Picture Me Healthy

State: CA Type: Model Practice Year: 2005

The "Picture Me Healthy" photo book program provides all families utilizing Public Health Department Immunization Clinics with a cost effective, educational incentive that encourages immunization compliance. In 1993, Madera County`s immunization rate for two year old children was one of the lowest in California. At a rate of 28%, nearly three quarters of young children were not fully immunized. Fearful of an outbreak such as occurred from 1989-1990 with Measles, where 55,000 U.S. children became ill and 123 died, staff strategized ways to address this problem. The idea of an incentive that would be attractive to parents and that would serve to improve the visit`s perception by parents, but one that would also be educational and motivational was born. Since many of the families served by this Department are of limited income, and often are not able to afford routine photographs of their children, the "Picture Me Healthy" baby photo book program was created Public Health programs were asked to contribute outreach messages to be included in the book (tobacco, perinatal). Since the project`s inception, immunization rates have increased to over 85%.
The public health issue addressed by the "Picture Me Healthy" program is that of early childhood immunization and improving immunization rates in a rural public health setting. The issue came to the forefront following the U.S. Measles outbreak in 1889 - 1990 where in our small county, we experienced over 100 documented cases. Fearful of another such event, staff made improving immunization rates in our county a top priority and set about to identify strategies which would not only be cost effective but easily implemented. The " Picture Me Healthy" program addresses this issue through a multi-faceted approach. First, parents/caregivers of children under two years of age all recieve an incentive (the photo book) at the first clinic visit. At each subsequent visit, a photo is taken and placed in the book. At completion, and if the parent chooses the family`s photo is taken and placed on the clinic bulletin board in honor of their accomplishment. Second, the book provides our nurses and program staff with an outreach and educational tool. At each immunization milestone two pages are devoted to growth/development and health information in a simple, low literacy format linked to the developmental period associated with the age the photograph was taken. Finally, below the photo is a space for the date of the next immunization to be written. This reminder is evident, everytime the parent looks at the photo or shows it to friends and family, reinforcing the need to return. The "Picture Me Healthy" program differs from other approaches as it provides postive reinforcement to parents through a simple low cost incentive (photo book and photos). It is unique as it was created to specifically meet the needs of the clients we serve in rural central California, but it can be easily adapted to any area or to changing program needs as it is maintained on our departmental computers. Many of the families served in the clinics are very low income or migrant, with little disposable income for photos of their young children. This simple to create and reproduce project provides an incentive to parents to encourage them to complete their child`s initial immunization series. It reinforces the clinic experience in a positive way and helps families to view the experience as something to look forward to as opposed to dread. Families participating in the program, frequently bring their children "dressed up" in anticipation of the photo to be taken. Another unique aspect of the photo book is that it is easily revised or changed. Created with free clip art on our departmental computers, as immunization schedules change or we have programs that want to include outreach information we simply make the changes of the document. In addition we have shared the book via disk with local providers in the community who can then customize and print their own version. As parents seek care in the community they can continue to complete the photo series.
Agency Community RolesAlthough this practice began as an internal project it has grown and expanded over the years. Developed initially though collaboration of public health department staff, the project has been shared in the community and to other immunization programs in other counties and states. The Madera County Public Health Department updates its version periodically and provides copies (computer disk or hard copy)without charge to interested agencies. In addition, staff are happy to share our department`s experience, suggestions for equipment and how the photo process works in the department with agencies wishing to implement it. Clinic staff also provide updates to participating community service organizations during their meetings to keep them informed regarding the program. This willingness to partner and share resources has led to increased dialogue between agencies, the community and providers. It has improved the perception of the Public Health Department in the community and decreased barriers for other collaborative activities such as immunization registry implementation, health fair participation and disaster preparedness training and coordination.  Costs and ExpendituresThe "Picture Me Healthy" photo book was originally created through a grant provided by the Maternal Child Health Immunization Outreach Program, which allowed for staff time to develop and initial printing. The cost of the book for professional printing and spiral binding is $3.00 per book, photos run approximately $.13 per photograph. The total cost per child to complete the book equates to approximately $3.50, but the cost savings can be huge if only one case of vaccine preventable disease is avoided. It is estimated that for every dollar spent in vaccinating against Measles Mumps and Rubella, $14.00 are saved in health care costs, other vaccines administered represent similar savings. For a total project cost of less than $2,000/year, the savings and benefits far exceed the cost. Staff that are already assigned to the clinic take turns as photographer when they are not with clients, so as not to incur additional staffing costs. As more programs have provided outreach and education information to be included, the cost of the book can now be shared by those programs as outreach materials. Local service organizations initially provided support through the provision of cameras and film, and are willing to assist as needed if funding decreases. The greatest cost to program sustainability is the printing and binding costs, but by sharing the cost between programs not only is the burden of cost reduced, other resources are now able to be leveraged and programs have been able to significantly increase their outreach and educational efforts.  ImplementationThe initial objective for the project was to improve immunization rates of young children in our county and in turn, decrease morbidity from vaccine preventable disease. The project was developed over a six month timeframe as staff worked to create a product that would meet the needs of our clients and be both educational an motivational to participants. Once the book was created,printed and translated into Spanish, staff began using it immediately. Clinic procedures were adjusted to allow for families to have the photo taken prior to the child receiving the immunization and to process the photo so that it could be placed in the book prior to the family leaving the clinic. With minor changes to the clinic`s standard operating procedure these adjustments were made and have become institutionalized. The photo book program has become an integral part of our immunization clinic operation.
The outcomes from this project were measured by analyzing Public Health Department immunization rates pre and post project implementation. Over the course of this project, immunization rates for children two years of age and under have increased from a low of 28% to now over 85%. Because other strategies including expanded clinic hours also occurred during this time period, the increased rate can not entirely be attributed to the photo book program, however, parent satisfaction surveys indicate that the program had a positive influence on their desire to return for additional services. In evaluating cost versus benefit, the significant increase in immunization rates translates into healthier children and a overall healthier community. The total cost for the book as mentioned earlier equates to approximately $3.50/book, but in health care costs for a vaccine preventable disease thousands of dollars can be saved. Finally, the unintended consequences have been significant. Parents now look at the clinic as a much more positive place to come. They bring their children dressed and ready for the photo they know is going to be taken and they remind us if we happen to forget. In addition, staff have also been positively impacted, as they enjoy creating seasonal backdrops and sharing with the parents the photos that are taken. Additionally, parents who might not otherwise be reached are receiving basic health, growth and development information in a cost effective manner that is likely to be seen and reinforced each time they look at the photos in the book. Although the photo book is only one aspect of our immunization improvement strategy, we now have immunization rates well over 85%. Parents come to our clinic looking forward to the visit, the clinic atmosphere is more positive, for both parents and staff and since for many of our families, these are thw only pictures that they have of their children, they truely appreciate this special opportunity. The results of this project are multi-faceted, we have improved immunization rates significantly in the County, staff and parents are more positive about the immunization clinic experience, we have built enduring partnerships with our community and most importantly, vaccine preventable disease incidence is extremely limited in our County.