Notes from file Field

Notes from file Field

Submissions to Notes from the Field (500 to 1000 words, preferably without references, tables, or figures) should be sent to Hugh H. Tilson, MD, Editor, AJPH Notes from the Field, Senior Medical Advisor for Health Affairs, Glaxo Wellcome Inc., 5 Moore Dr, Research Triangle Park NC 27709. This column presents information on newsworthy public health programs and project experiences at the community level. Guidelinesfor Contributors to Notes from the Field can be obtainedfrom the Journal office. Further information should be sought from the author(s) listed at the end ofeach article.

Developing Nontraditional Print Media for BiIV Prevention: Role Model Stories for Young Urban Women Health communications research suggests that realistic messages targeted to specific populations are most effective in promoting human immunodeficiency virus (HIV) risk awareness. Prevention messages should be conveyed with the language, cultural values, and imagery of the intended audience in mind. Printed materials, including pamphlets, leaflets, and fact sheets, are among the most commonly used media for conveying HIV prevention messages. Printed educational materials are economical and can be used in a variety of health education settings. The use of printed educational materials increases patient knowledge, and these materials can be even more effective when combined with personal reinforce-

ment.1-3 While the quality of HIV educational print materials has improved since the beginning of the acquired immunodefi-

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ciency syndrome (AIDS) epidemic, AIDS prevention programs have had limited options when using available print media to convey prevention messages to different target groups. Typically, programs have had to use preexisting print materials that are intended for broad audiences and that lack cultural specificity. The availability of HIV educational print materials that target women is still very limited, and such materials often lack any reference to "real-life" issues that can affect a woman's ability to protect herself from HIV (e.g., gender, poverty, childbearing). Furthermore, many women do not see themselves as fitting a certain profile of a woman at risk and therefore do not relate to many of the traditional prevention messages geared toward women. As part of a 5-year study funded by the Centers for Disease Control and Prevention, the Philadelphia Health Management Corp, a nonprofit health research and service organization, has developed its own HIV prevention print materials specifically targeting women living in one Philadelphia community. The Prevention of HIV in Women and Infants Demonstration Project is a cooperative agreement initiated in 1991 among five cities: Philadelphia, Pa; Pittsburgh, Pa; Oakland, Calif; San Francisco, Calif; and Portland, Ore. Although the project focuses on young women 15 to 34 years of age, the resources of the entire target community are used to deliver prevention activities. The primary behavioral objective of the project is to increase the use of condoms by young women at risk for HIV, sexually transmitted diseases, and unplanned pregnancy. In Philadelphia (population 1 600 000), the project is being conducted in one small area of the city, a predominantly lowincome, African-American community with a population of approximately 22 000.

One major strategy of the Prevention of HIV in Women and Infants Demonstration Project is the creation of special print materials called role model stories. The principle of modeling is well established as an effective way of communicating information and changing peer norms. Modeling entails the performance of a desired behavior by social models who can stimulate others to change their own behaviors. Role model stories are one way of communicating prevention messages through printed materials. In the project, role model stories portray the "real-life" stories of women from the target audience who have successfully initiated or maintained condom use with their sexual partners. The stories are written in the first person and emphasize the behavioral, cognitive, and emotional processes involved in changing risky behaviors. In particular, the stories are a vehicle for women from the target audience to teach their peers about the importance of using condoms and specific strategies for increasing or maintaining condom use. The stories also reinforce other risk-reducing behaviors such as abstinence. The stories reflect women in different stages of the change process and depict a diverse cross section of women from the target community. The credibility of these materials is enhanced by references to the local community landscape, culturally specific mores and norms, and the use of language that is easily understandable. Two to three new stories are produced each month by a full-time health communication specialist working on the project. In most cases, women contact the project directly, often inspired by reading another woman's story. The health communication specialist conducts the interviews and then edits the information into a short joumalistic format. An illustration is produced to accompany each story, and a American Journal of Public Health 289

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fictitious name is selected by the interviewee to represent her story. In some cases, stories are accompanied by the real name and/or a photograph of the interviewee. Prior to final production, women are asked to read over their stories to ensure that the stories accurately depict their feelings and experiences. The role model stories are distributed in the community in a variety of ways. One essential way is through indigenous outreach workers and volunteers who hand out the stories to women they meet through community outreach. During these personal interactions, project staff are able to select a role model story that most closely matches the HIV risk behavior and life situation of the woman they are speaking with and use the story to enhance oral counseling messages. Project staff use the role model stories to highlight the successes of other women in the community who have lowered their risk for HIV, thereby reinforcing the message that "if she (the woman in the role model story) can do it, so can you." Role model stories are also distributed through more than 100 businesses and institutions in the target community that support the project by serving as media drop sites. These sites include bars, hair salons, fast food restaurants, health centers, the local library, a parole office, and check cashing centers. In most cases, these sites provide counter space for the materials; some, however, are more actively involved in distributing the materials to patrons. For instance, the owner of a neighborhood variety store regularly places the materials into customers' bags. The project also is supported by the local community newspaper, which publishes a new role model story every month at no cost to the project, thereby reaching approximately 16 000 households. The project's evaluation involves annual, repeated cross-sectional surveys of women in the intervention community and a comparison community to assess exposure to the intervention strategies being employed and to measure behavior change over time. Although this evaluation is still under way, preliminary data indicate that the level of exposure to the project's role model stories is quite high. Two years after the initiation of this special media campaign in April 1993, 45.5% of women in the community indicated that they had seen the role model stories. During this time, 196 080 copies of 37 different stories were distributed in the community. During the final year of the outcome evaluation, additional 290 American Journal of Public Health

data will be collected to assess how women were exposed to the role model stories, how many different stories were read, whether or not women shared the stories with their peers, how the women related to the stories, and whether or not the stories had an impact on women's AIDS-related perceptions and behaviors. The initial response of women to the role model stories has been extremely positive. Project staff frequently encounter women in the community who have read many of the stories, know them by name, and even have favorites among the stories. This project has been successful in developing materials that are attractive and engaging as well as effective in delivering the important message of HIV prevention. Our experience supports the need for developing materials and messages tailored to reach the target population and for developing a variety of ways to deliver messages to a high-risk population that may not be reached through more traditional prevention campaigns. We believe that the creation of highly targeted educational print materials to promote behavior change may be an effective strategy for reaching different target populations and for promoting a wide range of health behaviors. r] Lisa Bond, MA Joanne Bowden-Proctor Jennifer Lauby, PhD Carla Walls, PhD Myra Wol, MS The authors are with the Philadelphia Health Management Corp, Philadelphia, Pa. Requests for reprints should be sent to Lisa Bond, MA, Philadelphia Health Management Corp, 260 Broad St, 20th Floor, Philadelphia, PA 19102.

References 1. Santelli JS, Celentano DD, Rozsenich C, et al. Interim outcomes for a community-based program to prevent perinatal HIV transmission. AIDS Educ Prev. 1995;7:210-220. 2. McAlister AL. Population behavior change: a theory-based approach. J Public Health

Policy. 1991;12:345-361. 3. Bemier MJ. Developing and evaluating printed education materials: a prescriptive model for quality. Orthop. Nurs. 1993;12: 39-46.

Ensuring Health Care for Foster Children through Medicaid's EPSDT Program Nationally, children are entering the foster care system in larger numbers, at

earlier ages, and with higher frequencies and severities of health problems than ever before. The health problems of children in foster care, which are most often related to preplacement circumstances (lack of prenatal care, drug exposure, lack of preventive and illness care, inadequate nutrition, abuse and neglect), impose an increasing responsibility on public agencies to address the foster child's health needs. Once the child enters dependency, however, the health care received may not improve; it has been characterized as lacking coordination, continuity, and documentation. Foster parents or relative caregivers may have little or no information about the need for continuous, comprehensive health care or how to locate doctors accepting Medicaid. The Early and Periodic Screening, Diagnosis and Treatment Program, a mandatory component of Medicaid's health program, provides comprehensive health exams and treatment for Medicaid children, outreach to families, and follow-up of identified conditions in order to avert disability. Children in out-of-home-placement foster care are eligible for the program. Because of their preplacement circumstances, foster children are at high risk for disability and need program services targeted to their special situations and needs. In early 1989, in San Diego County, California (population 2.7 million), the Department of Health Services designed and implemented a countywide program that uses Early and Periodic Screening, Diagnosis and Treatment Program services as a foundation for specialized assistance for the county's approximately 6000 children in out-of-home placement. This program is described as a potential model for other counties and states interested in improving foster children's access to and use of health care. The County of San Diego Department of Health Services, through the Early and Periodic Screening, Diagnosis and Treatment Program, funds public health nurses who, operating via an interagency agreement, are colocated with the foster children's social workers at the Department of Social Services. Working collaboratively, foster care public health nurses and social workers address the health care needs of the county's foster children. The foster care program has three objectives: to increase the numbers of children receiving preventive health care,

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to increase the documentation of existing health problems, and to increase the numbers of children receiving needed treatment for those health problems. Four public health nurses are funded by the Department of Health Services through a local county base of 25% that is matched at a 75% rate by program funds. The Department of Social Services contributes office space, computer hardware and software, and four clerical staff. The program has several components. * Informingfosterfamilies and relative caretakers of program services and the need for preventive health care. For each foster child entering dependency or undergoing a change in placement, a Department of Social Services referral is sent to the program, which then sends the foster caregiver a specialized foster care brochure, a letter explaining the importance of a preventive health care exam, and lists of medical and dental providers. Each referral is tracked to be certain that the child received the program's medical (or equivalent) exam and dental exam. The outcome information is shared with the child's social worker. * Following up on health problems diagnosed as a result of the program exam. All program exams are tracked by the program's public health nurses to determine resolution of identified problems. Assistance is given for clarifying and reinforcing the need for specialized care, for locating appropriate resources, and for continuing health care until the problem has been resolved or stabilized. * Providing education and consultation to social workers and foster parents. The program's public health nurses have developed training modules, and they participate with the Department of Social Services in initial training for all social workers and foster caregivers regarding health issues. These sessions include disseminating information on the program, health problems common to foster children, how to access community health resources, and how to use the "health passport" (the summary of the child's health history). On average, more than 600 foster parents and social workers receive health issues training annually. Consultation regarding individual children's health needs is given on request. The public health nurses serve on the Department of Social Services multidisciplinary case consulting team, participating with social workers and other professionals in decision making regarding the case plan and facilitating the February 1997, Vol. 87, No. 2

integration of the previously described program functions into the social work case management function. * Documenting health care. The San Diego County Department of Social Services has implemented a health passport system and, since 1989, has generated more than 7000 health passports (computer-based records of previous and ongoing health information). More than 50% of children in placement have passports; two thirds of the health passports are updated at least annually. The public health nurses coordinate the health passport system and review, summarize, and enter into computer format the individual child's information gathered by the Department of Social Services clerical staff. Program exam information is integrated into the passport, along with all obtainable medical, dental, psychological, and educational information. The health passport accompanies the child to all health care visits and is shared with the provider. As a means of updating existing health passports, program exam information is routinely entered; for nonprogram exams, the provider completes an update sheet. By having access to the health passport, program and other providers have a health history of the foster child that would not have been otherwise available. In 1992, three limited surveys were conducted to measure program effectiveness. The first survey, Social Work Case File Review, compared 50 case files prior to program implementation with 50 active files to determine the number of program exams documented. The number of program exams in the files sampled had increased from 3 to 47 (16-fold increase) during the two time periods reviewed. The second survey, Medical Treatment, was conducted to verify treatment of identified health conditions. Thirty-two children who had remained in the same placement for at least 12 months were selected. (This length of time in one placement is not representative of the usual foster child's experience.) During that placement time, a combined average of 2.6 preventive health care exams per child were documented. Twenty-one children (72%) met program exam periodicity criteria. Ninety-five health conditions were identified, and all conditions but one had either been completely treated or were receiving ongoing treatment. The Health Passport Utilization Survey was the third study. It documented use of and satisfaction with the passport

within its three user groups: foster caregivers, social workers, and physicians (n = 50 for each group). Responses were received from 63 individuals (42%). The health passport items cited as most helpful included listings of health problems, immunizations, and past/current providers. Survey results also indicated that health care providers were not always seeing the health passports, since foster children's caregivers were not presenting them at health care visits. Modifications made to the health passport process as a result of this survey were as follows: increased training for program providers, social workers, and foster parents; implementation of public health nurse contact with each foster parent and social worker receiving a passport; and strengthening of the social services management component. In summary, the Early and Periodic Screening, Diagnosis and Treatment Program has successfully demonstrated that it can provide a strong, cost-effective foundation for assisting foster children to get health care, for ensuring treatment for identified health problems, and for documenting the health care received. These efforts have resulted in improved health care status for individual foster children and increased health information for their health care providers, foster caregivers, and social work professionals. Although no single approach will be appropriate for all communities, innovative strategies involving the program are needed to ensure continuous, comprehensive, documented health care for children in depen-

dency. El Norma M. Ruptier, MSN, RN Requests for reprints should be sent to Norma M. Ruptier, MSN, RN, Department of Social Services, CHDP Foster Care Program, 2667 Camino Del Rio S, San Diego, CA 92108.

Partnerships in School Care: Meeting the Needs of New York City Schoolchildren with Complex Medical Conditions In response to the Individuals with Disabilities Act, which mandated free and appropriate education for all handicapped children in a "least restrictive" school environment, increasing numbers of children with complex medical illnesses have entered public school systems throughout American Joumnal of Public Health 291

Notes from the Field the United States. A smaller group of children assisted by medical technology require daily nursing care (e.g., involving ventilatory assistance, suctioning, oxygen, gastrostomy, jejunostomy, colostomy, ureteral diversion, urethral catheterization, dialysis, or intravenous feeding). An estimated 1 in 1000 children from 3 months to 18 years of age is dependent on medical technology and requires skilled nursing care,' a small proportion but one that consumes significant resources. The highest use of technology is in the first 2 years of life.2 In New York City, prior to 1980, these children were educated in the Public School Centers for Multiply Handicapped Children, in institutions, or at home. In 1980, 50 nurses were hired by the Board of Education to meet the mandate that such children would no longer be educated in a cloistered environment. As of September 1994, approximately 180 nurses were employed by the Board of Education to care for children in kindergarten through 12th grade who attended public school in all five boroughs of New York City (C. Marchese, written communication, August 1994). Those children included the multiply handicapped population as well as children who were survivors of advanced pediatric technologies largely unavailable and possibly unforeseen when the Individuals with Disabilities Act was passed in the mid1970s. In 1992, the Division of Child Development at the New York Hospital/ Cornell Medical Center, the NurseTherapist Chapter of the United Federation of Teachers, and the Division of Special Education/Office of Related and Contractual Services in the Board of Education came together to explore how a tertiary medical center could assist the public school system in fostering educational opportunities for children assisted by medical technology in a project called Partnerships in School Care-NYC. The project was part of a national multicenter program funded by the Robert Wood Johnson Foundation to address the needs of children requiring technology and treatment at school. A survey conducted by the project in the borough of Manhattan uncovered 83 children (the Board of Education statistics showed a lower number) who attended school in Manhattan and were assisted by medical technology. Sixty-three children (75.9%) were assisted by one technology, and 20 children (24.1%) required more than one technology. There were 145 597 children attending public school in Man292 American Journal of Public Health

hattan during the 1993/94 school year; thus, the overall prevalence rate was 0.57/1000. This prevalence rate was lower than that reported in a Massachusetts census,2 most likely because our survey included only children from kindergarten through 12th grade (rather than children 3 months of age and older). Our sample of children was derived only from educational sources rather than from both educational and medical sources, as in the Massachusetts study. Equal numbers of boys and girls were assisted by technology. The technologies most commonly used in our sample were intermittent catheterization (n = 32) and gastrostomy tubes (n = 34). The nurse-to-student ratio ranged from 1:1 to 1:9 depending on severity of needs. Seventy-nine percent of the children assisted by medical technology were in special education, 18.5% were in regular education, and 2.5% received home instruction; 36.1% of the children were of normal intelligence, 54.2% were below normal, and intelligence level was unknown for 9.6% of the children surveyed. In terms of racial distribution, our sample revealed the highest incidence of children assisted by medical technology in the Hispanic (61.9%) as compared with the Black (17.9%) or White (17.9%) population. Citywide, the racial distribution is 35.7% Hispanic, 36.9% Black, and 18.2% White. Children assisted by technology are no longer adequately served by traditional New York City school nurses providing public health services such as immunizations, physical examinations, and, if indicated, case management and referral services. The responsibilities of school nursing have expanded to include hands-on nursing care such as that found in a hospital setting. Today, the school nurse must have the ability to perform skilled nursing procedures and to educate students to achieve a level of understanding that will enable them to function independently in the least restrictive setting. Whereas the traditional school nurse was funded by the Department of Health, special education dollars have financed this new group of skilled nurses. To address the needs for specialized training and for increased interaction between the school nurse and the tertiary hospital community, partnerships in School Care-NYC designed a curriculum for the training of school nurses to be held at New York Hospital. The new corps of nurses hired for providing skilled nursing services to children at school were largely

from pediatric hospitals. Delivery of skilled nursing care in a school setting proved to be significanfly different from both the public health school nurse and staff nurse models. Nurses were often isolated from the medical community and had relatively little nursing supervision. There has been a notable lack of continuing education or in-service seminars for nurses to update their clinical skills or be introduced to the latest management and technology. Children's physicians have not always understood that complex medical procedures can be performed safely in schools and that they can be of assistance to the children's nurses. Many physicians have recommended home instruction rather than exploring skilled nursing services in the school. Also, nurses often have not possessed current medical information on the child. The curriculum covered the philosophy of inclusion and the relevant legislation, issues such as delegation of nursing services and liability of seeking outside medical advice from the medical community, and development approaches to caring for children dependent on technology. The curriculum also included review of specific skills and management of technology.3 The development of health care plans for children assisted by technology was reviewed in detail to address the issue of appropriate documentation. The seminar created a forum in which nurses could come together, network, and learn from each other's experience. Three training sessions, attended by a total of 66 nurses, have been held. Finally, the project was successful in assembling an advisory board that meets twice a year, bringing together medical, education, and public health professionals and parents to discuss the integration of children assisted by technology into school settings. In 1990, approximately 102 000 US children were assisted by technology, a number that will continue to grow.4 Addressing the unique needs of these children requires the systematic planning and cooperative efforts of many institutions and individuals. Partnerships in School Care-NYC offers a model for organizing tertiary medical centers, nurses, and educational institutions to best serve children with complex medical needs. El Evelyn G. Uipper, MD Maryjane Farr Carole Marchese, RN Judith Palfrey, MD B. J. Darby, RN, CSN

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Evelyn G. Lipper and Maryjane Farr are with the Division of Child Development, New York Hospital-Cornell Medical Center, New York, NY. Carole Marchese is with the Division of Special Education, New York City Public Schools. Judith Palfrey is with the Division of General Pediatrics, Boston Children's Hospital, Boston, Mass. B. J. Darby is with the United Federation of Teachers, New York, NY. Requests for reprints should be sent to Evelyn G. Lipper, MD, Child Development Center, 525 E 68th St, New York, NY 10021.

Acknowledgment Funding for this project was provided by the Robert Wood Johnson Foundation.

References 1. Technology-Dependent Children: Hospital versus Home Care. Washington, DC: Office of Technology Assessment, US Congress; 1987. 2. Palfrey JS, Walker DK, Haynie M, et al. Technology's children: report of a statewide census on children dependent on medical supports. Pediatrics 1991;87:611-618. 3. Haynie M, Porter S, Palfrey J, Project School Care. Children Assisted by Medical Technology in Educational Settings: Guidelines for Care. Boston Mass: The Children's Hospital; 1989. 4. Palfrey J, Haynie M, Porter S, et al. Prevalence of medical technology assistance among children in Massachusetts in 1987 and 1990. Public Health Rep. 1994; 109:226233.

A "Clinic without Walls": The Los Angeles Immunization Demonstration Project In 1989, the Centers for Disease Control and Prevention (CDC) initiated a series of demonstration projects to study causes of and possible solutions for the problem of low immunization coverage levels in large urban areas. The Southeast and Central health districts of Los Angeles County were selected for the Los Angeles County Department of Health Services Immunization Demonstration Project intervention as a result of the high incidence of measles cases in these districts during 1989 and 1990. It was recognized that the predominantly low-income Latino population in this area (which included approximately 32 000 preschoolers) had characteristics and problems comparable to those seen in less technically developed areas of the world; accordingly, the project incorporated ideas and approaches that had proved successful in those regions. All of the Immunization Demonstration Project February 1997, Vol. 87, No. 2

staff had prior experience with social programs in developing countries. A modified World Health Organization two-stage cluster survey was conducted at the beginning of the project to gather information about the target population, including immunization coverage, demographics, use of health services, barriers to health care, and suggestions for improvement in services. Focus groups were used to explore immunization beliefs, attitudes, and practices. The rapid nature of these surveys allowed assessment and interpretation of communityand clinic-based needs within the first few weeks of the project. Results were compared with those from later surveys to evaluate the effectiveness of the project. Cluster survey respondents most commonly identified long waiting times, absence of Spanish-speaking personnel, lack of transportation, and perceived cost of immunizations (despite the availability of free services at Los Angeles County facilities) as barriers. Respondents preferred Saturday and morning clinics. Some focus group participants feared deportation, while others worried about the pain of shots or lacked knowledge about times and locations of free immunization services. Initial evaluation of existing public services showed that no immunization clinic was open continuously throughout the day. Few clinics offered services on all weekdays, and there were no regular weekend clinics. Policies limiting patient load per provider often placed a ceiling on the numbers of immunizations that could be given each day. Routine temperature screens were common and care of children with mild illness was often deferred, despite California State Department of Health Services recommendations to the contrary. Time-consuming (and potentially distasteful) financial screening was sometimes required for patients requesting immunizations. Waiting for clinic registration preceded screening for vaccine eligibility. Mantoux testing and interpretation were consolidated into immunization clinic responsibilities; as a result, adult tuberculosis screening often displaced children awaiting immunizations. Baseline data indicated that approximately 45% of Latino preschoolers in the target area used the Los Angeles County Department of Health Services for immunization services. Thus, part of the project focused on providing services at one Los Angeles County Department of Health

Services comprehensive health center within the target area. This facility had no walk-in preschool immunization clinic prior to the Immunization Demonstration Project; vaccinations were given only in association with a pediatric clinic visit. The project placed one small desk in the entrance of the comprehensive health center, beneath a banner announcing "Free Vaccinations" in English and Spanish. One clerk registered and screened the immunization records of children requesting vaccination services and of preschoolers passing by. One licensed vocational nurse was stationed nearby, inside the lobby of the Urgent Care Department. The clinic was open Monday through Friday from 7:30 AM to 4 PM and Saturday from 8 AM to 12 noon. Using this model, the project provided 74 747 doses of vaccine during 35 375 child visits from July 1990 through December 1992. An important part of the "clinic without walls" concept involved actively seeking out undervaccinated preschoolers within the facility. A community worker spent several hours each day identifying families of small children throughout the health facility, screening immunization records, and referring eligible persons to the walk-in immunization clinic. This 'community inreach worker" also performed puppet theater presentations in the lobby, handed out educational packets, and generally promoted preventive health services to families attending the facilities. Up to 44% of new immunization patients were referred in this manner. Several ongoing evaluation procedures were used to monitor the functioning of the immunization clinics. Vaccine usage was monitored by comparing three independent sources of patient information. Vaccine storage and handling procedures were regularly checked. The project monitored the clinic "retum rate" (the ratio of children less than 2 years of age receiving a dose of diptheria-tetanuspertussis [DTP] 4 vaccine divided by the number receiving DTP1) to determine whether children under 2 years of age were completing the vaccine series. Exit interviews of parents with preschoolers were conducted periodically to determine how many children left the health facility underimmunized, which vaccines were most commonly missed, specific clinics visited, and the percentage of families carrying immunization cards. The Immunization Demonstration Project used a multidimensional approach to secure cooperation from the commuAmerican Journal of Public Health 293

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nity. Project staff conducted advertising and public relations campaigns, prepared weekly radio programs, appeared on talk shows, and designed culturally relevant educational materials for parents. Elementary schools within the target area were contacted regularly; the project addressed PTA meetings, provided referral slips to school nurses, and updated these nurses about new immunization requirements. Churches were contacted regularly by phone, by mail, or in person; we found approaching a central office more efficient than visiting individual churches. Cooperation of social service agencies and programs was secured through monthly visits to local Women, Infants, and Children clinics and Department of Public Social Services offices. The project conducted advertising and public relations campaigns with media sources willing to give free space or time. Local businesses were informed about low vaccination coverage levels and reminded that a healthy community is good for business. Outreach workers persuaded businesses to sponsor immunization clinics and provide incentives such as coupons for free food, toys, and clothing. Special promotions were planned for specific holidays; donated orchids, for example, were given out on Mother's Day. Zip codes and sources of referral were obtained for all children using the project's services. This information was used to estimate the numbers of children reached both inside and outside the target area and to evaluate the effectiveness of project outreach strategies. Television and radio were important sources for creating awareness in this population, but mass media were much less effective than "word of mouth" in motivating people to use project services.

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A model consisting only of wages, benefits, and overhead for the licensed vocational nurse, community worker, and clerk yielded a cost estimate of $2.11 per vaccine dose delivered. When program administration and research activities were included, the overall program delivered vaccine at $6.69 per dose. Many of the techniques and concepts applied in this project are well known in the developing world, although less so in the United States. Two-stage cluster surveys are less precise than the more commonly used retrospective methods for evaluating immunization coverage, but they allow rapid, unbiased estimation of current levels and inquiry into areas not covered by immunization record reviews. Focus groups are nonquantitative but provide valuable insights into health beliefs and practices within a community. These baseline studies allowed the project to tailor intervention and outreach efforts to the specific needs of the target population. The open design of the "clinic without walls" is familiar to anyone experienced in international community health. This design can be successfully applied within the context of a large county health department. By going outside the boundaries of traditional "departments," programs can reach out to children at risk whenever they come in contact with the health care system, thus making more efficient use of strained resources. The "clinic without walls" design continued essentially unchanged for 6 months after the termination of CDC funding. Subsequently, immunization service delivery was altered; nevertheless, some aspects of the Immunization Demonstration Project design were retained. Using additional corporate funding, the

project developed a curriculum for training "immunization technicians" (Merck) and an easy-to-use immunization screening tool (Unihealth Corp). Finally, exclusive concentration on improving services is not enough. In order to touch those children least likely to be vaccinated, the health care system must reach out into the community. Media, business, government, and social organizations can all play a part in this type of program, which requires relatively little new capital investment. C] Suzanne Westman, MD, MPH R. J. Halbert, MD, MPH Linda G. Walton, MS, RN Carol E. Henneman, MD Suzanne Westman is with the Immunization Demonstration Project, John Wesley Community Health Institute, Los Angeles, Calif. R. J. Halbert is with the School of Public Health, University of California, Los Angeles. Linda G. Walton and Carol E. Henneman are with the Los Angeles County Department of Health Services. Requests for reprints should be sent to R. J. Halbert, MD, MPH, Preventive Medicine Residency, UCLA School of Public Health, Box 951772, Los Angeles, CA 90095-1772. Copies of materials developed during the project may be obtained from Dr Westman.

Acknowledgments The Los Angeles Immunization Demonstration Project was funded by a grant from the Centers for Disease Control and Prevention to the Los Angeles County Department of Health Services, in conjunction with the John Wesley Community Health Institute Inc (grant 666/ CCU 901919-02). We wish to thank the staff of the Immunization Demonstration Project and the following Los Angeles County Department of Health Services personnel: Donnell Ewert, MPH, and Laurene Mascola, MD, MPH, of the Department of Acute Communicable Disease Control and Chuck Alexander of the Los Angeles Immunization Demonstration Project.

February 1997, Vol. 87, No. 2