2007 Model Practice Application (Public)

Keep Pertussis Out

Boulder County Public Health

Keep Pertussis Out targets parents of children aged 10-19 years and family practice, pediatric, and internal medicine healthcare providers throughout Boulder County and addresses the issue of high incidence rates of pertussis, especially among 10-19 year olds, in Boulder County. The goal of this project is to reduce the incidence of pertussis in Boulder County. The project objectives include:

• Develop a pertussis prevention campaign based on epidemiologic data, focus groups with parents, and key informant interviews with healthcare providers.
  
  
• Ensure that stakeholders are engaged into and updated on the development of this campaign at regular intervals.
  
  
• Have 20% of children aged 10-19 years immunized with the new pertussis vaccine by January 2007.
  
  
• Have 60% of patients with pertussis diagnosed within 14 days of illness onset by January 2007.

The practice intends to reduce the incidence of pertussis in Boulder County by:

• Influencing policy change with the Colorado Board of Health to require the new Tdap (tetanus, diptheria, and pertussis) vaccine for entry into 6th and 10th grades.
  
  
• Motivating parents to have their children between the ages of 10 and 19 years vaccinated with Tdap.
  
  
• Educating and motivating the healthcare providers to recognize, test, treat, and report pertussis, as well as to vaccinate their clients with the new Tdap vaccine.

Outcomes of practice include:

• Parents of approximately 35,000 children within this age group received information about the impact of pertussis.
  
  
• Approximately 300 healthcare providers received information about recommended practices regarding the testing, treatment, and reporting of pertussis.
  
  
• 200 public health staff and 1400 staff in other county departments received information and campaign materials via e-mail.
  
  
• 94 schools within the two local school districts received and posted campaign materials.
  
  
• 15 other public health agencies and 36 nursing service agencies in Colorado received information and access to campaign materials.
  
  
• In January 2007, the Colorado Board of Health voted to include the Tdap vaccination as a requirement for entry into 6th and 10th grades.

Pertussis poses one of the most significant communicable disease threats in Boulder County. A median of 83 cases has been reported in Boulder County (population: 297,003) annually throughout the last decade, with 176 cases being recorded in 2004. Since 1996, Boulder County has accounted for 7-37% of Colorado’s cases each year, while only representing 6.1% of the state’s total population. The program focused on three different areas to help best define this issue’s relevancy to the community: analysis of pertussis data, focus groups with parents, and key-informant interviews with healthcare providers. In addition to these specific areas, BCPH staff has been engaging other local stakeholders, such as the local school districts on an ongoing basis to control pertussis outbreaks and determine the best prevention methods to reduce the mortality burden in our schools. Analysis of pertussis data from 1996 to 2004 revealed two 5-year age groups (10-14 and 15-19) that on average account for 50% of all Boulder County cases. These age groups became a focus of the campaign. BCPH staff then engaged the public, using focus groups, to better understand perceptions about pertussis and potential barriers to introducing a new vaccine to adolescents. Finally, key-informant interviews with health care providers were used to help program staff better understand the perceived barriers and benefits of testing, treating, and reporting pertussis cases. Social marketing is being used to help achieve this change. The program goal was to develop messages that would encourage and empower parents to have their 10-19 year-old children immunized. To be most effective, and using proven social marketing practices, program staff gathered insights from the target audiences using focus groups and key-informant interviews. These findings led program staff to determine the most effective and most motivating message for each audience – a message that would lead to behavior change.

Social marketing is a tool that has been utilized successfully in public health practices throughout the U.S. and the world. This was the first time thorough use of social marketing practices was utilized to address the problem of pertussis. Most approaches to combat high incidence of communicable diseases relates to prompt reporting, timely and thorough investigation, and implementation of specific controls to prevent the spread from the patient. The social marketing approach, in this instance, was used to complement traditional epidemiological practices. By investigating barriers to recognizing the disease, fundamental community perceptions of the disease and the role of the health care provider, the campaign was able to motivate behavior change within the target audience. It also introduced a new vaccine into program services and facilitate the development of new policies. Although it is likely that other uses of social marketing have been submitted previously to the Model Practice Program, this project has rigorously followed social marketing "best practices" by including cross-functional and stakeholder groups, encouraging purposeful dialogue with the community, and strategically developing and distributing effective messages. In addition, the campaign put into practice the use of a newly approved vaccine, and advocated for the vaccine to quickly be added to the school entry vaccination requirement list. Together this campaign combined social marketing, the use of new technology (new vaccine), and community-based advocacy.

BCPH’s role was two-fold in this practice. First, BCPH provided leadership to the initiative in order to ensure an effective outcome that would meet the needs of the community. BCPH engaged community members at all levels, including local parents, health care providers, other local public health agencies, and other government departments. Second, BCPH was responsible for the development, implementation, and evaluation of the campaign. Key stakeholders played a vital role in the planning and implementation of the practice. Input was gathered from all of the stakeholders (i.e. other local public health agencies; the local medical community, including hospitals; local school districts and parents) to best define the needs and restrictions the campaign needed to address. School district staff, health care providers, and other public health agencies played a major role in the dissemination of the message to each specific audience. BCPH continuously fosters and maintains community partnerships by providing ongoing communication and discussion with the community through distribution of bi-monthly disease surveillance newsletters to health care providers, personal assistance and training to school district staff on controlling the spread and occurrence of communicable diseases within our schools, and regular collaboration with other local public health agencies on regional public health issues. This practice has helped to further build BCPH's credibility with partners and serve as an example of how working together can combat a community problem. Additionally, the campaign’s materials are being provided at no cost to assure accessibility of the message and further collaboration with these partners in the future.

Boulder County Public Health providing funding for this project and implementation, start-up, and in-kind costs totaled $25,000.

The development and implementation of this project began with the creation of an operational plan to help guide BCPH in achieving the overall goal to reduce the incidence of pertussis in Boulder County. Four objectives were established with multiple activities that would be used to implement this project. The objectives and services/activities are outlined below.

Objective 1: Develop a pertussis prevention campaign based on research findings.

• Define key audiences in decreasing the incidence of pertussis.
  
  
• Develop research objectives.
  
  
• Conduct focus groups and interviews with these audiences according to research objectives.
  
  
• Design a campaign based on research findings.

Objective 2: Ensure that other stakeholders are updated on the development of this campaign at regular intervals.

• Identify stakeholders at local, regional and statewide levels.
  
  
• Identify a method for sharing information about this campaign.
  
  
• Share information on a regular basis with these stakeholders.

Objective 3: Have 20% of children aged 10-19 years who attend public schools in Boulder County immunized with the Tdap vaccine by December 2007.

• BCPH will support every effort to make Tdap vaccination a school requirement prior admittance into middle school and/or high school. (Goal: required before end of SY 2006-2007).
  
  
• BCPH will design and distribute educational materials to parents.
  
  
• BCPH will hold immunization clinics for Tdap.

Objective 4: Have representation from 60% of Boulder County family practice, internal medicine, and pediatric physician practices at a BCPH-sponsored training related to Tdap.

• Develop and provide Continuing Medical Educational (CME) presentations within our local hospitals.
  
  
• Develop and provide training for health care provider practices.
  
  
• Develop and provide training to other public health professionals in Boulder County and throughout Colorado.

Primary and secondary research was completed in December 2005. Development and design of campaign materials was completed in November 2006. Initial distribution of materials was completed in February 2007. Evaluation of several process objectives was conducted throughout 2006. Due to the primary outcome we hope to achieve in this practice, evaluation will be conducted over the next several years to truly measure the change in pertussis incidence for Boulder County. However, the evaluation of some other outcome objectives has already begun.

Integrating stakeholders from the start was instrumental in gaining their confidence and ensuring their vested participation. Additionally, providing these materials to stakeholders at no cost, delivered to their work site, and available for download on-line, has made utilization of the campaign easy, and thus more likely to be used throughout the communities, and many others. The development of this campaign was designed to ensure its integration into ongoing communicable disease prevention efforts. Through strategic repetition of the messages over time, and the use of the materials throughout Colorado it is BCPH's hope that the campaign images and tag line will become easily recognizable. By investing resources into sound and effective research and design at the start, BCPH is now able to continue using the images and tag line long into the future without additional cost for development or research. In addition, the complimentary integration of the new vaccine into school entry requirements ensures ongoing action to address the problem of high pertussis rates in the county.

Goal: Reduce the incidence of pertussis in Boulder County

Objective 1: Develop a pertussis prevention campaign based on research findings by November 2006.

Performance Measures: Identify target audience by January 2006; Complete 5-10 focus groups by April 2006; Complete 10-15 key-informant interviews by May 2006; Complete campaign design and messages by November of 2006.

Feedback:10-19 year-olds are the tar-get audience. Opportunities for vaccination are limited due to fewer doctor visits among the target age group. Also, many providers want consolidated information to help them with diagnosis, treatment and reporting.

Outcomes: Increase awareness among parents and providers; Development of a campaign that can be utilized by other public health departments; Increased agency credibility with public and healthcare providers (anecdotal).

Objective 2: Have 20% of children aged 10-19 years that attend public schools in Boulder County immunized with Tdap vaccine by December 31, 2007.

Performance Measures: Have Tdap added to school entry vaccination list prior to 07-08 school year; Measure the percentage of public school children between 10-19 years of age that have received the vaccine by December 31, 2007 (goal 20%).

Feedback: 10-19 year olds make up 50% of all pertussis cases in Boulder County. Use of the Tdap vaccine in this age group will be the most important tool to decrease incidence of pertussis in Boulder County.

Outcomes: Colorado Board of Health approved policy to require Tdap for entry into 6th and 10th grades. Parents of 35,000 children in target age groups received encouragement to get Tdap vaccination.

Lessons learned include:

• Opportunities for vaccination are limited due to fewer doctor visits among the target age group (10-19 year olds).
  
  
• Many providers want consolidated information to help them with diagnosis, treatment and reporting.
  
  
• 10-19 year olds make up 50% of all pertussis cases in Boulder County. Use of the Tdap vaccine in this age group will be the most important tool to decrease incidence of pertussis in Boulder County.