Model Practices Database View

Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:

• Size of population in your health department’s jurisdiction
• Who is your target population/audience, what is the size of your intended population/audience for this practice and what percent of your target population did you reach?
•Provide the demographics of your target population (i.e. age, gender, race/ethnicity, socio-economic status)
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing.
• Describe the potential public health impact of the practice, and the likely effectiveness of the practice being implemented as intended, and the ease of adoption of the practice by other LHDs.

In your description, also address the following
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?

Snohomish Health District (SHD), the Local Health Jurisdiction of Snohomish County, Washington, provides public health services to the 3rd most populated county in the state. As of the 2010 U.S. Census, 713,335 people lived in Snohomish County. The Vaccine Preventable Disease (VPD) Community Program at SHD created an innovative resource for professionals who provide vaccines. The targets for this resource are the Vaccines for Children (VFC) providers who have the potential to immunize all 159,787 children, ages 18 and under, in the county. The card set was delivered to 75 Snohomish County VFC providers, as well as other vaccine advocates and community stakeholders. Before the widespread use of vaccines, communicable diseases caused untold suffering and death. In the pre-vaccine era, 20% of children did not live to their 5th birthdays. The incidence and mortality of these diseases has been reduced 90-99% through vaccinations. Most of today’s parents have never seen a case of diphtheria or measles. The rarity of these diseases and lack of knowledge about them has resulted in parents who are now more afraid of a vaccine than the disease it prevents. They are “hesitant” to vaccinate their children. They do not perceive the true risk of harm or death to an unimmunized child caused by a vaccine-preventable disease. In 2011, Washington State had the highest vaccine exemption rate in the United States. Six percent of the state’s children were not fully immunized against vaccine-preventable diseases. In July, 2011, the state legislature enacted a law that requires parents to get information about the risks and benefits of vaccination from a licensed healthcare provider before obtaining an exemption for their child. The exemption form must be signed by that healthcare provider. Previously, in Washington State, parents could simply sign a form to receive the exemption. The new exemption law is an opportunity to educate parents about the dangerous diseases that can threaten communities when vaccination rates are too low. Healthcare providers need powerful resources to turn exemption conversations into vaccination opportunities. Our goal is to increase the number of children in Snohomish County who are fully protected by all available vaccines. To support the healthcare providers who vaccinate the county’s children, the VPD Team developed a set of reference cards entitled “The Greater Risk? Disease vs. Vaccine.” This tool is to guide healthcare personnel to accurately portray disease risks vs. vaccine risks. The front of each card discusses a disease and the back details the vaccine, offering an instant, factual comparison. The sixteen pocket-sized disease/vaccine cards and a card with safety considerations for vaccine administration are hole-punched and secured by a ring to allow quick and easy access. Objectives for this resource follow a timeline of steps needed for completion and delivery. The disease/vaccine cards were developed during the fall of 2011. Printing and distribution took place in the winter and spring of 2012. Initial printing of 150 copies, including lamination and collation, cost $950. The card sets were distributed during our “Quick Visit” protocol for VFC providers. They were given to SHD employees, administrators and colleagues who are the “vaccine champions” of Local Health Jurisdictions all over Washington State. Provider offices have requested additional copies and other counties have requested purchase information for the card sets.

Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits.

Future objectives include making the card set available for downloading on our Health District website and using the images and information to create support materials, such as posters and brochures. Overall, the VPD Team plans to distribute these card sets to immunization staff who will become more articulate about vaccine-preventable diseases and communicate more effectively with” hesitant” parents. These parents will understand the risks of the diseases vs. the risks of the vaccines and make better, more informed decisions for their children. Children in Snohomish County will receive recommended vaccines on schedule, reducing the burden of disease on themselves, their families, and their communities. The potential to public health is a reversal in decreasing vaccination rates and higher levels of protection from disease outbreaks. “The Greater Risk? Disease vs. Vaccine” card sets focus on the issues preventing “hesitant” parents from having their children vaccinated, so they will be effective when used to answer parents’ questions about disease risk and vaccine safety. Other LHJs may also distribute the card sets to the vaccinators in their counties to be used as needed to counsel vaccine-hesitant parents.

You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles, etc.

Link to online view of card set
List of Acronyms used in Application

Describe the public health issue that this practice addresses. (350 word limit)

As a local health agency, we hear anecdotally about parents delaying vaccinations or choosing not to vaccinate at all. In 2011, Washington State had the highest exemption rate in the nation at 6%. In the vaccine world one hears of “herd immunity,” the effect of receiving protection from disease because those around you are immunized. At a 6% exemption rate, there might not be societal protection for those who choose not to vaccinate or those who have a true medical reason not to vaccinate. Without a high rate of vaccination, disease outbreaks occur. Infants receive their first dose of DTaP, protection from Diphtheria, Tetanus, and Pertussis, at 2 months of age. Infants too young for the vaccine are left extremely vulnerable to the disease and its complications. In August, 2011, a 27 day old baby girl died from Pertussis in Snohomish County. On April 3, 2012, Washington State Secretary of Health, Mary Selecky, announced that Pertussis reached epidemic levels in the state. As of this writing, over 500 cases of Pertussis have been diagnosed in Snohomish County in 2012. The number of Pertussis diagnoses is expected to rise to 700 by the end of December, 2012.

What process was used to determine the relevancy of the public health issue to the community? (350 word limit)

Snohomish Health District’s Vaccine-Preventable Disease Community Program strives to keep county residents fully vaccinated according to ACIP recommendations. The VPD team identifies trends that prevent and those that support adherence to vaccine standards. Team members study vaccine research and review innovative practices to share with the county’s VFC providers. The inspiration for the creation of “The Greater Risk? Disease vs. Vaccine” card sets came from Washington State’s high rate of vaccine exemptions and low vaccination rates. With the growing access to the internet, we heard anecdotally about the numbers of parents searching for vaccine information and often accessing misinformation. As more hesitancy to vaccines developed due to this information about vaccine safety and the perceived risks, it became evident that providers needed a concise resource to combat this trend. Parents were hearing and reading about risks of the vaccine without consideration regarding the risk of the diseases. Vaccines have been such a success story that the diseases are not commonly seen now and are not considered the greatest threat or risk. Many providers have not seen the vaccine-preventable diseases in years and young parents do not know the devastation they can cause. Permanent disabilities and even death are not considered when weighing the decision to vaccinate. The diseases are no longer commonplace in the United States. The threat parents are left to consider is “how safe is the vaccine?” A disease outbreak was on the rise as the development process began. A Pertussis epidemic was declared in Washington on April 3, 2012. Public Health officials determined that immunity from vaccines waned sooner than previously thought and that family members were likely infecting others, including infants too young for the vaccine. Recommendations for booster vaccines initiated a marked increase in vaccine uptake. The disease cards are vivid reminders of the suffering caused by vaccine-preventable diseases. We hope that the cards, rather than actual disease outbreaks, will convince parents to vaccinate their children on time.

How does the practice address the issue? (350 word limit)

Reduction of disease through vaccination is considered one of the top 10 achievements of Public Health. Most recommended vaccinations are given before age two. The science behind the recommendations is in support of early protection due to the increased risk of infant disease. Infants are at a much higher risk for disease complications than toddlers and older children. The combination of low overall vaccine rates and the onset of a Pertussis outbreak in Snohomish County confirm the need for additional resources to support vaccination efforts. It is believed that one reason parents choose not to vaccinate their children is that they have not seen many of the vaccine preventable diseases and do not acknowledge the risks associated with them. The disease card component of “The Great Risk? Disease vs. Vaccine” addresses this need directly while the other components guide the vaccinator with technical information about administering the vaccine. Vaccine hesitant parent often do vaccinate, though outside of the recommended schedules and time frames. Using a resource tool like “The Greater Risk? Disease vs. Vaccine” card set gives them information in a comparative format so that they may decide to vaccinate on time and maximize each vaccine’s potential for protection and disease reduction. The CDC lists several initiatives in Global Immunization as one of its “Winnable Battles.” Our “Winnable Battle” is Local Immunization. Our aim is to increase the number of children in Snohomish County who are protected by the full complement of available vaccines.

Does this practice address any of the CDC Winnable Battles? If yes, select from the following

Please list any evidence based strategies used in developing this practice. (Provide links or other materials for support)

Snohomish Health District’s Vaccine-Preventable Disease Community Program team members understood that many people in today’s society have not seen the dangerous diseases that vaccines prevent. The strategy used to develop “The Greater Risk? Disease vs. Vaccine” card sets is based on a strategy used by many organizations to call attention to disease risks. Telling true stories about individuals who contracted diseases and suffered severe consequences from those diseases is a compelling and effective way to make people aware of their presence. The CDC website (1) has a section entitled “Vaccines: Unprotected Stories” with accounts of children who contracted 8 vaccine-preventable diseases. These children developed severe illnesses requiring hospitalization. Unfortunately, not all of the stories end with recovery. The “Vaccinate your Baby” website (2) has similar true stories. Other websites focus on one illness and have stories of that disease’s worst case consequences. The “Families Fighting Flu” website (3) features the story of a healthy 17 year old boy who died from complications brought on by flu. The “Meningitis Angels” website (4) features stories of meningitis victims who died from the disease and survivors who were disfigured by it. The disease card component of “The Greater Risk? Disease vs. Vaccine” card sets tells the true story of a disease. It condenses the information on a pocket-sized card, along with a photograph, to show what vaccines have been so successful in preventing. 1. http://www.cdc.gov/vaccines/vpd-vac/unprotected-stories.htm 2. http://www.vaccinateyourbaby.org/why/victims.cfm 3. http://www.familiesfightingflu.org/member-families/the-booth- family/ 4. http://www.meningitis-angels.org/

Is the practice new to the field of public health? If so, answer the following questions.

Yes

What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review.

To determine that “The Greater Risk? Disease vs. Vaccine” card set was a new resource to the field of vaccination, members of the Vaccine-Preventable Disease team examined immunization-themed websites sponsored by public health organizations, hospitals, non-profit agencies, and coalitions. We found a large number of resources to be used for education about vaccines. One example is the “Vaccine and Immunizations” section of the Centers for Disease Control (CDC) website. Following a link will take the reader to the “Talking About Vaccinations” page which lists different topics and publications appropriate for different situations and groups. There are videos, fact sheets, disease sheets, and information about school attendance and exclusion for parents who choose not to vaccinate their children. The Immunization Action Coalition (IAC) subsidizes a website entitled “Vaccine Information for the Public and Health Professionals.” Again, there are numerous resources available. The site offers descriptive pictures and words, a collection of “unprotected people reports,” and photographs and video clips of vaccine preventable diseases. The information vaccinators need is available in many forms. However, no resource or tool had the information arranged in the accessible, connected format of “The Greater Risk? Disease vs. Vaccine” card set. Disease risk cards backed by vaccine risks, along with a reference card listing safety considerations in vaccine administration, is a unique combination in the vast assortment of immunization and vaccine resources.

How does this practice differ from other approaches used to address the public health issue?

Pharmaceutical companies have produced pictures of disease to promote their products. Merck, for example, has a wall chart for the differential diagnosis of rash illnesses in children. Measles, mumps, rubella, and varicella are not as common as they were before the development of the vaccines. The pictures remind parents that these extremely contagious, dangerous diseases can be prevented through vaccination. The Oregon Department of Human Services Immunization Program produced a bilingual booklet describing 13 of the vaccine-preventable diseases. The description includes a picture of the disease, its symptoms, and its complications. “The Greater Risk? Disease vs. Vaccine” card set uses both approaches to describe 16 vaccine-preventable diseases. The front of each card has a picture of the disease and lists the agent, transmission channel, incubation period, symptoms, contagiousness, complications, risks, and treatment. The back of the card describes the vaccine’s appearance, dose and route, and the vaccine’s risks and contraindications. There is also a page that catalogs safety considerations for administering vaccines. It covers universal contraindications for vaccines, defines a true contraindication and a precaution, lists common false contraindications, and states considerations for the immune compromised and patients who recently received antibody containing products. A quick check of this page may prevent an incorrectly administered vaccine. The innovation is the ability to compare disease risks and complications with the vaccine risks, back to back on one card. The disease/vaccine card set format puts vital information right into the vaccinator’s pocket.

Is the practice a creative use of an existing tool or practice? If so, answer the following questions.

What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review.

What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?

How does this practice differ from other approaches used to address the public health issue?

If this practice is similar to an existing model practice in NACCHO’s Model Practices Database (www.naccho.org/topics/modelpractices/database), how does your practice differ? (if, applicable)

Who were the primary stakeholders in the practice?

The primary stakeholders for this project are the Vaccine for Children (VFC) Providers, school nurses, Healthcare Provider Educators, and parents. Our stakeholders have a strong interest in raising immunization rates in Snohomish County through accurate vaccine information and safe vaccine handling and administration practices.

What is the LHD's role in this practice?

Snohomish Health District (SHD) has a critical role to assure that the VFC program providers administer viable vaccine to all children less than 19 years of age. The Health District monitors storage and handling, standardizes vaccine administration practices, and provides education and material development to improve the understanding of vaccines. Because SHD is an agency that administers vaccine in its own clinics, our advice comes from experiencing the same issues that providers face in their practices. With numerous reports of parents who delay vaccines, decide to follow alternative schedules, and authorize exemptions from recommended vaccines, the Vaccine-Preventable Disease (VPD) Community Program initiated a project to address childhood diseases and vaccines in a simple, accurate, concise way. The idea for a pocket-sized, laminated set of disease and vaccine cards to be used by medical providers and health educators was developed. The disease/vaccine card sets are a valuable resource in our mission to have 90% of the residents in Snohomish County fully vaccinated according to Advisory Committee on Immunization Practices (ACIP) recommendations.

What is the role of stakeholders/partners in the planning and implementation of the practice?

Our stakeholders and their needs were the inspiration for this project. The medical stakeholders voiced concern over resources that are not helpful in a fast-paced clinical environment. They find other materials to be too lengthy or not convenient to use. The school nurses had print materials for assessing student vaccine records, but not pictures and descriptions of all of the vaccine-preventable diseases. Data collected from focus groups on parent hesitancy found that parents prefer a knowledgeable and empathetic provider who can talk with them about their concerns. A pocket reference like “The Greater Risk? Disease vs. Vaccine” card set can easily help to focus and supplement a conversation about immunization. Educators expressed a desire for a tool that has succinct information about vaccines to enhance course studies that have minimal vaccine curriculum. Implementation began as the stakeholders received card sets to use according to their needs. Four months later, the VPD team sent, via email, a survey to each stakeholder to collect feedback and data for evaluation. The survey was conducted over the phone for the few provider offices without internet access.

What does the LHD do to foster collaboration with community shareholders?
Describe the relationship(s) and how it furthers the practice's goals.

Our community collaborations have developed over time. We support VFC Providers directly as they sign new contracts each January to continue their association with the Vaccines for Children program. Snohomish Health District intervenes when vaccine allocations occur due to shortages. We alert providers when it is time to order vaccine, explain protocols for using combination vaccines, and provide education and training about implementing complicated vaccine schedules and documenting each vaccine administered. School nurses depend on our support as new vaccines become requirements for school attendance, when there are disease outbreaks, to provide access and training for the state immunization registry, and when they need materials to educate and communicate with the school community. Healthcare Provider Educators depend on VPD team members for their expertise and suggestions to augment vaccine curriculums and increase hands-on training opportunities. Snohomish Health District runs two immunization clinics that provide services to county residents of all ages. Parents access the SHD website to find documents and information vital to making decisions about immunizing their children. These collaborations and their outcomes are essential elements to our goal of increasing the number of children in Snohomish County who are fully protected from vaccine preventable diseases. These relationships are important to Snohomish Health District’s vaccination rate goals due to their interactive, collaborative nature. Our community contacts provide information about their needs and challenges in providing and documenting immunizations. The Vaccine-Preventable Disease team works with each individual or group to find solutions that already exist or, if necessary, to create new solutions. Both sides evaluate and update as needed to ensure that each solution is a good fit. Our “The Greater Risk? Disease vs. Vaccine” card sets evolved from this type of problem-solving process.

Describe lessons learned and barriers to developing collaborations.

We learned a few valuable lessons while working on this project. First, vaccinators want quick, factual, graphic materials to share with parents. Second, more than one set of cards is needed in an office practice with more than one vaccinator. Third, word of mouth is powerful marketing tool. This confirmed our belief that these card sets were valuable resources for vaccinators. Finally, although we had hoped to provide “The Greater Risk? Disease vs. Vaccine” cards sets free of charge, the demand is more than the health district can support financially. SHD’s Board of Health approved a $10.00 per copy fee to cover printing and shipping charges. Some sense of barrier exists with specialty providers who tend to come and go in the Vaccines for Children program. Adolescent providers might only stock the Human Papilloma Virus (HPV) vaccine and not the other vaccines that are recommended for this age group. Some clinics operate one time per week. It can be difficult to connect with these providers and offer them the full complement of skills and knowledge needed to provide complete vaccination coverage to the patients they serve.

Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.

Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).

List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)

• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.

Objective 1:

PRIMARY OBJECTIVE #1 The first primary objective of “The Greater Risk? Disease vs. Vaccine” card set project was to create a tool for use by healthcare providers to convince “hesitant” parents to choose the risk of a vaccine over the risk of a child contracting a vaccine-preventable disease. Vaccines prevent pain and suffering, missed school and work days, and save money. According to the American Public Health Association, every $1.00 spent on childhood vaccines saves $16.50 in future health care costs. PERFORMANCE MEASURES for this objective are based on whether or not any “hesitant” parents chose to vaccinate their children after hearing disease risk information from “The Greater Risk? Disease vs. Vaccine” card set and how useful the card set is to providers. Additional respondent comments will be considered. 1. Have any parents chosen to vaccinate a child because of disease risk information in the card set? 2. Overall, how helpful is this resource to you when communicating with parents? 3. Is there anything else you want us to know about the card set? DATA was collected via an online survey sent to the 75 provider offices that received a card set. Thirty total responses were received after being sent one time and followed by one reminder email. Responses were collected anonymously. Results are as follows: 1. Have any parents chosen to vaccinate a child because of disease risk information in the card set? YES- Please briefly describe the situation(s) in the box below 7.1% “one vaccine resistant parent did; most still don’t” NO 42.9% I DON’T KNOW 50% 2. Overall, how helpful is this resource to you when communicating with parents? EXTREMELY HELPFUL 28.6% VERY HELPFUL 35.7% MODERATELY HELPFUL 21.4% SLIGHTLY HELPFUL 14.3% NOT HELPFUL AT ALL 0% 3. Is there anything else you would like us to know about the card set? YES-Please enter your comment in the box below * 27.3% NO 72.7% *QUALITATIVE DATA 1. Is there anything else you would like us to know about the card set? 1. “Having only 1 copy in the office, the cards didn’t get utilized well. This should greatly improve when there is one per provider and/or exam room so it is always readily available. Pediatricians don’t wear white coats so they have no

Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits.

pockets to carry the cards to have readily accessible. “ to parents.” 2. “Without one in each room, it is difficult to use for clients. I have the flip chart in my room from the Oregon Department of Human Services, Immunization Program and use it very often. I like the card set that you developed but it is not useful if it is not in the room where we are talking to parents.” 3. “Some of the concerns vaccine resistant parents have are not addressed (vaccine vehicle, additives, formaldehyde, etc.)” See objective #3 4. “We have it in the IZ room and use it if a patient or parent has questions. We like it-a huge help.” See objective #2 EVALUATION RESULTS The Snohomish Health District’s VPD Community Program learned that PRIMARY OBJECTIVE #1 was achieved. At least one parent chose to vaccinate a child after hearing disease risk information. This is a small step, but it is a step in the right direction. Some “hesitant” parents, hearing accurate information and clearly stated comparisons of disease risks vs. vaccine risks, will choose to prevent the greater risk and protect their children from dangerous, vaccine-preventable diseases. “The Greater Risk? Disease vs. Vaccine” card sets are a resource/tool to support vaccinators during such interactions and lead to higher immunization rates among children in Snohomish County, Washington. FEEDBACK The evaluation results were shared with each member of the SHD’s Vaccine Preventable Disease Community Program team. We learned that information from the disease cards did convince a “hesitant” parent to vaccinate a child, so our belief in this type of interaction was correct. Still, many “hesitant” parents did not make the choice for vaccine protection. Also, 50% of the respondents were unclear about whether or not the disease information resulted in a vaccination. Comments received indicate that accessibility is important, so we created an ordering process. “The Greater Risk? Disease vs. Vaccine” card set needs to be available every time a parent is faced with the decision of whether or not to vaccinate. The disease risk and vaccine risk information is vital to making the best possible choice for every child at every immunization opportunity and will, one vaccination at a time, increase the number of children who are protected.

Objective 2:

PRIMARY OBJECTIVE #2 The second primary objective of “The Greater Risk? Disease vs. Vaccine” card set project was to create a resource/tool that would be used by healthcare providers to support vaccination efforts by detailing the risks of 16 vaccine preventable diseases and allowing comparison to the risks of the vaccines that can prevent those diseases. The card set would be especially useful when counseling parents about vaccine risks and informing them of the dangerous diseases that children may contract without vaccine protection. The PERFORMANCE MEASURES for this objective ask the VFC Providers who received the card sets to let us know if they use the card set or not. If the respondent does use the card set, further survey items ask them to specify how and when it is used. 1. Have you used the card set “The Greater Risk? Disease vs. Vaccine?” 2. How often do you use the card set? 3. How do you use the card set? DATA was collected via an online survey sent to the75 provider offices that received a card set. Thirty total responses were received after being sent one time and followed with a reminder email. Responses were collected anonymously. Results are as follows: 1. Have you used the card set “The Greater Risk? Disease vs. Vaccine?” YES 50% NO 50% At this point, respondents answering “NO” were sent to submit the survey without answering any further questions. I DON’T KNOW 0% 2. How often do you use the card set? ALWAYS 7.1% OFTEN 21.4% SOMETIMES 42.9% RARELY 28.6% 3. How do you use the card set? (Check all that apply-more than one choice accepted) TO COUNSEL PARENTS 57.1% TO REVIEW DISEASE INFORMATION 71.4% TO CONFIRM VACCINE DOSE AND/OR ROUTE 7.1% TO CHECK VACCINE CONTRAINDICATIONS/PRECAUTIONS/CONSIDERATIONS 21.4% OTHER 14.3% 1. “When children are afraid to get immunized, I show them the cards and explain that these are the diseases the vaccines they are getting prevent.” 2. “Have shown students who are rotating through our clinic.”

Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits.

QUALITATIVE DATA The survey offered respondents an opportunity to include “anything else they would like us to know about the card set.” One comment concerning this performance objective was recorded. “We have it in the IZ room and use it if a patient or parent has questions. We like it-a huge help!” EVALUATION RESULTS The Vaccine Preventable Disease Community Program team learned that half of the survey respondents have used “The Greater Risk? Vaccine vs. Disease” card set to varying degrees, with 71.4% using it at least “sometimes.” This confirms that providers are using it when needed to supplement their vaccination activities. The reasons for use vary as well, most responses being “to review disease information,” by 71.4% of users, and “to counsel parents,” by 57.1% of users. This data proves that primary objective #2 for “The Greater Risk? Disease vs. Vaccine” card set has been achieved. FEEDBACK The evaluation results were shared with each member of the SHD’s Vaccine Preventable Disease Community Program team. We learned that the card set users accessed information about vaccine-preventable diseases and the risks they present and that the card set is used to counsel parents making vaccine decisions for their children. The card set is being used as intended, so no modifications are necessary.

Objective 3:

PRIMARY OBJECTIVE #3 The third primary objective in developing “The Greater Risk? Disease vs. Vaccine” card sets was to create a format in which pertinent information about disease and vaccine risks could be easily accessed by healthcare providers during the course of an office visit that included immunization opportunities. Sixteen cards with disease information and photographs were printed back to back with facts about the corresponding vaccine. An introduction to explain the purpose of the card set and a list of general safety considerations for vaccine administration completed the set. The PERFORMANCE MEASURES for this objective ask the VFC Providers who received the card sets to evaluate each component separately. 1. Is the purpose of the book clearly stated in the INTRODUCTION? 2. Is the SAFETY CONSIDERATIONS IN VACCINATION page helpful? 3. Are the DISEASE INFORMATION CARDS clear and informative? 4. Is the VACCINE INFORMATION useful? DATA was collected via an online survey sent to the75 provider offices that received a card set. Thirty total responses were received after being sent one time and followed with a reminder email. Responses were collected anonymously. Results are as follows: 1. Is the purpose of the book clearly stated in the INTRODUCTION? YES 93% NO 0% I DON’T KNOW 7% 2. Is the SAFETY CONSIDERATIONS IN VACCINATION page helpful? YES 86% NO 0% I DON’T KNOW 14% 3. Are the DISEASE INFORMATION CARDS clear and informative? YES 100% NO 0% I DON’T KNOW 0% 4. Is the VACCINE INFORMATION useful? YES 86% NO 0% I DON’T KNOW 14%

Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits.

QUALITATIVE DATA The survey offered respondents an opportunity to include “anything else they would like us to know about the card set.” One comment concerning this performance objective was recorded. “Some of the concern vaccine resistant parents have are not addressed (vaccine vehicle, additives, formaldehyde, etc.)” EVALUATION RESULTS The Snohomish Health District’s VPD Community Program learned that primary objective #1 was clearly achieved. Card set users responded positively, averaging 91.25 %, to all 4 PERFORMANCE MEASURES questions. “The Greater Risk? Disease vs. Vaccine” card sets have a format in which pertinent information about disease and vaccine risks can be easily accessed by healthcare providers during the course of an office visit that included immunization opportunities. FEEDBACK The evaluation results were shared with each member of the SHD’s Vaccine Preventable Disease Community Program team. We learned that the card set users agreed that the format and design elements were well suited to the displayed information. We agreed with the user comment regarding other vaccine issues that contribute to parent hesitancy to vaccinate. However, the explanations and evidence needed for those discussions could not fit on the cards due to the unique nature of each vaccine formulation and the number of ingredients each one contains.

What are the specific tasks taken that achieve each goal and objective of the practice?

The implementation strategy that produced the card sets, “The Greater Risk? Disease vs. Vaccine,” required Snohomish Health District’s (SHD) Vaccine-Preventable Disease (VPD) team to thoughtfully and thoroughly process the needs presented by community stakeholders. During the spring and summer of 2011, they determined that a pocket-sized set of cards featuring disease risks on one side and vaccine risks on the other side would be a valuable tool for vaccinators and other stakeholders interested in reaching our goals of educating parents and raising the county’s immunization rates. The objectives for this project correlated to the design and completion of each section of the card set. The size limits would challenge the authors to present important information in a brief and clear manner. The language used needed to convey important medical facts in a way that could be easily understood by parents making decisions about their children’s healthcare. The resource needed to be accessible and portable to take advantage of every opportunity to educate and vaccinate. The important addition of a list of “Safety Considerations in Vaccination” was the final touch in visualizing a finished product. Once the design and format of the “The Greater Risk? Disease vs. Vaccine” card set was determined, the VPD team members gathered pertinent information from available resources. They wrote the disease descriptions, chose suitable pictures, and condensed the vaccine information and instructions to fit the card layout. Proofreading and editing tasks were shared by individuals throughout the health district to ensure medical accuracy, broad readability, and legible formatting. The majority of this work took place during the fall of 2011.

What was the timeframe for carrying out these tasks?

The planning process and initiation of the production process began in the spring and summer of 2011. The final edit was sent to the printer early in 2012. The cards were laminated, collated, hole-punched, and secured on a 1 inch diameter ring. The resulting card set was an innovative resource to help community stakeholders in Snohomish County to raise immunization rates for its children. Distribution began in spring, 2012. The nurses at the Snohomish Health District’s immunization clinics were among the first to receive their copies. “The Greater Risk? Disease vs. Vaccine” card sets were distributed to all 86 enrolled VFC providers during a “quick visit” format. VPD staff visited the Health Care Providers’ offices and spoke to the vaccine coordinator or other available staff member. The SHD representative explained who should receive the resource and how it should be used. Contact information was given in case follow-up was needed. All visits were made in a 3 week time frame during the month of May 2012. Additional card sets were distributed to LHJ representatives from surrounding Washington State counties during an annual forum on June 19, 2012. The card set was introduced to attendees at the July meeting of Washington State’s Immunization Action Coalition. We allowed a 4 month trial period, including the busy back-to-school season, before sending out a survey to collect evaluation data about the uses and effects of the card set.

Please provide a succinct outline of some basic steps taken in implementing your practice.

“The Greater Risk? Disease vs. Vaccine” I. Needs Assessment - Listening to Stakeholders A. VFC Providers 1. Resources not helpful in fast-paced office environment 2. Materials too lengthy 3. Materials not convenient 4. Materials not written for lay people B. School Nurses 1. Have materials for assessing student immunization records 2. Need disease descriptions and pictures C. Healthcare Provider Educators 1. Need resources to supplement vaccine curriculum D. Parents 1. Want providers to talk to them about immunization concerns II. Review of Available Resources A. Disease Information and Risks 1. Fact sheets 2. Disease pictures and videos 3. Case histories B. Vaccine Information and Risks 1. Vaccine Information Sheets (VIS) 2. Package inserts C. Vaccine Administration 1. Package inserts 2. Training materials for vaccinators D. Parents access incorrect information online III. Confounding Factor - Parents Access Incorrect Information Online A. Healthcare Providers need accurate, straight-forward information to counteract website claims 1. Shows parent the risk of their child contracting a vaccine-preventable disease 2. Shows parent the risk associated with each vaccine 3. Parent can make an informed decision about vaccinating a child IV. Innovation - “The Greater Risk? Disease vs. Vaccine” Card Sets A. Tool for Healthcare Provider to use when counseling “hesitant” parents 1. Shows disease information and picture to clearly portray risk B. Tool for Vaccinator to use when administering vaccine 1. Lists pertinent information specific to each vaccine 2. Lists overall information for vaccine administration V. Timeline – Card Set Development and Distribution A. Summer 2011 1. Needs Assessment 2. Concept of Card Set chosen for development 3. Design and format details of card set finalized B. Fall 2011 1. Gather pertinent information for disease and vaccine cards 2. Edit information to maintain integrity while fitting allowed space C. Winter 2012 1. Card set sent to the printer for final assembly. D. Spring and Summer 2012 1. Distribution to VFC Providers and stakeholders E. Fall 2012 1. Survey created to collect data for Process and Outcome evaluations 2. Survey sent to VFC Providers and stakeholders 3. NACCHO 2013 Model Practice Application Submitted!

What were some lessons learned as a part of your program's implementation process?

There were several lessons learned by carrying out the process to create “The Greater Risk? Disease vs. Vaccine” card sets. First, was that we, through collaborations with other interested stakeholders, could identify and create the resource needed to help raise vaccination rates in Snohomish County. Second, no one person could have accomplished the tasks necessary to deliver the final product. Third, we acknowledged that this would have been a very different process without access to computers and the internet. Those tools were vital to gathering information and photos, composing, proofreading, and editing text, and formatting it all to fit our specifications. We were able to send our data files electronically to the commercial printer who printed, collated, and assembled the card sets. Pooling our knowledge and learning new methods, when necessary, allowed us to streamline the production process. We also learned that the connected group of vaccinators and vaccine advocates facilitated both distribution and marketing. It was easy to distribute the card sets during our visits to each provider office and through attendance at meetings that brought us together with other LJH representatives and vaccine advocates. Several requests for ordering information came just as we were finalizing the forms and getting them posted on the Snohomish Health District website. When needed, more copies of “The Greater Risk? Disease vs. Vaccine” card sets are just an email to the printer away.

Provide a breakdown of the overall cost of implementation, including start-up and in-kind costs and funding services.

The Vaccine-Preventable Disease Community Program undertook this project as part of its daily mission, working to support the vaccinators in Snohomish County. The work to write, edit, and format the cards was a team effort completed during normal work hours at the Snohomish Health District facility. The program budget was able to support the initial printing of 150 copies of “The Greater Risk? Disease vs. Vaccine” card sets. The first 150 copies were distributed without cost to our vaccine providers, colleagues, and community stakeholders. When positive response indicated that more copies would be requested, the VPD Program Manager approached the Board of Health for approval of a $10 per copy charge to cover the cost of printing and shipping. The Board agreed to authorize her request. New orders are set at 150 copies each to maximize the bulk ordering discount.

Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured.

Response from our stakeholders indicates that “The Greater Risk? Disease vs. Vaccine” card set is used in healthcare provider offices and healthcare provider education programs. We recently shipped 22 copies that were ordered by a pediatric practice in Mill Creek, Washington. The Everett Community College Nursing Department requested 25 copies for their campus bookstore. Students in the Medical Assistant Program will be required to purchase a card set as part of the curriculum. The disease and vaccine information will not change in the foreseeable future, so the card set will remain relevant. The pocket-sized card set is laminated, hole-punched, and secured by a 1 inch diameter ring, making it sturdy and accessible for busy professionals. This resource is valuable to its users and, at $10 per copy, a good value, too. In the future, cards can be revised and new cards can be inserted if additional vaccines are added to the Advisory Committee on Immunization Practices (ACIP) recommendations. We believe that Health Care Providers, as evidenced in the survey results, want to have this resource in the hands of everyone holding a syringe.

2013 Model Practices (Public)