Distribution Problems

B. Common Distribution Problems and Solutions

  1. Address label problem: “The hospital (or health department) won’t give us the address list because of HIPAA issues.”
  2. Difficult Partners
  3. Partners want to give all 12 newsletters at once?
  4. How can we reach families who speak Spanish?
  5. How do you keep track of parents who change addresses?
  6. How do you keep track of parents who give birth in neighboring counties or states?
  7. How can we identify new parents who move into our county or adopt?

1. Address label problem: “The hospital (or health department) won’t give us the address list because of HIPAA issues.”

HIPAA refers to the Health Insurance Portability and Accountability Act. Two primary objectives of HIPAA are: 1) to assure health insurance portability so individuals with pre-existing medical conditions can change jobs and still keep their health insurance; and 2) to guarantee privacy of health information. Health care providers (including doctors, nurses, hospitals, clinics and nursing homes) cannot share a person’s health information without the permission of the individual. For instance, health information cannot be shared with employers or used for advertising/sales purposes without permission. Health information can only be shared for particular reasons, such as doctors consulting about a patient’s care or making sure nursing homes are giving proper care. Providing the list of names and addresses of mothers who have given birth in a particular hospital or county may violate the privacy of health information according to the HIPAA act. This is probably the strictest interpretation of the new policy. However, in some counties hospital personnel view the newsletters as health information and thus see no violation of HIPAA regulations.

  • a. There are six solutions for getting the address list:
    • i. Confidentiality AgreementOne solution is for the Extension Agent to sign a confidentiality agreement with the hospital or health department that states the mailing list will not be shared and will only be used for mailing the newsletters.The Extension Agent has to sign a confidentiality agreement with the hospital or health department that states the mailing list will not be shared and will only be used for mailing the newsletters. The confidentiality agreement can state that the newsletters provide free health information (you can remind the hospital or health department that HIPAA does not prevent them from mailing health outreach publications to their clients, and our joint newsletter project is another part of their health education outreach). This allows project partners more flexibility in setting up a system to prepare the newsletters for mailing.
    • ii. Permission FormHave parents sign a permission form agreeing that their name and address can be shared for purposes of receiving the newsletters. For example, mothers could sign a permission form at the hospital to receive all 3 years of the parenting newsletters that is part of a standard permission form that also asks parents if they want their baby’s picture taken and the birth announcement put in the newspaper.
    • iii. Birth AnnouncementsAnother solution is to get the names of new parents from birth announcements in the newspapers. This method is often used by researchers who need to recruit a sample of children of a particular age. You can add addresses to your mail list each day, or go to the library once each month to collect a month’s worth of names and addresses. In some counties, however, the hospitals will not put birth announcements in the newspaper without parents’ permission.
    • iv. Staff AssistanceIn some places the hospitals use their own staff to put the mailing labels on the newsletters, so no one outside of the hospital staff sees the names (thus, confidentiality is not an issue). Someone from the hospital staff could also remain in the room while volunteers from Kiwanis clubs prepare the mailings (including putting on the address labels). Thus the patient information is never “out of sight” of the hospital staff.
    • v. Permission Form for Additional NewslettersIn some counties where parents are already receiving Parenting the First Year, they have tried including a permission card in the 12 month issue or sending a postcard asking parents if they would like to continue receiving the newsletters (Parenting the Second and Third Years). However, this hasn’t worked very well, since distribution has been cut by half or more. If you send out renewal postcards with one of the last monthly issues of Parenting the First Year, there is now a Spanish version of the renewal postcard available.
    • vi. Welcome LetterThe Public Health Department could send new parents a Welcome Letter that includes the first issue of Parenting the First Year and a subscription form if they would like to continue receiving the newsletters. The Public Health nurses then encourage families to sign up for the newsletters.

2. Difficult Partners

In some cases one partner may take certain actions on their own, for example stopping distribution or delivering all newsletter issues at once without telling the other partners. In other cases, some partners may begin to lose enthusiasm for funding the project (as budgets are stretched) or for providing addresses (because of HIPAA).

What can you do? In many counties, community partners like the local Kiwanis clubs help the project stay on track by keeping the hospital and health department involved and working together. Holding regular (annual or bi-annual) meetings of the partners to keep everyone talking, and doing evaluations to show the impact the newsletters are having locally will help you maintain enthusiasm for the project (see “How do I create a local partnership for distribution”). As in any collaboration, the key is regular communication. Avoid the temptation to ignore this project just because it runs so smoothly most of the time.


3. Partners want to give all 12 newsletters at once

This is a common idea, since it appears to be much easier (no sorting to be sure parents receive the correct issue) and to save on postage. The only problem: It undercuts the effectiveness of the newsletter intervention. A study in California evaluated the effectiveness of monthly age-paced delivery compared to quarterly delivery (3 issues at a time). Parents who received the newsletters monthly, compared to those who received them quarterly, reported reading more of the newsletters and making more positive changes in their parenting behaviors and attitudes. A good metaphor (especially for use with health care professionals): It would be a lot easier to give children their immunizations by drinking them in orange juice, since children hate getting shots, but we don’t do it this way because we have no reason to think immunizations would be effective if given this way. The same is true of our methods of delivery of the newsletter intervention. We know it works when delivered monthly, we have no evidence it works when delivered all at once, and we have some evidence that reducing the age-pacing of delivery undercuts the effectiveness.


4. How can we reach families who speak Spanish?

In some counties the hospital or health department includes Spanish-speaking parents on the regular mailing list, but specifies that they should receive the Spanish version of the newsletter. They keep a supply of the Spanish edition, “El Primer Año del Bebé,” on hand for this (you can have these printed by all the same methods as the English edition). If you send out renewal postcards with the last issue of El Primer Año del Bebé to see if parents are interested in receiving Parenting the Second and Third Years (El Segundo y Tercer Ano del Nino), there is now a Spanish version of the renewal postcard available. At one of the hospitals (with a small number of Spanish-speaking parents), the hospital nurses contact the person at the hospital who is in charge of the newsletters and that person takes care of each one of the Spanish mailings individually. However, in some counties the hospitals don’t want to put Spanish-speaking families on the mailing list for receiving the newsletters, because many of these families (e.g. seasonal workers) move around a lot so their addresses change frequently (and hospitals end up with newsletters being returned). One solution hospitals have used is to give all 12 issues of the Spanish version of Parenting the First Year (El Primer Año del Bebé) to parents when they leave the hospital. Another solution that has been tried is to have physicians who mostly serve Hispanic families give out several issues of the newsletters to families when they bring their child in for check-ups. A third solution has been to have WIC clinics and home visitors hand deliver Spanish versions of the newsletters to parents.


5. How do you keep track of parents who change addresses?

In some counties that contract with a mailing service, the service contacts the Extension office if addresses change. In counties that use bulk mailing, if you notify the post office they will collect newsletters that can’t be delivered because of address changes. However, you must pick the newsletters up from the post office.


6. How do you keep track of parents who give birth in neighboring counties or states?

In many parts of the state, the local project sends the parenting newsletters to all parents giving birth at the hospital, regardless of what county (or even state) they live in. In some places, two or more Extension Family Living Agents in adjoining counties partner to run a project with a mail list from a hospital that serves their multiple counties. This method of partnering even works across state lines. In other parts of the state, rather than forming a partnership to distribute the newsletters across county or state lines, the Extension and health offices simply share information about births and addresses. For example, the hospitals that serve Florence County are in Michigan. In this particular case, the Extension agent in Iron County, Michigan sends the list of birth names and addresses to the Extension agent in Florence County. Hospitals that serve adjoining counties may have a similar system. In summary, there are many ways to handle this issue, and the best way for you will depend upon local opportunities and constraints.


7. How can we identify new parents who move into our county or adopt?

You can ask local pediatricians and child care providers to inform parents (who are new to the community or have adopted) about the newsletters (perhaps providing an initial issue) and to encourage parents to contact you (their local Extension agent) about getting on the mailing list for the newsletters. In addition, you can ask them to post this flyer informing parents about the Parenting the First Year newsletter. If the hospital sends out the newsletter, the pediatrician could ask to have the parents’ names added to the mailing list. Another idea is to include information about the parenting newsletters in the Welcome Packets that the Chamber of Commerce provides to new families in the community.