initial priority. Activities that have achieved some success include promoting the removal of cigarette vending machines from areas accessible to children and adolescents and promoting expansion of smoke-free space in establishments such as malls and restaurants. Other CHNAs in the state have chosen to focus on issues such as immunization and a reduction in sexually transmitted diseases among 15- to 19-year olds.
The goal of the Arizona Partnership for Infant Immunization is to improve the preschool immunization rate in Arizona by influencing provider behavior. In 1991, initial efforts were made to address immunization of preschool children. Available data showed that providers' perceptions that they were immunizing all their patients were inaccurate. Despite a historic lack of collaboration between the physician and HMO communities, representatives from each sector were convened as stakeholders. Other identified stakeholders were advocacy groups, businesses, and foundations. Participation by pediatricians was high. Because influencing 2,000 providers directly would be very difficult attention was focused on the state's 25 health plans, hoping to influence providers via the payers.
To take further action, a formal partnership, the Arizona Partnership for Infant Immunization (TAPII), was formed. Collecting data on immunization rates was recognized as essential to the project, but reaching agreement on measurement methodology was difficult. Finally, CASA (Clinic Assessment Software Application), a tool of the Centers for Disease Control and Prevention (CDC, 1992), was chosen. Once a methodology was chosen, data collection and interventions were relatively easy to plan. Health plans are now using HEDIS (NCQA, 1993) and CASA methodologies to measure and collect data.
In 1993, only 46 percent of 2-year-olds were fully immunized. In 1994, the rates increased by 10 percent. These rates were determined from medical records but may have understated immunization levels if vaccine doses given by other providers were not recorded. In 1995, immunization rates measured by the National Immunization Survey were 77 percent.11 Provider education is a