Old North State Medical Society - CIDRAP



Old North State Medical Society

North Carolina

Pandemic Influenza

Health Disparities Prevention Project

Eugene C. Hines, Jr., M.P.H.

Project Coordinator

TABLE OF CONTENTS

Project Background--------------------------------------------------------------------------------3

Purpose----------------------------------------------------------------------------------------------4

Disparities Prevention Team---------------------------------------------------------------------4

Pilot Sites-------------------------------------------------------------------------------------------5

Process----------------------------------------------------------------------------------------------5

Rationale for Key Informant Interviews-------------------------------------------------------5

Who Was Involved--------------------------------------------------------------------------------6

Questions asked Key Informants ----------------------------------------------------------------6

Findings: The African American Community------------------------------------------------7

Findings: The American Indian Community--------------------------------------------------9

Findings: The Hispanic/Latino Community--------------------------------------------------11

Rationale for Focus Group Sessions------------------------------------------------------------13

Questions asked Focus Groups -----------------------------------------------------------------13

Findings: The African American Community-----------------------------------------------14

African American Focus Group Participant Profiles---------------------------------------15

Findings: The American Indian Community------------------------------------------------18

American Indian Focus Group Participant Profiles-----------------------------------------19

Findings: The Hispanic/Latino Community--------------------------------------------------22

Hispanic/Latino Focus Group Participant Profiles------------------------------------------23

Key Points------------------------------------------------------------------------------------------26

Recommendation----------------------------------------------------------------------------------26

Project Background

The North Carolina Pandemic Flu Program is charged with the task of preparing for influenza pandemic in an effort to minimize the impact of this natural disaster on the State’s residents. Specific goals include reducing pandemic flu related mortality and morbidity as well as social disruption. To achieve these goals, there must be a systematic implementation of rapid outbreak response actions and the provision of other countermeasures, including personnel, risk communication, and health interventions, and guidance to those at risk of pandemic influenza.

The funding guidance for Pandemic Influenza Guidance Supplement to the 2006 Public Health Emergency Preparation Cooperative Agreement Phase II includes a mandate to address the needs of vulnerable/special populations. The definition of vulnerable populations includes those who need extra support to be prepared as well as those who need community support to successfully respond and recover when most disasters or emergencies strike, including pandemic flu. Of particular concern is the development of strategies focusing on racial and ethnic minorities disproportionately impacted by health disparities so as not to further exacerbate these disparities at the time of pandemic influenza.

In order to guide the development of statewide strategies to reach vulnerable populations as mandated in the funding guidance, The Old North State Medical Society ( ONSMS), Inc. has implemented a health disparities prevention project focusing on pandemic flu planning, preparedness, and response in African American, American Indian, and Hispanic/Latino communities. ONSMS is uniquely qualified for this project given that the Society is the nation’s oldest association of black physicians. The Society was founded in1886 and has, from that date until the present, directed its energies to the objectives of equity in healthcare, equal opportunity for black professionals and equal care for black, other minorities, and very poor patients. The ONSMS represents the interests of 1,200 African American physicians practicing in North Carolina. ONSMS is dedicated to furthering equitable access and health care delivery to all patients, regardless of race, ethnicity, socio-economic status, or other indices. ONSMS advocates and helps promote strategies and partnership development to engage all our communities in eliminating health disparities and improving and maintaining the health status of North Carolina residents. This project brings to bear the leadership, vision, perspectives, knowledge, skills, abilities, and commitment of the state’s African American medical community to assist the North Carolina Division of Public Health (DPH) in pandemic flu planning, preparedness, and response strategies, and activities that help assure that African American, American Indian, and Hispanic/Latino communities in North Carolina are reached in the event of a pandemic flu outbreak and that the communities are not disproportionately adversely affected by the outbreak.

Purpose

Usual and customary methods of disaster and emergency planning, preparedness, and response often fall short in reaching every community resident. Experiences with natural and man-made disasters and other emergency events have shown that those with the greatest needs and the greatest risks may not be reached through the usual and customary process, channels, and messages. Pandemic flu planning, preparedness, and response dictate that officials responsible for planning and execution, develop and implement processes to define, locate, and reach segments of the population that may have special needs and who are at greater risk due to vulnerabilities such as language, culture, physical, or mental ability.

As a result of activities in this project, a process has been developed that guides the DPH in what it can do to locate and reach African American, American Indian, and Hispanic/Latino communities in pandemic flu planning, preparedness, and response and thereby increase the level of confidence in the public health system’s ability to meet the needs of and protect fairly and equitably African American, American Indian, and Hispanic/Latino communities in the event of a pandemic flu outbreak.

Disparities Prevention Team

A key component of this project was the formation of a racially and ethnically diverse, multi-disciplinary group to advise the ONSMS and the DPH on engaging and reaching African American, American Indian and Hispanic/ Latino communities on pandemic flu planning and response. Thirty-eight individuals from across the state were invited to participate on this team, which is chaired by the president of the ONSMS Dr. George L. Saunders III. The team organized three Work Groups to define, locate and reach African American, American Indian, and Hispanic/ Latino communities to serve as pilot sites for developing models for reaching special populations. The chairman of the African American Work Group is Mr. Moses Carey, J.D., MPH an African American. The chairman of the American Indian Work Group is Mr. Gregory Richardson, an American Indian. The co-chairmen of the Hispanic/ Latino Work Group are Ms. Florence Siman, MPH, a Latino and Dr. Peter Morris, a Caucasian member of a Latino community based organization. Each of these work groups has a Physician Liaison who is a member of the ONSMS.

The Disparities Prevention Team has held monthly meetings to review the progress of the project and make recommendations for future developments.

Pilot Sites

The African American Work Group selected Edgecombe County as it’s pilot site. Edgecombe County is located in the eastern part of North Carolina and has over 31,000 African Americans of it’s over 51,000 total population. The American Indian Work Group selected Robeson County as it’s pilot site. Robeson County is located in southeastern North Carolina and has over 49,000 American Indians of it’s over 127,000 total population. The Hispanic/ Latino Work Group selected Chatham County as it’s pilot site. Chatham County is located in central North Carolina and has over 6,000 Hispanics of it’s over 58,000 total population.

Process

The Work Groups helped to identify community leaders in each of the three counties that would serve as “Key Informants” to their work group on how to accomplish the project purpose. Some County Health Department Directors and some Key Informants helped to identify other Key Informants until a total of five Key Informants in each county were selected to be interviewed. Some Key Informants recruited one or two other persons to be interviewed with them. A Key Informant interview protocol was developed to guide the process of interviews. Key Informants were individuals from the respective racial/ ethnic group who are well know and well respected in their community. The interviews were conducted by the Project Coordinator, Eugene Hines, using the Key Informant protocol and where recorded. Prior to the interview, a power point presentation on Pandemic Flu was shown.

One Key Informant from each county was selected to organize and conduct two focus group sessions in their county with individuals from their respective racial/ ethnic group. A total of six focus group sessions where conducted using protocol developed to guide the Key Informant. Sessions were recorded on tape and by a note taker on flip charts. Prior to the session, a power point presentation on Pandemic Flu was shown.

RATIONALE FOR KEY INFORMANT INTERVIEWS

The rationale for conducting in-depth discussions with KEY INFORMANTS was the following

▪ Solicit from leaders in each racial/ethnic group, persons who are grounded in the community, with insights that can be highly useful in understanding the nature of communications within racial minority communities;

▪ Use their knowledge to help develop hypotheses for testing in phase 2 – community focus groups; and

▪ Gather from respected community leaders from each racial group an initial sense of how racial minorities might perceive and react to public health plans for risk communications during a pandemic.

WHO WAS INVOLVED

What follows is a list of the participant descriptions of each KEY INFORMANT interviewed. Please note of the 19 interviewees, some individuals may be in more than one category.

▪ Director Community-Based Organization

▪ Minister

▪ Leader/Staff Member, Tribal Council

▪ Rural Health Clinic Administrator/Staff Member

▪ Community Advocate

▪ Elected Official/County Government Administrator

▪ Outreach Coordinator For Community-Based Organization

▪ Americorps Staff Member

Questions asked Key Informants:

1. Describe their racial/ethnic group community.

2. Describe what, if anything distinguishes their racial/ethnic group from other racial groups in the community?

3. Describe how their racial/ethnic community group fit into the community at large including their county/town of residence and the state

4. Describe how they (KEY INFORMANT) interacts with the racial group

5. Identify who from their racial/ethnic community might be likely to miss important news about the emergency and how to respond (Hard to Reach)

6. Describe what, if any, experience they as Key Informants, had had in relaying vital information in a very quick time frame to this audience defined as might miss important news about an emergency.

7. Define circumstances that might make it difficult to relay critical pandemic flu information to individuals they defined as “might miss important news.”

8. Identify unique communication channels to relay pandemic flu information to individuals they defined as “might miss important news.”

9. Identify alternate communication channels to media – not television, radio, or newspapers – that would be the best communication channel to reach individuals they defined as “might miss important news.”

10. Identify the most effective way to reach individuals they defined as “might miss important news” with fairly complicated instructions about what to do to be safe.

11. Identify the elements of How should information be presented so it is understood and directions can be followed?

12. Identify who would be the best and least effective spokesperson.

13. Identify who might serve as a source of comfort in the event there was disease outbreak.

14. Identify where individuals they defined as “might miss important news” might turn to for more information.

15. Identify steps that would help to minimize panic and fear

16. Offer general advice that might be helpful to the project

17. Identify other agencies and organizations serving the racial population

18. Identify other KEY INFORMANTS

Findings: The African American Community

The African American position in the county:

When asked to describe their community the African American key informants in Edgecombe County believe that their community was over half of the population of their rural county with a high rate of illiteracy and a large number who were not attentive to health maintenance due to lack of funds. Generally speaking, the community is considered to be low in wealth with agriculture as the primary industry. There are a large number of single parent homes in what is considered a close-knit, cohesive community. Because of the large number of youth who leave the community, Edgecombe has become an aging community with transportation issues.

The difference between the African American community and other racial groups is that a higher percentage of African Americans live at or below the poverty level. 30% of the African Americans are thought to be on Medicaid and the poor tend to cluster together.

African American influence in the county is growing, but they are still under-represented based on their numbers in the county.

Key Informant Interviewees:

The key informants who were interviewed live in the African American community and work in the community or with all segments. Some serve or have served in elected office and/or as volunteers on various boards of community agencies that serve their community.

Identifying and communicating with the “Hard to Reach” in the African Community:

When asked who in the African American community might be likely to miss (hard to reach) important news about the emergency of pandemic Flu and how to respond, the following answers were given: The elderly and those in the age range from 16 to 25. The younger age group does not listen to traditional news outlets for information. In addition, those with substance abuse issues, the homeless, those living in public housing and those living in rural areas would be likely to miss the news.

Two of the key informants had prior experience relaying vital information in a quick time frame to hard to reach individuals.

Circumstances that might make it difficult to relay critical Pandemic Flu information to the “hard to reach” are as follows:

There are many citizens who do not have telephones or access to cable television. Senior citizens in some communities have set up a telephone tree to communicate about emergencies but those without telephones cannot participate. Senior citizens also have centers where they congregate and receive information, but transportation is a problem for a large number of them. If the appropriate messenger is not selected, some individuals will not believe the information. Some key informants believe that they have been excluded from developing response plans by the health department and do not know what the plan is; therefore they cannot help relay critical information to the “hard to reach”. Another key informant was concerned about their limited healthcare system and the impact of Pandemic Flu on their community infrastructure thereby making it difficult to relay information to the “hard to reach”.

Most effective means of communication:

The best communication channel to relay Pandemic Flu information included using the churches, community meetings and door-to-door outreach along with the use of traditional means. Traditional means included free community television using first responders such as fire and rescue squads, and cable television for reaching the youth. Telephone and cell phone outreach as well as Gospel radio and television programs were suggested. Another unique channel of communication mentioned was schools and businesses with their employees.

Least effective means of communication:

The least effective sources of getting information to the “hard to reach” are the newspaper, internet, a child bringing information home, relying solely on mainstream television channels and form letters. The least effective spokespersons are elected officials, the Health Department (one key informant) and people who do not understand the community and its dynamics.

In order for information to be understood and directions followed, information should be presented as simply as possible, not using long sentences and focus on what to do.

The best sources to deliver the information:

The best spokespersons for this kind of news was identified by three key informants to be the Health Department, people who live in the community and are community leaders, ministers, physicians, and pharmacists.

If people needed to find out more information about Pandemic Flu, the health Department, health care agencies, pastors and community based organizations were identified as places to go.

The Health Department, County Manager, ministers, the medical community, Red Cross, armed forces and law enforcement were identified as sources of comfort in the event of a disease outbreak.

The most important things that can be done to minimize panic and fear are to stress positive outcomes, be consistent with messages, and begin early education of people about Pandemic Flu.

Findings: The American Indian Community

The American Indian position in the county:

When asked to describe their community the American Indian key informants in Robeson County believe that their communities were mostly families and very family oriented. Indians make up about one-third of the county population with a large concentration found in the town of Pembroke. Indians are not all alike and are divided along economic lines between the perceived “haves” and ‘have-nots”. They are a proud people who are taught not to go out and ask for help for which they cannot pay.

The difference between the American Indian community and other racial groups is that Indians work primarily through informal networking. A lot of the Indian population would be slow to be informed about pressing concerns that would make their lives better. There is a lot of poverty in the Indian community which results in transportation problems and literacy issues.

The Indian population is politically cohesive and fairly represented in local government. They are involved in decision-making and have some professionals along with their working poor.

Key Informant Interviewees:

The key informants who were interviewed live and work in their communities and are community leaders who are heads of community-based organizations.

Identifying and communicating with the “Hard to Reach” in the American Indian Community:

When asked who in the Indian community might be likely to miss (hard to reach) important news about the emergency of pandemic Flu and how to respond, the following answers were given: the poor, those living with HIV, persons not active in the faith community, those who are homebound, the elderly, those with low educational levels, those with substance abuse issues and those who work all the time.

Four of the eight key informants had prior experience with relaying vital information in a quick time frame to hard to reach individuals.

Circumstances that might make it difficult to relay critical Pandemic Flu information to the “hard to reach” are as follows: the uniqueness of Pandemic Flu, economic circumstances of the “hard to reach”, the fact that the county is large geographically and some people live in remote areas.

Most effective means of communication:

The best communication channels to relay Pandemic Flu information included using community-based organizations, the faith community, word of mouth, Indian owned television stations and local leadership.

The fastest way to get in touch with “hard to reach” individuals is to train lay leaders of the churches; put fliers in beauty shops, barbershops, and little local dine-in areas.

Least effective means of communication:

The least effective sources for getting information to the “hard to reach” segment of the population are newspaper, relying on one communication source, relying solely on health authorities from Raleigh, to quote one key informant “I’ll tell you what wouldn’t work. Two hundred people from Raleigh just coming down here on buses deciding that they would just take care of this problem for us.”

The least effective spokespersons are perceived to be anyone from outside the community, the Health Department, politicians and law enforcement.

The best sources to deliver the information:

Giving “hard to reach” individuals fairly complicated instructions about what to do to be safe is best done by getting a think tank together to simplify the information and using churches and local people to deliver the information face-to-face.

In order for information to be understood and directions followed; lay outreach workers who are trusted members of the community should be trained to deliver the information. Graphics should be used as much as possible and information should be presented simply and as straight forward as possible.

The best spokesperson for this kind of news was identified as the Chairman of the Tribal Council, ministers and trusted organizations that are serving and know to the community.

If people need to find out more information about Pandemic Flu, churches, the tribal office, Indian health professionals, Indian law enforcement, health agencies and the Department of Social Services were identified as places to go.

Persons who had lived through a pandemic, churches, family members and health professionals were identified as sources for comfort in this event of a disease outbreak.

The most important things that can be done to minimize panic and fear are to develop plans for agencies with outreach workers to coordinate these efforts to do face-to-face education, and to begin immediate education of the public.

Findings: The Hispanic/Latino Community

The Hispanic/Latino position in the county:

When asked to describe their community the Hispanic key informants in Chatham County believe that their community makes up about 20% of the county population and about 50% of the town of Siler City. They described their community as hard-workers who are family oriented and do not like to participate in government events or draw attention to themselves because of concerns about their immigration status.

The difference between the Hispanic/Latino community and other racial ethnic groups is that they are more concerned about immigration issues. They have no representation in government and because they come from various countries, is not a homogenous group.

Key Informant Interviewees:

The key informants who were interviewed all work in their community and are trusted and known by community members.

Identifying and communicating with the “Hard to Reach” in the Hispanic/Latino Community:

When asked who in the Hispanic/Latino community might be likely to miss (hard to reach) important news about the emergency of pandemic Flu and how to respond, the following answers were given: people who live outside the city, those with substance abuse problems, people who are in the country illegally, and moms who are home without transportation.

Only one of the key informants has experience relaying vital information in a quick time frame to “hard to reach” individuals.

Circumstances that might make it difficult to relay critical Pandemic Flu information to the “hard to reach” are as follows: There are many Latinos who do not speak English and there are different dialects of Spanish. There is a low literacy rate in the community. Many do not have access to a television. A lot of Latinos work very long hours and have a lack of trust of authority figures.

Most effective means of communication:

The best communication channels to relay Pandemic Flu information included using churches, face to face communication, soccer leagues and through their employers. One of the fastest ways to get in touch with “hard to reach” individuals is using the radio. The church was mentioned as a good fast way to communicate by every key informant except one minister. He believed that his church was not the best vehicle because church is where people come for spiritual comfort. He thought that maybe the Catholic Church was a good way to communicate.

Least effective means of communication:

The least effective means of getting information to the “hard to reach” are through written materials, particularly poorly translated information. Television is a limited means of disseminating information. There is a distrust of the medical community and law enforcement should be avoided completely.

In order for information to be understood and directions followed, trained outreach workers should present it. Medical jargon should be avoided and step-by-step instructions should be used with images.

The best sources to deliver the information:

The best spokesperson for this kind of news was identified as agencies with Latino staff, the Health Department, lay leaders, community based organizations with a history of working with Hispanics and the Catholic Church.

If people needed to find out more information about Pandemic Flu, they are likely to go to a health clinic, “The Hispanic Liaison”, churches or agencies that they work with and trust.

“The Family Resource Center”, hospital and churches were identified as sources of comfort in the event of a disease outbreak.

The most important thing that can be done to minimize panic and fear are to make it clear that immigration status will not be an issue in providing services during a flu pandemic.

Rationale for Focus Group Sessions

The rationale for conducting focus group sessions is described as the following:

• Solicit from each racial/ethnic group members not considered leaders in the community, but with insights on understanding the nature of communication within racial minority communities.

• Test the hypothesis of community leaders on focus group participants

• Gather from focus group participants from each racial group how racial minorities might perceive and react to public health plans of risk communications during a pandemic.

Questions asked Focus Group Participants:

1. Are there some issues that immediately come to mind as “need to know” information for others in the community?

2. In the event of Pandemic Flu, what would be the best way to communicate with people in your community?

3. What would be the least effective way to communicate this information in your community?

4. What radio stations, television stations or newspapers should be used to communicate information about Pandemic Flu?

5. Who would be the best spokesperson to communicate information in the community?

6. How should information be presented so it is understood and directions can be followed?

(Focus Group sessions for the Latino population were done in Spanish with half of

the second Focus Group session participants able to speak some English)

Findings: The African American Community

When asked if there were some issues that immediately come to mind as “need to know” information for others in the community, African American participants responded as follows:

People should not go around visiting others when they are sick. Everyone should wash their hands often and cough into their arms or a tissue. Other “need to know” information was all of the power point presentation, how a vaccine would be distributed once it becomes available, who will pay for medicine for the indigent. People also need to know about preventive measures and that utilities will stay on if citizens are advised to stay home from work.

The best way to communicate information in the event of Pandemic Flu was identified as follows:

Let the proper authorities know such as the town manager, emergency manager, and emergency workers. Information should also be communicated on television, radio, newspapers, through churches and asking people to call friends to inform them.

The least effective way to communicate this information is by newsletters, “waiting until the last minute”, mailing information and by mass gatherings.

When asked what radio stations, television stations or newspapers should be used:

African American participants simply responded that all stations and newspapers should be used.

The best spokesperson to communicate information was identified as follows: Emergency management, Health Department, Policemen, Mayor, Town Manager, Ministers, Fire Chief, Red Cross, Military and Public Educators (teachers and principals).

When asked how information should be presented so it is understood and directions can be followed, the response was as follows:

Information should be given in writing with short answers to the questions of who, what, and where, without giving a lot of unnecessary information. It should be available in several languages and distributed in hard to reach communities door-to-door.

African American Focus Group Participant Profiles

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Findings: The American Indian Community

When asked if there were some issues that immediately come to mind as “need to know” information for others in the community, American Indian participants responded as follows:

People should cover their noses and mouths with their arms when sneezing. They should use hand sanitizer to clean their hands when soap and water are not available. People need to know how serious Pandemic Flu is and how important isolation is to keep from spreading the disease.

The best way to communicate information in the event of Pandemic Flu was identified as follows:

Verbal education in simple language from people in the community such as local leaders called “Gatekeepers”, use churches, the Pow-Wow circuit, flyers in grocery stores, bill boards, and local news outlets such as television stations, radio stations. In low-income areas, information will need to be communicated using door-to-door outreach. Other ways to communicate information would be at bike rallies, through the Indian Cultural Center, through Home Health agencies, at work places, pediatricians offices, at fire departments, the farmers market, at fundraising events, at town hall meetings, community meetings and public health forums. Literature will need to be developed in Braille for the vision impaired.

The least effective way to communicate this information is by flyers attached to cars, outsiders bringing the information, using “big words” and waiting until the last minute. If meetings are called to communicate information, not offering incentives is the least effective way to get people to come.

When asked what radio stations, television stations or newspapers should be used:

American Indian participants listed all of their local stations, particularly those directed at the Indian population such as “Native Visions Community News”, Braves Bulletin, and Turning Point.

The best spokesperson to communicate information was identified as follows: County Commissioners, clergy and lay leaders, community organizations, educators, law enforcement, EMT and “Gatekeepers”. The Tribal Chairman, Dr. Mike Cummings (Baptist Churches), Dr. Robert Mangum (United Methodist Churches) and Chancellor Meadors at the University of North Carolina at Pembroke.

When asked how information should be presented so it is understood and directions can be followed, the following responses were given:

Use simple terms on a sixth grade reading level. Use visual presentations by local people who lived through past flu epidemics. Give incentives along with information, “people love free stuff”. Use inserts in Sunday and Wednesday newspapers. Place information in the Public Library and with employers. Give information out at senior citizens meetings and fast food restaurants. Present a seminar at the university and give class credit. Give out information at benefit rides, health fairs, and the Lumbee (Indian) Homecoming parade.

American Indian Focus Group Participant Profiles

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Findings: The Hispanic/Latino Community

When asked if there were some issues that immediately come to mind as “need to know” information for others in the community, Hispanic/Latino participants responded as follows:

People need to know they should get the flu shot when it is available. They need to know what the shot does for them and what other community resources are available. They also need to be aware of Pandemic Flu.

The best way to communicate information in the event of Pandemic Flu was identified as follows:

The news of Pandemic Flu needs to be confirmed by “high authorities”. It needs to be communicated by word of mouth and over television stations. It also needs to be communicated through churches, or Spanish language radio stations, at clinics, in newspapers and with work place checks or punch cards. There will also need to be some outreach into the community.

The least effective way to communicate this information is by newspaper, through a non-Hispanic messenger, by mail, computer and trying to put together a focus group.

When asked what radio stations, television stations or newspapers should be used:

Latino participants identified Spanish language radio and television such as La Preciosa, Univision, Telfutura Telemunde,Galavision and MTV-Espanol.

The best spokesperson to communicate information was identified as follows:

Someone who is a Latino community leader, doctors, leaders of the Latino work places, the Governor, the President, famous people, religious officials and school officials.

When asked how information should be presented so it is understood and directions can be followed, the response was as follows:

Information should be presented “short and to the point”. Make a story with pictures and words that inform people ahead of time.

Hispanic/Latino Focus Group Participant Profiles

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Key Points

People who were most often identified as “hard to reach” were the elderly in six of the fifteen Key Informant interviews; those with substance abuse issues in four of the fifteen interviews; and those living with HIV in two of the fifteen interviews.

Churches were identified as the best communication channel by five of the fifteen interviews. Churches were also identified as the best way to communicate with the community by four of the six Focus Groups, with work sites mentioned by three Focus Groups.

The Health Department was mentioned as the best spokesperson for information about Pandemic Flu by four of fifteen Key Informants. Ministers/Pastors were mentioned as the best spokesperson by six of the fifteen Key Informants.

Recommendation

As a next step, it is recommended that the Division of Public Health contract with Community Based Organizations and churches that provide services to African Americans, American Indians and Hispanic/Latinos to provide education sessions concerning Pandemic Flu. The education sessions should contain basic information on Pandemic Flu and how to prepare for its occurrence.

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