Presentation titleSUB TITLE HERE

Jo Ann Shoup, MA, MSW, MS1

Russ Glasgow, PhD 2

1 Kaiser Permanente Colorado, Institute for Health Research2 National Institute for Health, Dissemination and Implementation

Science, Division of Cancer Control and Population Sciences

Applying the RE-AIM Framework to Policy:

The example of vaccine policy

Presenter Disclosures

(1) The following personal financial relationships with

commercial interests relevant to this presentation existed

during the past 12 months:

Jo Ann Shoup

“No relationships to disclose”

Learning Objectives

• Identify the implications of vaccine policy as a strategy to maintain our public health infrastructure

• Describe elements of the RE-AIM model as relevant to policy

• Identify the broader application of RE-AIM as an emerging policy tool to communicate the impact of vaccine policies to public health officials, policymakers, school officials, parent groups, and medical providers

Public Health Policy

• Public Health Policy� “laws, regulations, formal and informal rules”

• Generally improve population health with

limited resources

• Wide acceptance of policy leads to

changes that are far reaching compared to

individual change

Vaccine Policy: Public Health Context

• Vaccines are among the top 10 public health achievements of 20th century� Significantly reduced or eradicated infectious

diseases in United States

� One of the most cost effective preventive services to date

• Advances in vaccines� Emerging infectious disease

� Non-communicable diseases such as cancer

Maturity

Incidence

Disease

VaccineCoverage

AdverseEvents

Prevaccine IncreasingCoverage

1

Loss ofConfidence

Outbreak

Vaccinations

Stopped

Eradication

Eradication

2 3 4 5

Resumption of Confidence

Evolution of Immunization Programs and

Prominence of Vaccine Safety

Chen & Hibbs, Pediatr Ann., 1998

Historical Comparison of Common Vaccine Preventable Diseases

Policy Impact on Multiple Levels

Individual level � Shift in concerns from risk of disease to risk of

vaccine (safety of vaccine)

Community level� Risk of decrease in community level protection

Policy level � Shift from focus on vaccine coverage programs

to exemption policy

States and Vaccine Policy

States decide exemption policies

Institute for Vaccine Safety, www.vaccinesafety.edu

School Entry Vaccines: Colorado

• All children who enter public school are

up to date on vaccination

• For a child in kindergarten:� DTap (5th dose)

� Polio (4th dose)

� MMR (2nd dose)

� Hepatitis B (3rd dose)

� Varicella (2nd dose)

Birth to 6 Years Vaccine Schedule

Source: CDC.gov

School Exemptions from Vaccination: Colorado

Vaccine exemptions� Medical� Religious� Personal belief

• Colorado rate of personal belief exemption for school entry vaccination is > 5.5% with geographical clustering of 30%+ in some areas

• Vaccine rates are increasing as exemption rates are increasing

Vaccine Exemptions

Three exemption types in Colorado

PHYSICIAN SIGNATURE

PARENT SIGNATURE

Source: Colorado State Health Department

Policy Tools

Lacking policy tools to convey information � Currently policy tools are targeted toward

specific audiences (i.e. policymakers)

� Current policy frameworks are large in scope

and difficult to convey current and proposed

changes

� Current tools do not succinctly convey

� Impact of policy design, development,

implementation, and change

RE-AIM Application to School Entry Vaccination

Policy: Four Questions

• Whose health is to be improved as a result of the policy?� Population of Denver (children in particular)

• What organization or governing body is responsible for passing, or adopting, the policy?

� State level: Colorado

• Who is responsible for adhering to or complying with the policy?

� Parents of children; school officials; State Health Departments

• What organization, institution, or governing body is responsible for enforcing the policy?

� State Health Departments; legal court systems to uphold laws

Source of questions: Jilcott et al (2007) “Applying the RE-AIM framework to Assess the

Public Health Impact of Policy Change”, Annals of Behavioral Medicine.

RE-AIM Dimensions Applied to Policy

• Policy scenario � School entry vaccination policy in Colorado

• *Reach (People impacted)� Number of school aged children who vaccinate

� Percent: Ideally above 80-90%

� Representativeness: Children home schooled are not represented

� Unintended consequence of personal belief exemption—pertussis risk for infants or measles in adults

• Effectiveness (Risk reduction)� Stability or decreases in infectious disease rate; stability or

decreases in exemptions

Source of dimension definitions: Jilcott et al (2007) “Applying the RE-AIM framework to

Assess the Public Health Impact of Policy Change”, Annals of Behavioral Medicine.

RE-AIM Dimensions Applied to Policy

• Adoption (How schools respond)� Core policy component includes maintaining public

support for policy in light of eroding public trust

• *Implementation (Level of enforcement)� Health Departments monitor and enforce the vaccine

policy through data and mandates; court systems uphold mandates

• Maintenance (Sustainability)� Respond to changes in disease rates/exemption rates;

consider policy change if there are significant changes

Conclusions

• RE-AIM can serve as a policy tool, however, data

and dimensions must be presented accurately to

avoid misrepresentation

• Reach and Implementation as dimensions are

the most accessible in RE-AIM

• RE-AIM, in concert with epidemiological data,

may yield a policy tool that is useful to

conveying policy information to broader

audiences

Conclusions

• Vaccine policy is an important strategy in maintaining population health (impact and reach)� Promotes change on individual and community levels

� Reduces risk of infectious disease outbreaks

• Understanding reach and adoption of vaccine policy is important to ongoing maintenance� Examining reasons why trust in policy is eroding

� Considering various mechanisms to reach individuals who decline to participate in vaccination

� Individual level

� Media

Future Directions

• Comparative effectiveness research

� Comparison of vaccine policy options and outcomes

• Social media

� Focus on provision of accurate data and information to

parents making decisions about vaccination

� Using new technology to address concerns (i.e. blogs,

tweets)

� Social media as purpose of empowerment, to give the

user control over the information, as opposed to the

traditional top down approach—Jason Glanz, PI

Acknowledgements

• Russ Glasgow—for mentoring and partnering with me on this idea and presentation

• Jason Glanz—for mentoring in the area of vaccine hesitancy and review of slides

• The RE-AIMers—Russ, Diane, Bridget, and Deanna: for their efforts in bringing together a great panel discussion