Good afternoon everyone. Welcome to today's webinar hosted by Patagonia Health. Today's webinar topic is on increasing immunization health equity. If you are not familiar with the Zoom webinar platform, take a look at the control panel at the bottom of your screen. Here you can configure your audio settings, send chat messages, and ask questions. This is just an introduction to see if that chat function is working.
As a quick background about our speaker today, Rachel Barrtman got her start working in vaccine equity where she was helping to develop the new Vaccines for Children strategy. This project was centered on applying COVID-19 lessons learned to the Vaccines for Children space in North Carolina.
In her current position, she is one of seven immunization consultants and covers the western region of the state. Rachel is a 2025 HPV-RT Emerging Leaders Fellow through the American Cancer Society. In her spare time, Rachel volunteers with the North Carolina Immunization Coalition and the Community Care Clinic of Forsyth County.
All right Rachel, we are so excited to hear from you and you can go ahead and start sharing your screen.
Presenter Introduction
Thank you everybody for joining us today. I am really excited to share all about the intersection between health equity and quality improvement.
I see we have lots of people joining us from lots of states. Special call out to my home state of Michigan and all of my fellow North Carolinians here. I'm going to go ahead and jump right in. As Dayna said, my name is Rachel Barrtmans. I am a regional immunization consultant for the state of North Carolina, and we are here to talk today about utilizing quality improvement methods to address immunization health equity.
Part of my job is to go to different providers’ offices who are enrolled in the Vaccines for Children program, also known as VFC, and do the Immunization Quality Improvement for Providers visits, or IQIP visits. This program is set up by the CDC to help manage provider-level quality improvement.
During these visits, we discuss things like workflow reports for recall and tracking, utilizing the state’s IIS, and other immunization-related items to identify opportunities where that particular office or health department could help increase vaccine uptake and decrease vaccine hesitancy.
CDC Strategies
As part of this program, the CDC has four predefined strategies. These include:
- Facilitating return for vaccination
- Leveraging IIS functionality
- Giving strong vaccine recommendations
- Strengthening vaccine communication
These strategies have possible action items including:
- Recalling for missed appointments
- Calling parents within three to five days if a well-child or immunization appointment is missed
- Scheduling the next appointment at checkout
- Measuring coverage levels
- Activating patients in the IIS
- Establishing a reminder process for scheduled appointments
Other action items relate to giving a strong vaccine recommendation. This is associated especially with HPV, giving a presumptive recommendation the same way, the same day, every time a child is due for vaccines, and recommending the HPV shot at age nine.
The last predetermined strategy is the vaccine communication strategy. This has to do with vaccine policies, educational materials, clinic materials, and related items.
Identifying Gaps in North Carolina
In North Carolina, we looked at these strategies and our population and realized this was not enough for the people we were seeing in our doctors’ offices. We needed to fill gaps for underserved populations whose needs may not be met within a normal provider workflow.
We started by looking at vaccine disparities in North Carolina. We reviewed COVID-19 coverage from August 2021 to March 2022 and saw dramatic differences in booster vaccination status by race and ethnicity. Asian Pacific Islander patients had the highest vaccination rates and multiple race individuals had the lowest.
We also looked at vaccine hesitancy for COVID-19. One major trend was that urban areas had much lower vaccine hesitancy than more rural areas.
After reviewing these outcomes, we wanted to see if this applied to childhood immunizations as well. Using CDC VAC View and backend IIS data, we looked at coverage at 24 months and saw significant differences between racial and ethnic groups for the seven-series vaccines. White non-Hispanic populations had the highest uptake. This trend reversed when looking at 17-year-old HPV coverage, where multiple race non-Hispanic populations had the highest uptake for one dose and for being up to date.
Using all of this information, plus lessons learned from COVID-19 vaccination implementation and literature reviews, we developed an additional IQIP strategy that would be added as a fifth option for providers.
We wanted this strategy to be data-driven and focused on engaging low-vaccination populations.
National Trends
Before jumping into the strategy, I want to show you a higher-level view. At the national level, vaccination coverage continues to vary by race and ethnicity. Trends shift slightly when looking at HPV, where the Hispanic population has the highest uptake for one dose and is tied for up-to-date status with multiple race non-Hispanic individuals.
Equity Strategy Overview
We created a list of possible action items to give providers a starting point. These include:
- Educating staff on health equity and how it relates to immunization coverage
- Collecting and recording race and ethnicity in the IIS
- Exploring barriers to immunization and providing resources
- Ensuring resources represent the patient population
- Working with community partners and local health departments
- Building an inclusive workforce representative of the population served
Below, we explore each item in greater detail.
Staff Education and Level Setting
The first action item is implementing staff education to ensure everyone understands what equity is, how it relates to immunization, and where gaps exist.
Common barriers include:
- Transportation issues. If a parent cannot get to the appointment, they will not stay up to date on immunizations.
- Accessibility concerns. Can patients physically enter the building?
- Food insecurity. Patients will focus on basic needs before medical care.
- Language barriers and health literacy. Consider interpreters, virtual or phone services, and ensure staff avoid excessive medical abbreviations.
Patients need to understand what is being said and should not rely on a child to interpret medical information.
Collecting Race and Ethnicity Data
To ensure accurate data, race and ethnicity should be collected based on patient self-reporting rather than staff observation. There are three main options:
- Asking during appointment check-in
- Verbal confirmation during check-in
- Confirming during rooming with clinical staff
This information helps offices focus efforts on unvaccinated populations and plan targeted outreach. It also supports preparedness efforts by allowing data-driven prioritization.
Addressing Barriers and Providing Resources
Equity requires addressing the whole patient, not just administering a vaccine. One method is conducting Social Determinants of Health screenings at every visit. These surveys typically include five to ten questions about:
- Food insecurity
- Housing insecurity
- Interpersonal violence
- Bill pay assistance
Screenings may be verbal or written, but consider sensitivity, reading levels, and language barriers.
The most important step is using the information. Many counties have community resource guides that include housing, food, clothing banks, bill pay assistance, dental resources, and more. Sharing these resources or assisting directly helps patients meet basic needs.
Educational materials should match patients’ literacy levels and may incorporate pictures in addition to text.
Technology access should also be considered. Provide appointment scheduling options that do not require internet access and ensure patients can confirm appointments by phone.
Health literacy varies widely. Twenty-six percent of adults have basic or below-basic health literacy. Using the question-response method helps verify understanding.
Engaging Community Partnerships
This may be my favorite part of health equity. Many organizations already have strong relationships with underserved populations. Partnering with them can fill gaps quickly.
Examples include:
- Working with local food banks to have bags of non-perishable items available in the office
- Sharing contact information with patients who screen positive for food insecurity
- Participating in school events, parades, festivals, farmers markets, and health fairs
- Maintaining consistent presence and follow-through
Social media is also a powerful tool. Providers, as trusted messengers, can share vaccine information and community resources. Use clear, cited facts and avoid overly clinical language. CDC, the American Cancer Society, and many other organizations already offer free graphics and materials.
Inclusive Workforce
Finally, having a workforce that reflects the patient population helps increase trust and reduce language barriers. Patients are more likely to trust healthcare professionals who share similar backgrounds or communication styles.
A study from California found that racially or ethnically concordant surgeon-patient pairs had lower readmission rates and shorter hospital stays.
Tools and Resources
After developing the strategy, we created resources for field staff and providers.
County-specific vaccination coverage reports:
These reports show vaccination coverage by race and ethnicity using immunization registry data. They display both county and state benchmarks.
Vaccine toolkit:
Includes GIS maps showing social determinants of health, vaccine educational materials, historically marginalized population toolkits, slide decks, and social determinants screening guides.
Equity toolkit deck:
Used for staff education during IQIP visits and shared internally within clinics.
GIS social determinants map:
Shows variables such as median household income, employment, and rental occupancy by region.
Educational materials and videos:
CDC and AIM have high-quality videos and podcasts on health equity and community partnerships.
Social Determinants of Health screening tool:
Covers food insecurity, housing, safety, and urgency of needs.
Resource directories:
Many states and counties publish resource guides available online.
Outcomes and Interest
In North Carolina, we have seen significant interest from VFC providers in local equity data. Stakeholders and partner organizations have also expressed interest in working with us to address health equity gaps. Because of this, North Carolina DHHS and our epidemiology section continue to prioritize this work.
This is my contact information if you have any questions. I am going to look at the questions now.
Yes, we do have time for questions. If anyone has questions, feel free to put them in. While people are thinking, Rachel mentioned this earlier. This webinar is recorded and the slides and recording will be sent to the email you used at registration within the next few days. You are welcome to share that with your team or with anyone who could not attend.
Someone just said, perfect. That was my question. Awesome Jessica, I am glad I was able to answer that. That was an easy question, Jessica.
If you have any follow-up questions, feel free to email Rachel. If you would like to learn more about us at Patagonia Health, we are an integrated EHR practice management and billing solution designed specifically for public health departments.
Thank you so much, Rachel, for coming on today and sharing your expertise. We really appreciate it.
Thank you so much.
Thanks everyone for joining us. Have a great day.
