Immunization is an issue very close to home for Maria Romero. As a child in Mexico, her brother contracted polio. "He's 36 now," she says, "and he's suffered throughout his life. I wouldn't want my children or any other child to go through this emotional devastation."

Even so, she admits, "I was a procrastinator about immunizing my own kids." That was until she began her job as a community health promoter at T.H.E (To Help Everyone) Clinic, a nonprofit in Southwest Los Angeles.

Romero, a mother of five, is one of two health promoters funded through the Immunize L. A. Kids project to work with T.H.E.'s African American,

Latino, and Asian communities. Sponsored under the CDC's REACH 2010 (Racial and Ethnic Approaches to Community Health) Program, the project works to improve immunization rates by:

• Increasing outreach to parents
• Improving the immunization practices of doctors
• Pulling together a coalition of health, education, advocacy, and community-based organizations, including parents from the communities served

Outreach to parents

Romero admits that before learning about immunization, she had some fears: "I was concerned that my baby would get the 'fever' after an immunization. You hear so many things from other parents." She had also heard that nursing a baby the first six months provides automatic protection against all childhood diseases.

Romero and her co-worker, Karla Smith, explain immunization and address issues like these during home visits to new mothers and street outreach at health fairs, grocery stores, even the Department of Motor Vehicles. At T.H.E. clinic they created an immunization area near the intake desk. "We try to attract the kids with colorful decorations, so the parents will come chasing after them," says Smith. They don't just talk about immunizations-they schedule appointments and offer referrals to other services.

"It's about the personal relationships with parents," says Romero.

Different agencies, different approaches

Health promoters are key to outreach work at three Immunize L.A. Kids a-gencies: T.H.E., the Clinica Monseñor Oscar Romero, and the Esperanza Community Housing Corporation. Each has its distinct approach.

Health promoters at Esperanza Hous-ing, for example, go door-to-door with health information. Last summer they became actresses in community parks, presenting La Viruela llega a la Vecindad (Chicken Pox Comes to the Neighborhood). In the skit adapted from the popular Mexican TV show, El Chavo del 8, the main character, the only one smart enough to get immunized, escapes a chicken pox epidemic.

Doctors' office changes

"It's easy to lose track of my daughter's vaccinations," admits Oralia Rodriguez, a 19-year-old mother from Dur-ango, Mexico. But now Romero, who also acts as her translator, calls Rodriguez with regular immunization re-minders. Regina Duru, a recent immigrant from Nigeria, has been able to keep her two children's immunizations up to date since T.H.E. helped her sort out an immunization record mix-up.

Helping doctors' offices set up systems to remind parents when a shot is due is a major emphasis of Immunize L.A. Kids. The Immunization Practices En-hancement team-a health educator, a nurse, and data entry assistants-visits the office to review immunization records and offer a record-keeping system to send notices when children need immunizations. They also evaluate the "cultural competence" of the office-for example, whether information is available in the patients' languages.

The team gave positive feedback to the Central Neighborhood Medical Group in South Central Los Angeles, which "encourages us that we're going along the right track," says Tony Brown, the clinic's general services manager. Brown's agency was already offering immunizations on a walk-in basis before 3 p.m. on weekdays-free for those without insurance. Staff members speak four different languages. And Brown makes home visits to families he hasn't seen for a while.

A "family kind" of coalition

Monthly workshops sponsored by Immunize L.A. Kids pull together health promoters from the three community partners. T.H.E.'s Karla Smith says, "With Immunize L.A. Kids, it's a family kind of group thing. So many people coming from different clinics and we're all working together. It keeps us up on what's happening."

Today, the coalition includes 100 people from over 30 organizations, including county and state health departments, the UCLA School of Public Health, health care providers, and community-based organizations.

What makes Immunize L.A. Kids unique, says the coalition Co-Investigator Rachel Golden, is that "it's not just community-based organizations participating, but also parents and community residents," some of whom are paid stipends so they can attend meetings. Translators are present at every meeting, and the chair of the coalition is a local pediatrician.

Ultimately, says coalition Coordinator Maria Fernandez, "We're not just out to improve services and educate parents. We need to see the broader picture. Parents are becoming advocates. The ultimate goal is to improve the quality of life in our communities."

Racial Differences in Immunization

The Pattern

Percentage of L.A. two-year-olds on schedule with immunizations*

Latino
1995 = 59%
1997 = 72%

African American 
1995 = 52%
1997 = 52%

White
1995 = 63%
1997 = 71%
 
Asian American 
1995 = 78%
1997 = 80%

* as reported in the California Retrospective Kindergarten Surveys of 1999 and 2001.

Tough Challenges

"Since our program started, Latino immunization increased a lot, largely due to programs like ours," says Rachel Golden, Immunize L.A. Kids co-investigator. But African American immunization rates remain low-Immunize L.A. Kids has created an African American task force to figure out what to do.

"People in the African American community have a trust issue with providers," says task force member Diane Whitfield, a nurse at the South L.A. Health Project. "That has to be addressed by admitting things that happened in the past that were not fair [such as medical experiments on African American prisoners], by reaching people at their own level," and by creating appealing, easy-to-read materials. Another key ingredient is educating providers-"letting them know that parents don't come back because they don't like how you treated them last time."

Common Barriers

But African Americans, Latinos, and other communities with many low-income families also face some common barriers to immunization.

• "Continuity of care" is a major problem, says Oliver Brooks, M.D., chief of Pediatric and Adolescent Medi-cine at Watts Health Foundation. People with lower in-comes move more frequently. And "people get on and off various types of insurance when they change jobs," adds Maria Fernandez, Immunize L.A. Kids coalition coordinator.
  
  
• Cost is an issue for many families, says Golden, and free immunizations are "few and far between."
  
  
• Fewer providers work in low-income communities, Golden adds-and now L.A. County budget cuts are closing 11 clinics.
  
  
• Cultural issues are also important, says Golden: "We hear from both African American and Latino parents who don't want to return to providers who they don't feel are treating them well."
  
  

Immunization checklist for parents

My baby received immunizations at:

• 2 months
• 4 months
• 6 months
• 12 months
• 15 months
• 2 years
• Before Kindergarten

For more information

In California:

National Immunization Hotline
800-232-2522 (English)
800-232-0233 (Spanish)
www.cdc.gov/nip

In Los Angeles County:

L.A. County Health Department
800-427-8700

Immunize LA Kids:

Maria Fernandez, Coalition Coordinator
323-757-7244 x235

Rachel Golden, Co-Investigator
323-757-7244 x228