Houston Middle School Initiative (Texas)
||Houston Middle School Initiative
||5th and 6th
grade students in two Houston area school districts
||National Foundation for
Infectious Diseases, Episcopal Health Charities, Houston Endowment, GlaxoSmithKline, Texas Department of Health and Human Services, City of Houston
Department of Health and Human Services, Saint Luke’s Episcopal Hospital, and
other organizational and individual volunteers.
did program begin?:
||Project took place during
the 1998-2001 school years
||Over three years, the
program vaccinated about 14,000 students.
||William J. Martone, MD
National Foundation for Infectious Diseases
4733 Bethesda Avenue, Suite 750
Bethesda, MD 20814
Phone: (301) 656-0003
Fax: (301) 907-0878
In a public health initiative of hepatitis B education and immunization programs in Houston, Texas
middle schools showed that underserved adolescents could be successfully
vaccinated through school-based programs. The initiative identified factors associated with and barriers to program participation and
receiving a complete vaccine series. A separate survey of fourth graders’ parents of diverse socioeconomic
status (SES) found additional potential barriers to this approach.
The Houston middle school initiative was initiated to improve immunization rates
among the underserved in Texas, a border state with a large unimmunized population. During the
three school years from 1998 through 2001, participating schools in two Houston area school districts
offered school-based hepatitis B immunization for 5th or 6th grade students. Participating schools had a high
percentage of students from lower socioeconomic levels (as measured by
percentages of children receiving free lunch and percentages of "at risk" youth
based on school system profiles). The program provided all immunization doses
free at school with parental consent. Educational activities included
orientation for participating school nurses, a video for students shown in
schools, and speaking engagements at parent organizations. One environmental
influence was a state school entrance requirement for hepatitis B vaccination by
age 12, which took effect in year three of the program.
Sponsored by the NFID, the project received financial and/or indirect support
from Episcopal Health Charities (year 1 and year 2), Houston Endowment (year 3), GlaxoSmithKline, the Texas Department of Health and Human Services, the city of
Houston Department of Health and Human Services, Saint Luke’s Episcopal
Hospital, and other organizational or individual volunteers. program were having
Medicaid or private insurance and being female.
Middle School Program Results
Each year the majority of participants received all three doses in the
hepatitis B series, and the percentage of those receiving the full series
increased each year. Some students received all doses at school, while others
had one or two outside of the program. Over three years, the program immunized
about 14,000 students. Factors associated with completing the series included
race and ethnicity (Latinos 81%, whites 77%, and blacks 69%); Medicaid or
private insurance among whites; and being female among Latinos and blacks.
Researchers concluded that, since access was equal, cultural differences
independent of socioeconomics might affect immunization decisions. More study of
these factors is warranted.
Barriers to Participation
The primary barrier to participation was the state requirement that parents
sign a consent form for each immunization. Forgotten consent forms and the repeated need for teachers and
nurses to collect forms impeded sign-up and scheduling.
In a separate survey regarding hepatitis B immunization consent and site
preferences conducted among fourth graders’ parents of diverse socioeconomic
status, 27% of parents said they preferred to sign consent for each dose, and
almost half wanted to sign all three forms and be present for all immunizations.
These preferences remained consistent across all ethnicities and incomes.
Addressing parental preferences in a way that does not hinder immunization
completion will be an important issue for school-based programs to resolve.
Most parents in both high and low SES groups preferred the school clinic for
immunization; however, 36% of parents in the higher income group preferred receiving the vaccination
series from a private doctor versus 28% in the lower SES group. Latinos were
more likely to prefer the school site.
The survey of parents identified another potential barrier: lack of parental
knowledge about hepatitis B and the vaccine. For example, large percentages of parents did not know that
hepatitis B is transmitted by unprotected sex (60%), IV drug use (55%), or exposure to infected blood
(39%). Almost one in 10 thought you could get the disease from the vaccine.
Although the school requirement for hepatitis B vaccine took effect during
the final year of the immunization campaign, the program noticed no difference
in the number of children needing immunization. Possible explanations are that
no change occurred because it was a new regulation that parents and schools were
not familiar with or that the requirement was not well-enforced. Enforcement is
an important aspect of improving immunization rates through school requirements.
After discussing the issues related to adolescent and adult immunization
among the ethnically diverse populations in the U.S. and Canada, the panelists proposed a number of
approaches for achieving full immunization among all populations. In addition to supporting the
recommendations of individual presenters, the panel agreed on broad strategic principles and actions to
address immunization disparities comprehensively. These recommendations include:
Advocate for state insurance commissions to require all medical insurance
underwriters to provide coverage for recommended routine vaccinations for adolescents and
Conduct pilot projects to evaluate new approaches and use the results to
refine programs and strategies; disseminate results to promote wider use of effective
Require all medical insurance programs, both public and private, to pay
for recommended immunizations for adolescents and adults and to remunerate healthcare
providers sufficiently for vaccine services.
- Initiate and advocate for government-sponsored adolescent and adult
immunization programs that provide infrastructure and support for vaccine
purchase, vaccine administration, and educational programs.
- Develop a clear, harmonized immunization schedule and immunization
standards that include all vaccines recommended for adolescents and adults.
- Where possible, use age-based, universal recommendations rather
than risk-based categories. Identifying risk status is more
difficult than determining age for providers trying to follow
- Make the standards as simple as possible to facilitate use.
- Distribute these standards widely to providers to create a
standard of practice and provide practical guidance.
- Encourage the expanded involvement of nontraditional vaccine providers
who offer immunizations at convenient sites in the community.
- Bring government-funded immunization services to institutions housing or
serving high-risk or underserved populations. These include:
- Sexually transmitted disease clinics
- Nursing homes and hospitals, where standing orders and prompts
might be written
- Initiate and advocate for state middle school entry immunization
requirements for adolescents.
- Develop educational interventions to improve the knowledge, attitudes,
and skills of healthcare providers.
- Increase provider understanding of and response to the needs,
preferences, and cultural issues of underserved adolescent and adult populations.
- Encourage writers and publishers of medical school textbooks on
internal medicine topics to address immunization issues
- Include outreach to healthcare providers who treat high-risk
adolescents and adults they can play an important role in informing
their patients about vaccination needs. Also involve obstetricians
and gynecologists, who often serve as primary care providers for women.
- Create educational interventions to improve the knowledge, attitudes, and
behaviors of consumers.
- Target campaigns and materials to underserved audiences to
maximize their effectiveness. Make sure products and messages reflect the needs,
preferences, and cultural sensitivities of the audience.
- Create developmentally appropriate materials for adolescents.
- Increase the use of interventions shown to be effective in increasing
immunization rates, such as provider reminders, patient reminder/recall, assessment and feedback, and
- Offer immunization record cards for adults to fill out and keep