Immunization Program

State: TX Type: Promising Practice Year: 2019

The City of El Paso Department of Public Health (CEPDPH) serves the West Texas counties of El Paso and Hudspeth. The City of El Paso is the principal city in the area and is the sixth largest city in Texas and the 20th largest city in the US with a 2015 census population estimate of 681,124, a 4.9% increase from the 2010 census and a 20.84% increase from the 2000 census ( El Paso is located in the Southwest Region of the country and in the Far West corner of Texas abutting the US/Mexico border. El Paso is one of the poorer areas in the nation, with a per capita income of $18,705 that is only 65.50% of the national average of $28,555, thus meeting the criterion of an Economically Distressed Area as defined by the Government Accountability Office. El Paso County's 2014 estimated poverty rate of 23.4% far exceeds the 17.7% state rate and the 15.6% national rate. The leading health disparities in the El Paso area are diabetes, hypertension, obesity, and heart disease. In 2017-2018, El Paso experienced a major influx of influenza, with 12,405 reported cases compared to 4,619 reported cases in 2016-2017, and 6,144 in 2015-2016. The community also lags behind national rate in having proper preventive dental care. With extremely high rates of uninsured persons with limited or no access to preventive health, local providers face multiple challenges in serving El Paso, a community with a disproportionate physician/patient ratio, a high teen pregnancy rate, and a usage of the emergency room for treating basic and preventable health issues.

Issue: The CEPDPH faces multiple challenges in providing the HPV vaccine, as well as other vaccines for preventable diseases. Having a large service area with both urban and rural areas, the CEPDPH needs to work closely with community partners in reaching families with education about the HPV vaccine. It is crucial to have a basic understanding of the challenges that the CEPDPH faces in serving a demographic where many families face very poor prospects to adequate health care, making public health services extremely more important than in other communities where poverty and the lack of adequate health insurance are not as pronounced. The CEPDPH works in a resource-poor backdrop where socio-economic barriers are experienced by the majority of its clients. To illustrate a snapshot of these challenges, when compared to other states, Texas has the largest number of uninsured people in the nation, with more than 4.3 million Texans, including 623,000 children lacking health insurance (Texas Medical Association, 2016). Texas is one of 19 states that has not expanded Medicaid.  In such states, 3.1 million poor uninsured adults fall into a coverage gap” and will likely remain uninsured (Kaiser Foundation, 2016).  These individuals would have been eligible for insurance coverage under the Medicaid expansion; however, they do not earn enough for premium tax credits to purchase Marketplace coverage, which begin at 100% FPL. Disconcertedly, there are over three million uninsured poor non-elderly adults in the coverage gap. In this pool, there are approximately 700,000 uninsured Hispanic non-elderly adults, of which a staggering 52% reside in Texas (Kaiser Family Foundation, 2016). Comparatively, of the uninsured nonelderly adults in the US, 19% of the 1.4 million of the whites and 16% of the 0.9 million blacks live in Texas. Together all subgroups comprise over five million Texans lacking health insurance in 2014, nearly one of every five individuals. Texas makes Medicaid available to persons with disabilities who have incomes below 75 percent of the FPL (under $9,000 a year for an individual); pregnant women with incomes less than 200 percent of the FPL (about $23,500 a year); and parents with incomes less than 19 percent of the FPL (just under $5,000 a year for a family of four) (Heberlein et al, 2012). In a study funded by The Commonwealth Fund, 1,000 Texans low-income Texans were surveyed in late 2013, 2014 and 2015, comparing to 1,000 low-income individuals surveyed in Kentucky and Arkansas, both of which expanded Medicaid under the ACA.

To address the problem, The CEPDPH's Immunizations Program is one of the most engaged prevention programs in Texas with 109 Texas Vaccines for Children (TVC) participating providers and over 60 community partners, including public and private schools, the Housing Authority of the City of El Paso, homeless shelters, community-based organizations, and higher education institutions. The staff works diligently using a multi-pronged strategy comprised of a technical assistance component, a dissemination of information component, and a direct service component. A standout feature of program is the emphasis placed on illness prevention, and in the case of HPV, the prevention of cancer. The strategy allows the staff to focus on the possible negative health outcomes that can comes from not vaccinating, instead of focusing on the modes of transmission, which often is the deciding factor for partners in having their children vaccinated for HPV. Through its technical assistance capacities, the CEPDPH oversees and provides technical assistance to the various participating providers. Technical assistance consists of onsite compliance visits, approving vaccines for ordering, and providing guidance to the providers on strategies to maximize the disbursement of vaccines to the targeted clientele. To disseminate important information about vaccinations, including cancer prevention, statistical information, and best and promising practices, the CEPDPH publishes a bi-monthly electronic newsletter for its TVC and community partners and the staff communicates through an email distribution list for more pressing information. The department also issues frequent news releases to educate the community at-large through feature articles in the El Paso Times and the El Paso Diario, a regional Spanish language newspaper. The CEPDPH also provides vaccines through its own clinics throughout the El Paso area. The department's website provides information in Spanish, as well at and

Goals and objectives: A nurtured healthy and sustainable community; improved communication among a network of partners; and increased HPV vaccinations. The CEPDPH partnered with local TVC providers to develop and implement a community-wide plan to ensure that parents are educated about the benefits of having their children vaccinated for HPV. Moreover, through education on cancer prevention, the CEPDPH increased the number of HPV vaccines over the last five (5) years.


  • 48,254 children, youth and adults vaccinated in 2017;
  • 3,611 HPV vaccines HPV vaccines administered to children and young adults ages 9 to 18 in 2016;
  • 2,258 HPV vaccines administered in 2017; and,
  • 46 outreach events, 40 community presentations, and 47 health fairs in 2017.

The CEPDPH website is:

Issue: As for health-related services, there is a lack of effective coordinated processes to address public health needs, with healthcare prevention. According to the U.S. Census Bureau, in 2016, the City of El Paso was comprised of approximately 683,000 residents ( Of the said amount, eighty percent of the population identified as being of a Hispanic or Latino origin. Characterized by high poverty rates, the population had a per capita income of $18,705. Additionally, according to the American Community Survey, computed from 5-year estimates based on 2012-2016 data, approximately 30% of El Paso residents ages 18 years and older were estimated as having no health insurance coverage in 2016.

Those targeted for the TCV program were families with minor children within from ages nine (9) and older. Specifically the program focused on promoting HPV vaccinations. The program was based on two (2) models that together formed the basis for implementation and long-term success. These models are the Collective Model and Health Information Technology. The Collective Impact Model is based on the assumption that a singular approach is insufficient in satisfactorily addressing complex social problems (Krania and Kramer, 2011). In fact, the model affords a more encompassing approach at managing large group efforts in bringing about change. There are five key elements that comprise the Collective Impact Model. The following gives a brief overview of how the proposed program employs these elements:

  • Element #1: Common Agenda – the proposed program brings together the CEPDPH and its partners in quarterly discussions to foster a greater awareness and joint planning efforts in improving staff readiness and confidence in employing preventive health techniques when necessary. This is accomplished through periodic reviews of existing policies and procedures in how preventive health issues are dealt with and how frontline staff members engages the public.
  • Element #2: Consistently measuring results – the program staff used a circular approach to process evaluation in order to continually learn and share with program partners the short-term successes and to identify areas needing improvement in order to address them in a timely manner.  The Plan-Do-Check-Act Cycle, described in the evaluation section of this document, is a commonly used approach for conducting ongoing process and outcome evaluation in order to continually enrich the process throughout the program period. It serves to ensure that lessons learned through the process can serve for future activities that will support greater awareness and staff's skill sets in the service areas, as well as fostering a responsive network of partners in linking persons to needed services.
  • Element #3: Mutually-reinforcing activities – with a staff comprised of health care professionals and with program partners able to leverage their own skill sets to serve the greater good of influencing and coordinating a higher degree of systemic changes, the CEPDPH was successful in implementing far-reaching and coordinated strategies, than through unplanned and disparate activities.
  • Element #4: Continuous communication – As mentioned before, communication with partners was maintained through formal meeting documents, such as meeting agendas, minutes, and other program materials; thus creating a historic record of the program.
  • Element #5: Backbone organization(s) – While the CEPDPH worked with its partners as needed to ensure community-wide coordination. The CEPDPH ensured that all program activities were accomplished in a timely manner.

According to David Lakey, MD, former Texas Health Commissioner, Texas ranks 47th among the states in HPV vaccination coverage. However, if El Paso County were a state, it would rank 2nd among the 50 states. (, retrieved January 24, 2018). This accolade is truly due to the tireless work of all of the partners working together toward a common goal. To give an example of the collaboration within the network of partners, the CEPDPH Immunizations Program collaborates with the CEPDPH's Medicaid Waiver Program in a manner that enhances and maximizes revenues generated through the Medicaid Waiver Program. In this collaboration, the staff conducted follow-up services to assure a continuum of care after the screening process was given to all clients. Immunization services were tracked through the advance voucher system was an impressive 1,191 for children vaccines (MMR, TDAP, Varicella), 292 HPV, 57 influenza and 97 pneumococcal.

The current practice is better in a variety of ways. First, the partners are now able to track client/patient data over time using both physical records and through the Health Information Exchange, of which the CEPDPH and local hospitals and other medical providers track their client. Secondly, the HIE is equipped with GIS capabilities, making it feasible for identifying "hotspots" within the region where, for example, infections of HPV, STDs and HCV may be occurring at higher rates. The evolution of information technology has created an opportunity for the healthcare industry to provide an improved, lower costing, and efficient patient care system. Secondly, the network of partners that meets frequently on a continuous basis to strategize how the canvas the El Paso area in reaching more and more parents and their children each year has served as the principal tool for the network's successes. Thirdly, the services are tailored for a primarily Hispanic demographic among people who value prevention efforts as a means to deter debilitating illness and to maintain the highest level of health outcomes as possible. In this approach, cancer prevention efforts are typically what broaches the discussion with parents concerning the HPV vaccine.

In 2014, the CEPDPH developed a trans-organizational system for conducting research and implementing public services through a united front, whereby four service agreements and business associate agreements would then be executed. Early in its inception, the Border Public Health Interest Group (BPHIG) facilitated one strategic analysis of the standard operating procedures across partners to create a functional multi-agency work plan, and subsequently implemented a standardized referral interview instrument to enroll, serve and track clients through, as well for conducting future strategic planning, informing policy, and developing programs to meet the public health needs of the community. This is exemplified through the creation and maintenance of the BPHIG, comprised of researchers from the three major El Paso area academic institutions (University of Texas El Paso, University of Texas Houston School of Public Health, and Texas Tech University) supported by epidemiology services from the CEPDPH.

Strategic direction began with a solid targeted mission statement and desired end goals. The CEPDPH strongly encourages other local health departments to forge strong and long-lasting alliances with community partners that can further their mission and reap mutual benefits. The CEPDPH's success largely stems from its institutional capacity and knowledge that is realized through talented, highly skilled professionals, most of which come from El Paso's unique culture bringing tacit knowledge of the community's values and philosophies on preventive health and health care in general. El Paso is also uniquely situated in a landscape far from its state capital and is part of on one of the world's largest border communities. Therefore, the city relies heavily on its own resources and its partners to disseminate preventive health messages and implement its menu of services. Moreover, the CEPDPH bases its programs on evidence-based models and best and promising practices. These models, such as the Collect Impact Model, often are the foundation for adapting widely-accepted practices for the El Paso community, which entails cultural relevance, bilingual staff and program literature, and a team approach to reaching goals. Finally, knowing the community's strengths and health disparities should drive decision-making it developing and implementing public health programs.

The annual budget for the Immunizations Program is $1,120,037. As mentioned before, the Program uses general revenue, Medicaid-Waiver generated funds, and provides services through the state TCV Program.

The program had an evaluation component through which evidence of accomplishment, evidence of completion, and evidence of effectiveness can be measured commensurate with the program's stated goals and objectives. Restatement of goals: A nurtured healthy and sustainable community; improved communication among a network of partners; and increased HPV vaccinations. The evaluation plan included both process and outcome evaluation activities utilizing universally-recognized methodologies. In particular, the program called for the Plan-Do-Check-Act (PDCA) Cycle as the basis for performing program activities, collecting and analyzing data, and completing an evaluation process. The data elements consisted of key indicators, comprised of the number of partners/stakeholders; percent increase in leveraged resources (in-kind, cash, staffing); the number of partner agreements developed; the number of policies or procedures created, amended, or rescinded; the number of small media coverage; the number of participants trained; the percent of participants trained who reported an increase in knowledge; skills, abilities; and the number of trainings conducted. PDCA is a cycle that begins with planning, including defining specific problems (the lack of skills among staff members in dealing with clients with mental health issues), developing a theory to resolve the problem, setting up performance expectations, and identifying key steps to achieving an intended goal (Tague, 2004).  By using this model, the program manager led the staff and partners in identifying key data variables and a united data platform crucial to measuring the success of the long-term strategic plan, and as preparing and analyzing project data for the planning project. The staff is well-versed in organizing data using a variety of graphics (tables, pie charts, bar graphs) to represent a collection of data sets. Hard data was organized in a manner that demonstrates a clear picture of how the program is being implemented and what affects it has brought. A narrative was written quarterly to help explain programmatic data sets and the effectiveness and efficiency of the program. In keeping with this evaluation model, the CEPDPH performed both process and outcome evaluation on the proposed program. Process evaluation consisted of project reviews and QI activities in order to identify and describe evidence of fidelity and necessary deviations from the stated activities, whereas outcome evaluation served to identify and describe evidence of accomplishment and evidence of effectiveness. Correspondingly, process evaluation served to make improvements to the program as needed. As for quality assurance, data was shared with partners and will be evaluated to ensure that all program activities and projected outputs and outcomes remain on schedule. Program reports were written using aggregate data suppressing all private information.

On the other hand, outcome evaluation consisted of utilizing evaluation checklist instruments based on the program objectives, as well as one-on-one and evaluation activities with partners in order to answer whether the proposed program was effective and to what extent. Using a program logic model as a basis for data collection and evaluation, the CEPDPH was able to create a spreadsheet to compile, store and submit data for reporting and evaluation purposes to the project officer. As a result of its comprehensive evaluative functions, the CEPDPH's progress reports to funders contain both qualitative and quantitative data, thus demonstrating a well-rounded approach to answering key evaluation, such as What was provided to whom?” What outcomes resulted?” How did community members respond to the services?” and What impact, if any, did the service(s) have within the target community, and to what extent?”

Lessons learned and accomplishments: The CEPDPH's mission is to conduct high quality research and evaluation, as well as to provide prevention, intervention, and mobilization services to the people of El Paso so they can be healthy, productive, safe, and secure. Most of the CEPDPH's 263 staff members are bilingual (English/Spanish) and bicultural, a true reflection of the community it serves. Its budget for FY 2017 is just over $19 million with approximately 70% from grants, 20% from fees, and 10% from local funds. The department's current grant funding streams include the Texas Department of State Health Services (DSHS), Texas Health and Human Services commission (HHSC), Borderplex Workforce Solutions, Paso del Norte Health Foundation, and Caring for Children Foundation. Lessons learned include: 1) develop and implement culturally-relevant service offerings with highly-skilled staff to reach the community. Be sensitive to cultural norms and values; 2) diversity funding streams through proactive advocacy and development; 3) partner with regional organizations that have complementary goals in order to reach public health goals, 4) build multifaceted interventions that minimize clients falling through the cracks; 5) have a system of rewards to recognize top performing staff and partners to build morale and pride; 6) have clear lines of accountability clearly communicated to all personnel, 7) and employ a reliable and consistent communication plan for staff and partners throughout the implementation of projects.

The sustainability of efforts will be realized by implementing a multi-pronged approach. The CEPDPH is dedicated to ensuring that its policies and systems remain conducive to addressing the community's public health needs through empirical data gleaned from periodic and sustained needs assessments designed for identifying areas where HPV vaccines are lacking along with other health disparities. Joint planning: through the network of partners, efforts will be sustained in the coming years by continuing coordinated planning efforts that maximize the use of funds and partnerships.

I am a previous Model Practices applicant |Colleague in my LHD