunity to review their

child(ren)’s immunization schedule and address additional concerns, further dispelling myths

about vaccines and VPDs, and reducing perceived barriers.

The second component of the CityLink Immunization Program is a monthly, on-premise

immunization clinic, staffed by a clinician from either the public health department or a privately

employed practitioner. As part of a multicomponent intervention, expanding access has proven

successful in improving vaccination coverage, including nonmedical settings encouraging target

populations in their congregation places (Briss et al, 2000). Consistent with CityLink’s vision to

integrate services under one roof, it is a natural expansion of the existing Health and Wellness

Center to provide immunization services. The on-site delivery of vaccines removes two well-

established barriers to vaccinations: lack of health insurance and accessibility. CityLink clients

come to the center at least twice per week for services such as GED preparation and job training

and free childcare is provided. With appointments scheduled ahead of time, CityLink can order

vaccination supplies in advance from the Cincinnati Health Department and contract for public

health nurses to efficiently deliver services and keep costs low.

Scattered immunization records, which are more pervasive for children living in poverty,

have been noted as a barrier to achieving immunization compliance (Rodewald & Santoli, 2001).

Interventions conducted within the Women, Infants, and Children (WIC) clinics have

successfully and cost-effectively improved immunization rates by screening young children for


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vaccination status and referring eligible children for vaccination either onsite or to their provider

(Hutchins et al, 1999). This program seeks to apply a similar approach for the third component,

immunization record keeping and reminders, by capturing the CityLink client’s children’s

immunization records in a database onsite (with permission from the parent) as part of the

already established information gathering and individualized goal-setting process. With

CityLink’s central location, the records will be easily accessible to parents whether they are

actively seeking services. In a recently conducted randomized controlled trial designed to

evaluate the use of text messaging reminders for immunization, researchers found that cell

phones were widely used among low-income groups, parents were willing to provide their cell

phone number for this purpose, and immunization compliance improved (Ahlers-Schmidt et al,

2010). CityLink will use a module of their IT system or commercially available cloud-based

software (e.g. Salesforce.com) to maintain immunization records, notify parents of upcoming

immunization needs and provide reminders for appointments.

3.2 Staffing Plan

The in-house staff for the CityLink Immunization program will consist of the Program

Director, three Service Coordinators, an Administrative Assistant and a Program Evaluator.

Consulting staff consists of an IT consultant, a public health nurse and an immunization

specialist. Chart 4 provides the detailed description of roles and responsibilities, reporting lines,

and credentials.

Chart 4: Staffing Plan for CityLink Immunization ProgramRole/Title Responsibilities Background/Education

Program Director

Provide general operations and oversight for program Supervise the activities of the Service Coordinators and

Administrative Assistant Hire and provide direction to the consultants and sign off

on contracted deliverables

Bachelor’s degree in marketing, communications or public health with 5+ years relevant


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Track and report against program budget Reports to CityLink Board of Directors

experience in nonprofit management

Service Coordinator (3)

Educate CityLink clients about vaccine preventable diseases (VPDs), immunizations, and the CDC immunization schedule.

Work individually with clients to assess and document the immunization status of the clients’ children and develop a plan to bring them in compliance with the age-appropriate immunization schedule

Track status of action against plans for each client Administer data collection tool Reports to the Program Director for matters related to

this program

Licensed MSW social worker with 2+ years of experience

Administrative Assistant

Order and maintain supplies for clinic, including vaccines and vaccine storage unit

Make copies of relevant documents for immunization clinic

Enter and maintain immunization records for clients Set appointments and reminders for immunization clinic Reports to the Program Director for matters related to

this program

High School Diploma or GED and 5+ years experience in administrative work, preferably in a non-profit agency

Program Evaluator

Analyze data and evaluate program based on evaluation design

Produce quarterly and final report on program effectiveness

Reports to CityLink Board of Directors

MBA in non-profit administration with 5+ years of relevant experience

IT Consultant Configure IT software to meet program needs to track immunization status

Ensure reporting capabilities from ETO are consistent with program evaluation plan

Reports to the Program Director for matters related to this program

IT professional with 2+ years of experience working with CityLink’s IT software. Previous experience with CityLink preferred.

Public Health Nurse

Ensure clinic is appropriately set up and supplies adequate

Create list of needed vaccines based on appointment schedule and client needs

Administer vaccines during monthly clinic, including necessary documentation

Reports to the Program Director for matters related to this program

RN (LPN or BSN) with 2+ years public health experience

Immunization Specialist

Develop customized educational and marketing materials for CityLink Clients

Educate Service Coordinators on vaccine preventable diseases, immunizations and parental counseling

MPH with epidemiological specialty and 5+ years of experience related to


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techniques Advise on program design and evaluation instruments Reports to the Program Director for matters related to

this program

vaccine preventable diseases and community interventions

3.3 Timeline

CityLink’s Immunization Program, per Attachment 3, will begin in January of 2016 and

continue through December of 2016. The program will begin by establishing management and

hiring consultants. In February, an immunization specialist will educate Service Coordinators

and program materials, facilities and systems will begin to be developed. Service Coordinators

will recruit participants after the program materials and systems are finished in March. This

recruitment phase will continue through the end of the pilot program in December, as it is

important to be available to provide immunizations to children throughout the length of the

program, and not be limited to those who signed up during a designated period. Beginning in

April, parent education sessions with Service Coordinators will begin, followed by the

establishment of vaccination appointments and physical administration of immunizations. Much

like the recruitment and enrollment of participants, education sessions, appointments and

immunization administration will continue throughout December. On a quarterly basis (March,

June, September and December), data will be collected and analyzed and a report developed to

monitor the progress of CityLink’s Immunization Program.

3.4 Work Plan

As presented in Attachment 4, CityLink’s Immunization Program is broken into three

components: parent education and counseling, on-site immunization clinics, and immunization

record keeping and reminders. All of these components work towards the overall goal of

reducing the incidence of vaccine-preventable infectious diseases among children within

participating families in the city of Cincinnati decrease by 15% from the state’s baseline rate of


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39.9 per 100,000 population within 24 months of program implementation. The program

evaluator, CityLink’s Executive Director, will evaluate all aspects of the program.

Parent education and counseling will fulfill the objective of educating parents on the

CDC recommended immunization schedule, the safety, side effects, risks and benefits of

immunizations and the transmission routes, symptoms and health effects of vaccine preventable

diseases by month six of program implementation. By February, an immunization specialist will

educate Service Coordinators about immunizations and counseling techniques for parents. The

immunization specialist will also develop the training materials used by Service Coordinators by

March. Beginning in April, Service Coordinators will distribute these resources to educate

parents with the information necessary to meet the stated objectives.

The on-site immunization clinic will seek to accomplish, within 12 months of program

implementation, 70% of participating child compliance with the CDC recommended age specific

immunization guidelines and 90% of participating families maintaining their vaccination

appointments. By March, the public health nurse will have developed a list of necessary

materials, which the administrative assistant will order, including the immunizations and the

storage container. The administrative assistant will also develop the necessary paperwork by the

end of March and will be instrumental in scheduling immunization appointments through

December. The Service Coordinators will counsel parents, while a public health nurse will

administer the vaccinations.

The immunization record keeping and reminder systems will assist in accomplishing the

same objectives as the immunization clinic itself. The Information Technologist consultant will

have the reminder, record and evaluation system developed by March. After development, the

administrative assistant will be responsible to use the systems throughout the end of the year,


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receiving and maintaining client immunization records, while sending appointment reminders at

the appropriate times.

3.5. Budget & Budget Justification

The budget for the one year CityLink Immunization Program is $61,100. The grant

request includes $35,000 for CityLink staff and $9,600 for consultants to provide the necessary

leadership, administration and subject matter expertise for successful program delivery. A total

of $2,145 is requested to cover office supplies and local travel. Program-specific costs of $7,900

have been identified to cover a vaccine storage unit, vaccines and related clinic supplies and

printing costs for brochures and posters. CityLink has a 13% fundraising and administrative

overhead rate. The detailed budget and budget justification can be found in the appendix -

attachment 5.

3.6 Evaluation Plan

Purpose & Type of Evaluation and Evaluation Design

The purpose of the proposed evaluation is to assess the knowledge, beliefs, and attitudes

of program participants following participation with the CityLink Center Immunization program.

This evaluation will follow a summative evaluation design in order to statistically analyze the

effects of the program’s one-on-one counseling and supplemental education materials on the

behaviors of the participants. The evaluation ultimately intends to measure the percent of

participants who successfully receive immunizations compared to how many received

immunization education in their one-on-one counseling sessions. This can be extrapolated to the

larger scale general population served as the program continues.

CityLink Center utilizes on-site employees to conduct program evaluations. The

evaluation will be conducted as a pre-experimental design and include the components of a


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pretest and posttest for participants. This design will allow for the comparison of the

participating groups before and after education and immunization. The immunization records

will be kept on site abiding with HIPPA and will permit for the linking between individual

records and surveys to better understand the success of the advocacy program and intervention

once an appropriate sample size of a minimum of thirty participants has been collected.

Pretest questionnaires will be provided to participants prior to receiving immunization

education (once records are obtained for the participant’s children) and will consist of 20 basic

multiple-choice questions. These questions will focus on knowledge, beliefs, and attitudes

towards immunizations and common VPD’s. The posttest will be offered to participants six-

months following the receipt of VPD and immunization counseling and educational materials to

measure long-term knowledge, beliefs, and attitudes towards immunizations.

Evaluation Questions

Included below are samples of the expected evaluation questions:

Did the incidence of VPD’s reduce by 15% from the state baseline of 39.9/100,000

within 24 months of the program start date?

Were the three Service Coordinators successfully trained prior to the program start date?

Did at least 90% of participating families maintain their scheduled immunization

appointments?

Did at least 300 parents receive immunization counseling for their children?

Were at least 300 informational packets were distributed to participating parents?

Were at least 900 appointment reminders conducted?

Were the immunization records for at least 450 children collected from participants?

Were at least nine immunization clinics conducted?


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Were at least 450 immunizations administered to participating children?

Did participating parents report improved understanding of VPD’s and immunizations?

The Sample & Sampling Plan

Sampling for the evaluation will occur internally through CityLink Center’s individual

meetings with participating families. All families who receive immunization counseling will be

eligible to be included in the sample regardless of the decision to immunize on site. The expected

sample size is to be at least 200 participants with a reach goal of 300 participants from the pool

of families receiving immunization counseling. There will not be a comparison or control group,

as the sample will be compared to itself utilizing pre and posttest models in a pre-experimental

format.

Measurement InstrumentsConstruct/Outcome Measure(s) Description Authors

Perceived Severity, Perceived Risk

National Health Service MMR Decision Scale

A 27-item survey assessing perceived risk, severity, and attitudes towards the MMR vaccine, clinician relationship, and the diseases covered. Utilizes a Likert scale to rate opinions. Includes demographic data.

Brown et al, 2011.

Perceived Barriers Searching for Hardship and Obstacles to Shots (SHOTS) scale

An instrument using a Likert scale with 23 items measuring parental barriers to immunizations. Written at a 4th grade reading level for parents of children ages birth-8 years.

Niederhauser, V. (2009).

Cues to Action Brighton and Hove area MMR Uptake Prediction Questionnaire

A questionnaire developed specifically to measure prospectively parental attitudes towards pediatric vaccinations with a matched patient immunization records. Indicated which attitudes and provider actions lead to cues to action for parents. Measured on a 5-point Likert scale.

Flynn, M. & Ogden, J. (2004).

Data Collection Procedures


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CityLink Center’s program director will work closely with the program evaluator and

funder during the implementation of the immunization pilot program. An implementation plan

created in collaboration between CityLink and the funder will guide the center through the

initiation of immunization services on site. Data from participants will be collected in the pretest

and posttest phase of the immunization education program, on the initial visit for the family and

again two to six months later at the next immunization appointment depending on the child’s

age. If a child has reached an up-to-date status and will not receive an immunization in the next

six months, the parent will receive their posttest at least two and no more than six months

following the most recent immunization appointment at the next meeting with their CityLink

counselor. The posttest will then be collected and inputted into the statistical analysis tool.

Data Analysis Plan

In the analysis phase, univariable statistical analysis will be conducted on each item in

the survey using CityLink’s statistical analysis software on site. Univariable analysis will ensure

proper understanding of each line item as opposed to connecting findings. The pretest and

posttest will have matched questions, leading to the utilization of the matched-pair t-test that will

provide an analysis of whether the participant’s attitudes or beliefs have changed regarding the

question since receiving immunization and VPD education.

Dissemination Plan

Findings from the CityLink Center evaluation will be shared internally with appropriate

CityLink staff only and confidentially with the funder for measure of success purposes. These

findings will be reported at the end of the pilot program, 12 months after program

implementation. Findings will not be disseminated at conferences or via publications at this time.


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Stockwell, M., Westhoff, C., Kharbanda, E., Vargas, C., Camargo, S., Vawdrey, D., & Castaño, P. (2014). Influenza vaccine text message reminders for urban, low-income pregnant women: a randomized controlled trial. American Journal of Public Health, 104(1), e7-e12.

Suryadevara, M., Bonville, C., Ferraioli, F., & Domachowske, J. (2013). Community centered education improves vaccination rates in children from low-income households. Pediatrics, 132(2), 319-325.

Turner, M., Edelman, P., Poethig, E., Laudan, A., Rogers, M., & Lowenstein, C. (2014). Tackling persistent poverty in distressed urban neighborhoods: history, principles, and strategies for philanthropic investment. Urban Institute. Retrieved Jan 31, 2015 fromhttp://www.urban.org/UploadedPDF/413179-Tackling-Persistent-Poverty-in-Distressed-Urban-Neighborhoods.pdf U.S. Census Bureau (2014). State and County Quick Facts: Cincinnati, Ohio. Retrieved March 9, 2015 from http://quickfacts.census.gov/qfd/states/39/3915000.html

Wood, D., Halfon, N., Donald-Sherbourne, C., Mazel, R. M., Schuster, M., Hamlin, J. S., & Duan, N. (1998). Increasing immunization rates among inner-city, African American children. A randomized trial of case management. Jama, 279(1), 29-34.

World Health Organization. (2013) Global vaccine action plan. Retrieved March 9, 2015 from http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_19-en.pdf?ua=1


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Part V: AppendicesAttachment 1: CDC Recommended Childhood Immunization Schedule


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Attachment 2: Program Logic Model

Inputs Activities Outputs Immediate Outcomes

Intermediate Outcomes

Long Range Outcomes

· Funding of $61,100· Public Health Nurse· Immunization Specialist· CityLink Service Coordinators· Program director and evaluator· CDC immunization schedules & information materials· CityLink Wellness Center·Immunization storage system· Immunization and vaccination supplies· Records tracking module·Appointment reminder module

The program will consist of 3 components, each with associated activities:1) Education & Counseling:· Educate CityLink staff members on immunizations and VPDs· Conduct training seminars for Service Coordinators· Create marketing materials for CityLink Center (posters/ brochures/info packets)· Create and distribute informational packets· Service Coordinators conduct 1-1 immunization counseling with CityLink clients2) On-site Immunization Clinics· Purchase and maintain vaccine storage unit, supplies & vaccines· Collect and print all necessary immunization forms and waivers· Administer immunizations at clinics3) Record Keeping & Reminders· Configure records tracking/reminder module· Capture and record immunization status of participating children· Set up appointments for immunizations· Trigger appointment reminders

· 1 CityLink staff seminarConducted· 3 CityLink Service Coordinators educated· 25 VPD posters hung at CityLink· 300 informational packets distributed· 300 parents receive immunization counseling· 450 child immunization status records obtained & stored· 450 immunization appointments made· 900 immunization appointment reminders sent to parents of participating children· 9 immunization clinics held (1/month)· 450 immunizations administered to children

· Within 6 months, participating parents understand the CDC recommended immunization schedule for their child’s age group and perceive the benefits to be worth the effort.

· Within 6 months, participating parents understand the safety & and benefits of CDC recommended immunizations for their child’s age group and perceive the risks and side effects of immunization to be acceptable.

· Within 6 months, participating parents understand the transmission routes, symptoms, and health effects of vaccine preventable diseases and perceive their children to be susceptible.

· Within 12 months following implementation of the Program, 70% of the participating children of the program are compliant with the CDC recommended age specific immunization guidelines.

· Within 12 months following implementation of the program, 90% of the participating families have maintained 100% of their scheduled immunization appointment(s)

· Within 24 months of program implementation, CityLink’s Immunization Program will reduce the incidence of VPDs among children in participating families by 15 percent, using the state of Ohio’s rate of 39.9 per 100,000 as the baseline..


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Attachment 3: CityLink Immunization Program Timeline

Tasks/Activities Jan Feb

Mar Apr May

Jun Jul

Aug Sep Oct Nov Dec

Form Management Oversight Group

X

Hire Consultants X

Educate Service Coordinators

X

Develop program materials, facilities and systems

X X

Recruit & Enroll participants

X

Educate Parents X

Counsel Parents on Immunizations

X

Make Vaccination Appointments

X

Administer Vaccinations at Monthly Clinics

X X X X X X X X X

Conduct Pretest Survey X

Conduct Posttest & Follow-up Surveys

X X X

Data Analysis X X X X

Quarterly & Final Report X X X X


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Attachment 4: CityLink Immunization Program Work Plan

Component 1: Parent Education & Counseling

Goal: 24 months after successful implementation of the CityLink Immunization Program, the incidence of vaccine-preventable infectious diseases among children within participating families in the city of Cincinnati will have decreased by 15% from state’s baseline rate of 39.9 per 100,000.

Objective: Within month six of program implementation, parents will understand the CDC recommended immunization schedule, the safety, side effects, risks and benefits of immunizations and the transmission routes, symptoms and health effects of vaccine preventable diseases by month six of program implementation.

Supporting Activities/Tasks Responsibility Deadline/Completed by

Evaluated by

Educate Service Coordinators and train on parental counseling techniques

Immunization Specialist

February Program Director

Preparation of educational materials Immunization Specialist

March Program Director

Distribute of educational materials (fliers, books, activities, etc.)

Service Coordinators

December Program Director

Teach parents the vaccination schedule recommended by the Center for Disease Control and Prevention (CDC)



Teach parents the safety, side effects, risks and benefits of vaccines



Teach parents the transmission routes, symptoms and health effects of vaccine preventable diseases



Component 2: On-site immunization clinic


Objective: After 12 months of program implementation, 70% of the participating children compliant with the CDC recommended age specific immunization guidelines and 90% of participating families maintaining their vaccination appointments.


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Evaluated by

List of necessary materials Public Health Nurse March Program Director

Purchase of immunizations and immunization storage



Development of proper paperwork Administrative Assistant


Recruit and enroll participants Administrative Assistant


Parents go through vaccine counseling Service Coordinators December Program Director

Administration of vaccinations Public Health Nurse December Program Director

Component 3: Immunization Record Keeping and Reminders


Objective: After 12 months of program implementation, the intermediate outcomes are 70% of the participating children compliant with the CDC recommended age specific immunization guidelines and 90% of participating families maintaining their vaccination appointments.


Evaluated by

Development of reminder, record and evaluation systems

IT Consultant March Program Director

Receive and maintain client immunization records



Send reminder messages prior to vaccine appointment




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Attachment 5: CityLink Immunization Program Budget and Budget Justification

The CityLink Immunization Program Budget is inserted here as an excel file:

Please double click to open file.

CITYLINK IMMUNIZATION PROGRAM

BUDGET NARRATIVE FOR THE PROJECT

Submitted March 16, 2015

Grant Period: January 1, 2016 to December 31, 2016

I. PERSONNEL

NAME & POSITION

Program Director – The Program Director, Marissa Abernathy, will be responsible for the

general operations of the project and will supervise the activities of the Service Coordinators and

the administrative support and provide direction to the consultants. The Program Director will be

responsible for implementation including budget tracking and reporting. The Program Director’s

level of effort will be 25%.

Service Coordinators (3) – The Service Coordinators are licensed social workers and will be

responsible for educating clients about vaccine preventable diseases (VPDs), immunizations, and

the CDC immunization schedule. Service Coordinators will work individually with clients to

assess and document the immunization status of the clients’ children and develop a plan to bring

them in compliance with the age-appropriate immunization schedule. Each Service Coordinator


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works with 150-200 clients and the additional effort required to integrate immunizations will be

5% each.

Administrative Assistant – The Administrative Assistant will be responsible for ordering

supplies, stocking the clinic, and maintaining the immunization appointments and reminders. The

effort will be 5%.

Program Evaluator – The CityLink Director will serve as Program Evaluator with

responsibility for reviewing and approving program design and evaluating outcomes on a

quarterly basis. The effort will be 5%.

Fringe Benefits and Facility & Administration Rates:

Fringe benefits are calculated at a rate of 25% for salaries and the facilities and administration

costs are 13%.

SUBTOTAL PERSONNEL: The subtotal for personnel for one year is $35,000, including

benefits.

II. CONSULTANTS

IT Consultant – A consultant from Social Solutions Global (SSG) will be contracted to

configure the Efforts to Outcomes (ETO) software currently used by CityLink to meet the needs

of the program for tracking immunization records and vaccination appointments. This work will

take a total of 20 hours at the rate of $150 per hour for a total of $3,000.

Public Health Nurse – A public health nurse will be employed to set up the clinic and

administer vaccinations at the monthly on-site immunization clinics. There will be 12 hours for

preparation and set up and 4 hours for each of the 9 monthly immunization clinics at a rate of

$100 per hour for a total of $4,800.


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Immunization Specialist – An MPH epidemiologist specializing in immunizations will be

contracted to develop informational brochures for the CityLink clients and provide a 2-hour

training seminar to the Service Coordinators for a total of 12 hours at a rate of $150: $1,800.

SUBTOTAL CONSULTANTS: The subtotal for consultants is $9,600.

III. SUPPLIES

Office Supplies – The requested budget for supplies is $300 to include copier paper, stationery,

markers, and tape throughout the one-year program.

Telephone – The requested telephone budget is $500 to cover the additional requirements for

automated texting reminders for the program. This is estimated to be $50 per month for 10

months for the add-on module to the existing CityLink telephone system.

Copying – A total of $500 is requested for copying of immunization waiver forms and CDC

immunization guidelines. For on-site copying, CityLink uses a rate of $0.50 per page for black

and white copies, allowing 1000 pages to be copied.

Postage/Courier – The requested budget for postage is $500 to cover the costs of shipping

vaccines and other clinic supplies. This rate allows for an initial set up of clinic supplies for $140

and then for each of the nine monthly immunization clinics, there will be an additional $40 each

to stock ongoing supplies.

Local Travel – The requested budget for local travel is $345 to cover the cost of staff traveling

to pick up vaccine supplies from the Hamilton County Health Department. Using the federal

reimbursement rate of $0.575 per mile, this allows for 50 miles per month during the one-year

program.

SUBTOTAL SUPPLIES: The subtotal for supplies is $2,145.


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IV. OTHER COSTS (grant specific)

Vaccine Storage Unit – The requested budget is $5,000 for a small to mid-size commercial

grade refrigerator to store vaccines.

Vaccines – Although some vaccines may be available free of charge from the Hamilton County

Health Department, we are requesting $800 to cover the costs of vaccines not available through

this source.

Clinic Supplies – The requested budget is $800 for the purchase of standard immunization clinic

supplies including alcohol wipes, gloves, bandages, needles, syringes, gauze pads, thermometers,

disposal containers, paper towels, and disinfecting spray.

Brochure Printing – Printing 400 customized immunization brochures to provide to the parents

is budgeted at $2 each for a total of $800.

Poster Printing – Printing 25 posters to market the immunization clinic within CityLink Center

is budgeted at $20 each for a total of $500.

SUBTOTAL OTHER COSTS: The subtotal for other costs is $7,900.

V. SUMMARY OF PROGRAM COSTS

TOTAL DIRECT COSTS (TDC): The total direct costs are $54,645.

MODIFIED DIRECT COSTS (MTDC): The total modified direct costs are $49,645.

Indirect Costs (@13%): The indirect cost recovery rate for CityLink is thirteen percent of

MTDC for a total of $6,454.

TOTAL PROGRAM COSTS: This figure is the total TDC plus Indirect Costs $61,100


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Ethan Taylor PUBH 6500 Assignment 4

Documents

Transcript of Ethan Taylor PUBH 6500 Assignment 4