Guest Blog: Annette Carley, Michele Foster, Carla Medina

If You Had $100 Million for Global Health

November 2014
David Vlahov

Recently, I participated in a well-attended panel discussion on the challenge of global population growth, sponsored by a consortium of academic global health programs in the San Francisco Bay Area. The discussion ranged from the pressing problems of inadequate and diminishing access to water and food to the megatrend of unremitting urbanization and the need to shift development dollars to where people are and will be.

As the session moved to audience questions, one participant asked, “If you had $100 million and were not allowed to divide it between priorities, how would you spend it?”

A hundred million dollars may seem like a large sum of money, yet it really is not when you consider the range and size of needs in global health; in 2012, the World Health Organization (WHO) reported that global spending on health exceeded $6 trillion annually. Thus, considering what the top priority should be if we had only $100 million to spend is an important exercise in triage because, sad to say, resources will always have limits.

Certainly, the possibilities are overwhelming. Some point to the need for research and development of vaccines and enhancing the availability of existing medications and treatments. Others focus on social determinants of health, which include water, sanitation and transportation infrastructure; or on the promise of shared governance, such as expanding the Latin American model of participatory budgeting, which has led to improvements in infant mortality and life expectancy. Still others propose investing more in the WHO’s urban health observatory, which carefully monitors populations and evaluates programs and policies in areas where most people live around the world; this could be extended to more countries where city growth is rapid, especially in the slums. 

Another area with the potential for a large return on investment is primary education that consciously includes women. The case for this is especially strong in low- and middle-income countries, because education builds human capital, and the inclusion of women enables countries to mobilize the entirety of their human resources.

Perhaps it’s not surprising, though, that I would argue another important direction for progress in global health is investing in the education of nurses. Doing so complements existing structures and resources such as medical schools and tertiary care hospitals for specialty care. Expanding the nursing workforce in community and public health supports essential population health initiatives in prevention, surveillance, primary care delivery and referral. More nursing education also is the fastest way to bring skilled health care workers to the front lines of all forms of health promotion, primary care and midwifery. And more nurses creates a larger workforce of community-level clinicians and leadership-trained community health workers, thus raising the collective knowledge of health and increasing the presence of quality health services for a greater proportion of any country’s population. That would be a pretty good return on a $100 million investment.

Nursing at the Front Lines of Ebola – and Beyond

October 2014
David Vlahov

This month we learned about yet another case of Ebola in the US, where a second Dallas nurse became infected after treating a patient who flew here from Liberia.

We can only imagine what these infected nurses are experiencing. Our thoughts and prayers go out to them and to the others infected in the US, Europe and West Africa. We feel the caution, anxiety and fear of the nurses and other workers who are at the front lines. From a distance we sense the rising level of alarm. Yet as a profession, as colleagues in arms, we can take steps to address this threat.

The first is to put the threat into proper perspective and to not mince words: Ebola is a very dangerous virus. The Centers for Disease Control and Prevention (CDC) and the US Department of Agriculture classify possible infectious agents into levels of threat. Those agents in the highest level (Category A) can result in high mortality rates, might cause public panic and social disruption and require special action for public health preparedness. Category A includes viral hemorrhagic fevers, one of which is the Ebola virus. Given its high rate of mortality (around 50 percent; mortality rates of past outbreaks have varied from 25 percent to 90 percent), it is handled only in the most secure, Biosafety Level-4 laboratory settings. (A note: While the categorization framework was developed for planning around bioterrorism, there is no suggestion or hint of that here. What we are witnessing is an outbreak turned into an epidemic, with the potential to spread through global travel.)

With no vaccine yet and treatment limited to supportive care, step two involves health care workers making sure we can protect ourselves, so we can not just help contain the epidemic, but also address the accompanying public panic and social disruption. Guidelines for prevention are available at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html.

Next, as nurses, we have a role that begins with professional screening, identification and care of the individual patient, family and co-workers, but we must go beyond that. We have a crucial role in educating the communities where we live and the wider community throughout the country and the world. Preventing public panic and minimizing social disruption depends on individuals and communities having information and a sense of support, rather than stigmatization. This will be especially important as the fever and headaches of flu season kick into gear, and as people interact with friends, neighbors and family members who have come from overseas – even those who arrived here long ago. Even as I write this morning, there was a report of a community college in Texas that refused to admit a student from Nigeria.

The first law of epidemics is that whatever goes up must come down. We can make the number of cases and the anxiety surrounding them come down faster if we stick to our training and work together. By conducting objective assessments, making appropriate referrals, providing care with appropriate precautions, and calming others even in the worst of circumstances – this will be yet another time when nursing will be absolutely central to an effective public health response.

Global Disaster Nursing

September 2014
David Vlahov

If ever there was a time to open a discussion about the need for global disaster training in nursing, that time is now.

As the epidemic of Ebola virus infections continues, organizations and individuals around the world are calling for the assistance of health care workers, including nurses. The USAID (United States Agency for International Development) website has information on who is needed and how to volunteer. The most urgent need is for those with training and experience in disaster response, but programs for advanced practice nurses in disaster preparedness and response are few and far between. We believe that needs to change.

Hiroko Minami (DNSc ’82, UC San Francisco School of Nursing), president of the University of Kochi, has been a leading proponent of disaster nursing, having initiated it as a specialty in her school’s PhD program. The vision for that program emerged after the 1995 Kobe earthquake and became especially resonant after the 2011 Tōhoku earthquake and tsunami, which led to the Fukushima Daiichi nuclear disaster and radiation exposure.

UCSF, Kochi and other nursing programs in the so-called Pacific Ring of Fire – home to many earthquakes and volcanic eruptions – have completed memoranda of understanding aimed at promoting programs for education and research in disaster nursing. A few schools in the United States have even developed certificate programs, although a number of those are limited to online education.

Now, however, the response to the Ebola virus epidemic has made clear that other than programs that emerged in direct response to the HIV pandemic, few prepare clinical specialists in infectious disease and population infection control. We believe we can build on existing programs to quickly create full-fledged disaster nursing curricula that include didactics, simulation and experience in epidemiology, and emergency preparedness and response for a wide range of possible events.

Doing so will fill a critical need, as natural and man-made disasters – be they hurricanes, tornadoes, earthquakes, floods, fires, chemical spills, radiation events or terrorist attacks – occur with disturbing frequency. One need only look at this map, which is updated regularly, to understand the urgency.

A key to surviving disaster is to prepare for it. That’s why now is the time to create a cadre of expert nurses who can not only help communities around the world prepare for and respond to population events, but also pursue and promote the much-needed education and research.

 

Ebola Virus Disease and the Nursing Workforce

August 2014
David Vlahov

The World Health Organization reported that as of August 11, 2014, the number of cases attributed to Ebola virus disease (EVD) in four West African countries stood at 1,848, with 1,013 deaths. More than 145 health care workers who have provided care to Ebola patients have also become infected, with 80 deaths so far.

Concern has spread to the United States, as two American health care workers who contracted the disease were flown here and are under care. Tom Frieden, director of the Centers for Disease Control and Prevention, has assured the public that the probability of EVD spreading within the US is remote. Nevertheless, both here and around the world, the virulence of the disease, some misunderstanding of how it is transmitted and a failure to have proper protections in place in some health care settings have caused alarm among those charged with treating EVD’s victims.

Those fears recall memories of when I was an infection control nurse in Baltimore, caring for patients with AIDS early in the HIV epidemic. I remember seeing an AIDS patient placed into full isolation, with nurses and physicians congregated outside the room expressing anxiety about whether they should go in at all. As the Health Resources and Services Administration’s Ryan White HIV/AIDS Program history project noted, some physicians and nursing staffs even refused to provide treatment to those with AIDS symptoms. As people died, stigma and willful ignorance kept many funeral homes from accepting bodies for burial. In 1987, the New York Times published an article titled “When Doctors Refuse to Treat AIDS.” As the country faced a new and highly fatal disease, fear was palpable.

With today’s Ebola outbreak – just as with HIV and other viral outbreaks, such as SARS (severe acute respiratory syndrome) and H1N1 influenza (swine flu) – some health care workers have volunteered to be at the front lines, but others have been reluctant. Such reluctance is understandably highest in the earliest days, especially if the routes of transmission are not well understood, health care workers don’t know how best to protect themselves – and don’t trust their employers to provide them with all of the appropriate protections. That appears to be what’s behind reports of nurses going on strike in the affected West African nations.

Given the dire need for treating EVD patients and containing future outbreaks of the disease, we must:

  • Strengthen the global nursing workforce with increased clinical and public health training.
  • Establish an adequate inventory of equipment and supplies.
  • Provide a public health infrastructure for rapid and effective monitoring and response to emerging events.
  • Train governments to lead efforts in public health preparedness and response.

This is what we eventually did with HIV/AIDS and did more quickly with SARS and H1N1. Such preparedness builds a reservoir of trust and confidence that otherwise can be tested and undermined during emergencies such as the one we are currently witnessing.

Nurses play a crucial role in establishing that trust – not just by our presence at the bedside, but through use of our public health expertise to develop policies and lead and organize our communities. By addressing understandable concerns for our own safety and that of our colleagues and communities, we can help ensure patients receive the care they so desperately need.

 

Reducing the Impact of the Doctor Shortage in a Year

July 2014
David Vlahov

With startling regularity, stories continue to appear in publication after publication in which the authors fret about how to respond to the growing demand for health care, particularly primary care, and the accompanying shortage of doctors. Typically, the writers call for more medical schools, more money for medical students to lower debt, and incentives for medical students to go into primary care.

As we have noted many times before – and in many settings – such measures are important, but they will not be enough and they will not get solutions in place as quickly as is necessary. Meanwhile, there is a more immediate, research-based solution right in front of us – if only state legislatures would listen objectively to the evidence.

Nurse practitioners (NPs) are RNs with at least a master’s degree who are nationally certified for a particular specialty area, such as family health care, midwifery or adult-geriatric care. Compared with physicians, NPs take less time to train, the programs are less expensive to run and the amount of student debt is less. Equally important, studies that the Institute of Medicine has characterized as valid have shown that NPs can safely and effectively deliver 90 percent of pediatric primary care services and 75 percent of general primary care services. Other studies have shown that each discipline sends patients to specialists when needed. Moreover, NPs are more likely than physicians to practice in underserved areas, both urban and rural, where the shortages are most severe.

Despite such findings, we still find articles in national publications in which the authors or their sources espouse relegating NPs to “performing vaccinations and strep tests.” That is a woeful underutilization of highly skilled practitioners. It reflects limited scope-of-practice rules and a narrow vision for addressing the desperate need for more high-quality primary care, which nearly every expert agrees is critical to improving people’s health – and reducing the exorbitant cost of care in this country.

The Bay Area Council Economic Institute recently issued a white paper that, among other things, noted that allowing nurse practitioners in California to practice to the full extent of their education and training could save the state $1.8 billion on preventative care visits alone over 10 years while increasing the number of those visits by 2 million per year. The lead author of the report notes: “While no single policy change will be a panacea for the critical cost and access issues facing California, this reform [allowing nurse practitioners to provide the health care services they were trained and licensed for] could be an important first step to bring down some of the barriers that are keeping healthcare costs artificially high.”

To be clear: having nurse practitioners practice to the full extent of their education and experience does not remove the need for more schools, more funding for the health professions and incentives to draw more professionals into primary care.

But those are longer-term concerns. To meet the shorter-term health needs of individuals and populations, there is a solution available now. It is time for legislatures to stop being distracted by false arguments and expensive lobbying efforts. They should act immediately to free nurse practitioners to practice to the full extent of their education, so NPs can help address the health care needs of the people our legislators serve. 

An Opportunity to Reduce Premature Births

June 2014
David Vlahov

Premature birth is a major public health problem. According to Born Too Soon – a 2012 report co-produced by the March of Dimes, The Partnership for Maternal, Newborn & Child Health, Save the Children and the World Health Organization – worldwide, approximately 15 million babies are born prematurely each year. More than 1 million of these infants die due to complications of prematurity. Prematurity is the leading cause of death for babies in the first four weeks of life, and second behind pneumonia for all children less than 5 years old. Moreover, many survivors face a lifetime of disability, including learning disabilities, vision problems and hearing loss. Even more disturbing, trend data from 65 countries show rates of preterm birth rising in most countries around the world, rich and poor.

However, as the report notes in its executive summary, premature babies can be saved if one considers that, “Inequalities in survival rates around the world are stark: half of the babies born at 24 weeks (four months early) survive in high-income countries, but in low-income settings half the babies born at 32 weeks (two months early) continue to die due to a lack of feasible, cost-effective care, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties. Over the last decade, some countries have halved deaths due to preterm birth by ensuring frontline workers were skilled in care of premature babies and improving supplies of life-saving commodities and equipment.”

UC San Francisco recently received a grant to address this global problem: a combined commitment of $100 million from Lynne and Marc Benioff and the Bill & Melinda Gates Foundation. The funding is to address prematurity risks, education, prevention and treatment in both the wealthy and less wealthy nations. We are proud to share that the School of Nursing played an important role in preparing the proposal and that we are now contributing interprofessional leadership for the planning year that has already begun. Linda Franck, chair and professor of Family Health Care Nursing, is one of the planning-year deputy directors, representing a department that includes nurse-midwives, neonatal intensive care clinical specialists and pediatric and family nurse practitioners. Professor Emerita Sally Rankin has been a key link between the School’s global health nursing program and UCSF Global Health Sciences. I am proud to serve on the project’s Internal Advisory Board.

This is timely, essential work. The research on factors associated with the incidence of prematurity, prevention methods and treatment is incomplete. Over the next decade, this project will frame and address key unanswered questions, taking advantage of a unique opportunity to generate ideas that are both transdisciplinary and transformative. We look forward to joining forces with colleagues from many disciplines to reduce the burden of preterm birth worldwide.

Five Reasons to Support a Commonsense Solution for the Primary Care Shortage

April 2014
David Vlahov

Note: A version of this blog appeared as an op-ed piece in the Thursday, April 10, edition of the San Francisco Examiner.

Congress should reauthorize and fully fund nurse practitioner residencies in primary care clinics. Though relatively new, these programs can play a key role in addressing America’s burgeoning primary care crisis.

Here are five reasons why:

First, the country already lacks enough primary care physicians to meet our health care needs. The problem is especially dire in underserved communities, both rural and urban, where federally qualified health centers and nurse-managed health clinics deliver a huge portion of primary care.

Second, the primary care shortage is worsening due to the Affordable Care Act and the aging US population. According to the Association of American Medical Colleges, by 2025, there will be a shortage of 65,800 primary care physicians. Unless we make a full-bore effort to revitalize the provider pipeline – physicians, nurse practitioners and physician assistants – increasing numbers of needy Americans will be unable to receive the care they need, even if they are insured.

Third, a substantial body of research has shown that for the overwhelming majority of primary care concerns, nurse practitioners, or NPs, perform as well as physicians on clinical outcomes and patient satisfaction. Moreover, NPs can be trained faster and less expensively than physicians and have demonstrated a willingness and ability to work in underserved areas. This does not negate the need for more physicians, but we desperately need all hands on deck.

Fourth, despite the research showing NPs’ excellent clinical results, newly graduated NPs are often discouraged from joining federally qualified health centers because of the intensity and demands of providing service in these complex clinical settings. In fact, the Institute of Medicine’s landmark 2010 report, The Future of Nursing: Leading Change, Advancing Health, called for residency programs, partly in response to concerns that newly graduated NPs would not have had enough experience or training.

This leads to reason No. 5: Nurse practitioner residencies address these concerns. The residencies provide an extra year of hands-on training for newly graduated NPs, often including the opportunity to work in teams with physician colleagues, much as primary care physicians work with specialty colleagues. While it is too soon to rigorously gauge the value of the first wave of NP residency programs, residency is a proven model for training physicians, and the anecdotal evidence about NP residencies – including that from our own program in collaboration with Glide Health Services in San Francisco – is quite encouraging.

Inspired in part by Margaret Flinter, an advanced practice nurse who is the country’s leading advocate for NP residencies, Congress originally authorized a three-year pilot program (2011-2014) that established nurse practitioner residencies in federally qualified health centers and nurse-managed health clinics as part of the Affordable Care Act. Now, US Sen. Bernie Sanders, I-Vermont, has proposed that the NP residencies be reauthorized and funded at $75 million for the next five years.

On Wednesday, April 9, Flinter testified in front of the US Senate Committee on Health, Education, Labor and Pensions in support of that proposal. Hers is a voice the entire country – not just politicians and health care professionals – needs to hear.

After all, in the short term, reauthorizing and funding another five years for NP residencies is an effective, economical way to extend the primary care workforce in the clinics implementing these programs. Long-term, it gives researchers and policymakers an opportunity to rigorously gauge the value of the NP residency concept and establish best practices.

Given the urgent nature of the primary care crisis, the history of NPs delivering exemplary primary care and the low-risk, high-reward nature of this proposal, how can we afford not to support its reauthorization and funding?

I urge both the health care community and members of the general public to ask their representatives in Congress to support this desperately needed program.

How Nursing Can Meet the Needs of an Aging Population

March 2014
David Vlahov

To address the complex health needs of an aging society, schools of nursing have a moral and professional obligation to generate a well-prepared workforce and produce high-quality research that advances health and health care for the elderly. Research efforts must be ambitious but focused, with attention to (1) building evidence-based health promotion and patient care strategies, (2) advancing the science of symptom assessment and management, (3) providing care for the family caregiver, (4) designing community-level interventions to promote safe and healthy environments and (5) analyzing health policy to promote an effective workforce and payment for care.

To achieve these aims at UC San Francisco School of Nursing, we have systematically drawn together faculty across three academic departments, our organized research unit and the rich and enthusiastic array of faculty in geriatric medicine at UCSF School of Medicine. The effort cross-fertilizes with organized and interprofessional faculty activities in our areas of excellence in symptom science and palliative care. The idea is to leverage the work of individuals by fostering creative collaborations that can accelerate and enhance our ability to meet a rapidly growing need. This past week we saw some of the first fruits of our efforts.

On March 17, the John A. Hartford Center of Gerontological Nursing Excellence, led by Meg Wallhagen, PhD, GNP-BC, held a conference on “Innovations in Geriatric Nursing Care.” Organized by Laura Wagner, PhD, RN, the day included talks on new research from our guest presenter, Elizabeth Capezuti, PhD, RN, who is the William Randolph Hearst Foundation Chair in Gerontology at Hunter College of the City University of New York, as well as from several of our junior nursing faculty, to a large audience of academics and clinicians from nursing and geriatric medicine. The conference ended with a discussion between our lead in nursing administration and leadership, Mary Louise Fleming, RN, PhD, and renowned geriatrician John Rowe, MD, from Columbia University’s Mailman School of Public Health, on how nurses and geriatricians can better work together to advance health among the elderly. (Coverage of the conference and other aging-related issues will appear in our April posting of Science of Caring, as well as in subsequent posts.)

And because we are fully on board with the UCSF mission of “advancing health worldwide,” earlier in March, the School held a Sino-American Summit on Geriatric Nursing with Dean Diana Lee and faculty from the Nethersole School of Nursing at the Chinese University of Hong Kong. The summit highlighted the unique challenges in a society where care for the elderly intersects with rapid urbanization and the one child rule; not only are there fewer young people available to care for their elders, but as young people migrate to cities for economic reasons, social relationships within families undergo significant change. The Nethersole School of Nursing faculty has stepped up its efforts to prepare nurses to meet these challenges. Later this year, we anticipate a visit with the dean and faculty from the Hong Kong Polytechnic University, known for its cutting-edge research and education. The goal is to foster a collaboration between our two schools to advance nursing science. Both of these efforts build on our recent trip to China and are a centerpiece of our far-flung efforts to engage in global geriatric nursing care.

All of which speaks to the type of institutional commitment required if nursing is to mount a credible response to the growing health needs of an aging population. The response must go beyond recruiting the best faculty and students and fostering a supportive environment that nurtures excellence in research, education and service. We must prepare geriatric clinicians, while simultaneously generating and integrating knowledge into the curricula for both adult and family care nurse practitioners and clinical specialists. We must focus on individual-level health promotion and nursing care for the elderly, but also address the needs of family caregivers and create a policy climate that encourages independent living. At a school of nursing, all of these things demand enriched mentoring and support of junior faculty, organizing and developing a community of scholars dedicated to this effort, and advancing partnerships with other professions and disciplines.

In a recent UCSF-wide exercise, a broad cross section of faculty, students, alumni and community stakeholders combined to develop a vision for the future of UCSF. The most prolific group on campus was “Team Aging,” an interest group from different professions and disciplines that sees UCSF leading the way in promoting a society that honors and cares for its aging members, whose numbers are increasing rapidly. This group reflects the depth of commitment and the breadth of enthusiasm to make UCSF responsive to one of society’s most pressing health care needs. The vision is inspiring and the promise is great: UCSF can serve as a model for health sciences institutions and schools of nursing around the country. Now, however, we must act on this promise and turn vision into reality.

 

Thank You, Dr. Relman

February 2014
David Vlahov

Dr. Arnold Relman has been a highly influential medical educator and is a former editor of a prestigious medical journal. In the February 6 issue of the New York Review of Books, he wrote of an experience this past summer when, at age 90, he fell down the stairs at home. He suffered a cracked skull, broken vertebrae in his neck and broken bones in his face. He received emergency treatment to check bleeding from his brain and restore his breathing. Resuscitation saved his life, and over 10 weeks, he underwent numerous medical procedures and experienced a number of complications. Almost miraculously, he not only survived, but with rehabilitation, is mostly recovered. His survival is a testament to the emergency care and rehabilitation services he received, as well as to his strong will to live.

His essay is a firsthand account of his hospital experience, combined with some insightful observations about the health care system. In one passage, he points out that “What personal care hospitalized patients now get is mostly from nurses” and confesses that he “had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.”

Just as Dr. Relman is grateful for the nurses’ role in patient recovery, we are grateful for his recognition of that role – though, of course, deeply sorry that he had to suffer this personal trauma to come to a realization that speaks to an often hidden insight about how to improve care.

In short, despite years of advocacy from powerful voices in nursing and medicine, a widely publicized Institute of Medicine report and various nationwide initiatives such as the Magnet program, the role of nursing remains underappreciated and, often, poorly understood in many clinical settings. This lack of understanding can create a culture where low expectations erode the contribution highly trained nurses are capable of making and, at worst, can diminish nurses’ willingness to do their best work.

It’s a culture that most schools of nursing across the country are fighting hard to combat, and as Dr. Relman’s insight makes clear, we are making some progress. We are proud of the training our graduates receive in the technical aspects of care, role differentiation that readies them for working in teams, and communication skills needed to work effectively with patients and families. And we are constantly seeking ways to up the ante, to demand more of our graduates so their patients can reap the benefits.

Thank you, Dr. Relman, for helping us advance understanding.

“And in Flew Enza”

January 2014
David Vlahov

An old joke runs like this:

A child was alone in her cavernous bedroom at the top of a wide, curling staircase in a Victorian Gothic-style house balanced atop a craggy hill. On this pitch-black night with gusty winds and cold, pelting rain, the house was lit only with the strobe of lightning. Windows rattled with each boom of thunder. Suddenly, tall, hinged windows in the bedroom heaved and burst open. With the funnel of cold spray, through the flapping sheers, in flew Enza.

Influenza. It’s that time of year again, and it’s important to remember that influenza is no joke. It comes with morbidity and mortality that are serious threats to public health. As of early January, the CDC reports over 2,600 influenza-related hospitalizations have occurred already this flu season, with 20 states reporting high levels of influenza-like illness. Nationwide, 10 children have died from influenza since October - and in California, the number of deaths is already very close to the number for the entire flu season last year - and we are just entering peak season, which typically occurs from January through March.

The real tragedy here, however, is that providers and individuals too often ignore or underuse effective strategies to mitigate the threat.

As health care providers, we have to make clear to patients that strategies to reduce the risk of an influenza epidemic include education about hand washing, covering one’s mouth and nose when coughing or sneezing – but not with one’s hands – and taking sick days to minimize transmission. Parents should keep sick children home from school.

Immunizations, of course, are especially important, but in past years, rates of influenza immunization have been disappointing. Factors that have influenced low uptake of immunization include the sense that influenza is a trivial inconvenience, that the vaccine is not very effective and that it comes with side effects that might be worse than getting influenza itself. On a population level, data simply do not support these beliefs.

Some also voice concerns about allergy to eggs – some flu vaccines contain tiny amounts of egg proteins, although reactions are uncommon. Some have resented the increasing use of mandatory programs on principle, often expressing mistrust of government, “Big Pharma” or both. Strategies and messages to address these concerns are evolving.

Clinical settings can, of course, help allay these concerns, but especially for hospitals, clinics and neighborhood pharmacies in underserved areas, limited access to care, limited availability of the vaccine and health care providers’ failure to recommend the vaccine have been shown to be the most important factors in unnecessarily low rates of immunization.

There is, however, a model for improving immunization rates. An outreach program I led – with nurses going to communities with high levels of wariness and low access to care – has shown positive results in increasing uptake of immunizations. Project VIVA arose from the Harlem Community and Academic Partnership (HCAP), which was created as a partnership of 30 community-based organizations, four academic institutions and the local health department. In an effort to address health disparities in Harlem, the basic strategy of HCAP was to have health professionals work with communities to develop nontraditional tactics to enhance the work of public health departments.

After establishing an intervention work group to address the low rates of influenza immunization, the Project VIVA team began by assessing the reasons for the lower rates. Then, by tapping into the leadership ability of community members, we developed a number of strategies, including having community members design brochures for distribution and having outreach workers provide education and referral to convenient, nontraditional settings such as street corners where nurses provided immunizations. The result was that even among those who expressed reservations about the vaccine and were frustrated by the inconvenience of scheduling visits in traditional clinical settings, our efforts improved the rates of immunization.

We believe the presence of nurses was a crucial success factor. Over the past decade, nurses consistently top national opinion surveys about the most trusted professions. No matter the setting, our taking the time to talk with patients about influenza – including behavioral steps to reduce transmission and the role of immunizations – is an important strategy for reducing the risk and impact of influenza epidemics.

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