OBJECTIVE: We partnered with the Salvation Army to educate resource-poor families regarding childhood immunizations in an effort to improve vaccine coverage rates.
METHODS: Eligibility for enrollment included children of families presenting at registration for our Salvation Army holiday gift program, available to families with an annual income <150% of federal poverty guidelines. Parents completed a questionnaire, were provided each child’s vaccination status as documented in the New York State Immunization Information System, and interacted with the study team to address immunization-related concerns. Missed vaccines were identified and parents were directed to their child’s medical home for necessary immunizations. Vaccine coverage was ascertained via the New York State Immunization Information System every 6 to 8 weeks with telephone follow-up for children who remained delayed. The McNemar test and standard 2-proportion comparison were used to determine confidence intervals when analyzing matched or independent data, respectively.
RESULTS: A total of 1531 children were enrolled; 416 (28%) of the 1477 children with accurate immunization records were vaccine complete. When we excluded influenza vaccine, 1034 (70%) of children had received all other recommended vaccines. Nine months later, vaccine completion rates increased from 28% to 45%, largely because of improvements in influenza vaccination rates, which increased by 17% (confidence interval [CI] 15.5–19.5), a significant improvement over county (8%, 95% CI 7.4–8.1) and statewide (5%, 95% CI 4.7–4.8) rates during the same period.
CONCLUSIONS: Immunization rates in poor children are suboptimal. Partnering with community-based organizations to address parental concerns, provide education, and perform follow-up was effective in improving immunization rates, particularly for influenza vaccine.
- CBO —
- community-based organization
- CI —
- confidence interval
- HPV —
- human papillomavirus
- NYS —
- New York State
- NYSIIS —
- New York State Immunization Information System
- PCV-13 —
- conjugate pneumococcal-13 vaccine
- TIV —
- trivalent influenza vaccine
What’s Known on This Subject:
Obstacles to vaccine delivery, including poverty, reduced access to medical care, and incomplete understanding of vaccine safety and importance, result in suboptimal coverage rates in some populations, allowing for disease outbreaks. Multicomponent interventions are successful in increasing immunization coverage rates.
What This Study Adds:
We show that collaboration with local resources, including the county health department and a large community-based organization, effectively increases immunization coverage rates in low-income, resource-poor children.
Obstacles to vaccine delivery continue to result in suboptimal coverage rates in some populations, allowing for disease outbreaks. Although the 2011 National Immunization Survey results reveal a 73% vaccine completion rate in 19- to 35-month-olds nationally, the rates of fully immunized children in New York State (NYS) are lower (65%).1 There is also a discrepancy between coverage rates for individual vaccines, as >91% of US children are fully vaccinated against poliovirus, measles, mumps, and rubella, but only 84% have received a complete series of conjugate pneumococcal vaccine.1 Racial disparities are also evident. Nationally, African Americans are less likely than children of other races/ethnicities to receive conjugate pneumococcal vaccine.1
Understanding the obstacles to vaccine completeness is necessary to develop interventions that effectively increase pediatric immunization coverage. For example, the National Immunization Survey found that county-level vaccination coverage was lower in circumstances associated with poverty, including lower income and housing stress.1 Poverty is associated with numerous barriers, including the lack of access to medical care and an incomplete understanding of vaccine importance and safety among this population.2
Multicomponent interventions aimed at increasing immunization coverage rates are more successful than single interventions, perhaps with the exception of patient reminder and recall systems.3–5 The most successful interventions described allow families to explain their health concerns, address perceived barriers to vaccination, improve community awareness of services already available, and engage health care outreach liaisons as a bridge to medical providers.3,6 Similarly, studies have shown the importance in identifying community-wide partners for collaborative efforts in improving a program’s impact.7,8
We collaborated with our local health department and our largest community-based organization (CBO), the Salvation Army, to reach resource-poor families and their children, address individual vaccine concerns, and educate regarding vaccine importance and safety in an effort to increase immunization coverage rates in this high-risk population.
This prospective, intervention study was performed in collaboration with the NYS Onondaga County Health Department and the Salvation Army of the Greater Syracuse Area. Each December, the Salvation Army hosts a gift distribution program where low-income families receive food and gifts for the holiday season. Eligible families must have at least 1 child younger than 17 years, live in Onondaga County, and have incomes based on 150% of federal poverty guidelines for families with 2 members, with the addition of $5730 per year for each additional family member. In December 2011, registration for the program occurred on 12 days, at 10 different community sites. Our study team, consisting of 2 pediatric infectious disease specialists, attended each registration event and met families accessing this service. All children younger than 19 years from families that met the financial criteria to register for this program were eligible for enrollment. Informed consent and assent were obtained, as appropriate, for each child (SUNY Upstate Medical University institutional review board 267177–3). We met with each parent for ∼10 minutes, addressed vaccine concerns, and provided appropriate parental education with discussions of vaccine importance and review of both the pediatric immunization schedule and relevant vaccine information sheets.
Demographic data were collected. The parents/guardians (“parents”) were asked a standard set of questions (Table 1) to assess their use of a medical home, their understanding of the importance of vaccinations, and potential barriers to vaccine completeness for their children. The study team responded to the parents’ answers, providing information regarding vaccine importance and safety, age-specific universal vaccine recommendations, and any identified perceived and real barriers to immunizations for their child(ren).
Immunization records for each child were accessed, on-site, via the NYS Immunization Information System (NYSIIS), the state electronic immunization registry. In 2008, NYS passed a public health law mandating that health care providers electronically document all new and historic immunizations administered to children 0 to 18 years of age into NYSIIS within 14 days of administration.9 Currently, 3322 health care practices use the electronic registry with 57.3 million immunizations entered for 4.3 million patients statewide.
Immunization records were reviewed for vaccine completeness or delay, as per Advisory Committee on Immunization Practices recommendations at the time of study enrollment. For each immunization-delayed child, recommended immunizations were identified by highlighting a copy of the record given to the family. The families were encouraged to bring the record to their primary care provider to facilitate the identification of overdue vaccines. If a child was not already established in medical care, parents were given the contact information for local providers. We then offered conjugate pneumococcal vaccine-13 (PCV-13) to any child younger than 6 years and trivalent inactivated influenza vaccine (TIV) to any eligible child and/or family member. Immunizations given on-site to enrolled children occurred after the educational intervention and were documented as postintervention vaccine updates for data analysis.
After enrollment was completed, all immunization records were reviewed. If the records appeared incomplete, the medical home was contacted to ensure accuracy of the information documented in the registry. If the immunizations in NYSIIS were inaccurate when compared with the records from the medical home, a study member completed the update before determining if the child was vaccine-complete or -delayed at the time of enrollment. An updated copy of the NYSIIS immunization record was then mailed to the family.
During the following 9 months, the study team accessed NYSIIS every 4 to 6 weeks to document vaccine updates performed in medical homes. Families with children who remained vaccine-delayed were contacted by telephone at 1 and 3 months postintervention to reemphasize the importance of vaccine completion.
Immunization coverage rates at enrollment were compared with coverage rates 9 months later. Influenza vaccine coverage rates preenrollment were compared with coverage rates 6 months later (June 2012). Influenza vaccine coverage rates were also compared with background increases seen in all of Onondaga County, and all of NYS, excluding New York City, as provided by the NYSIIS program manager.
The McNemar test and a standard 2-proportion comparison were used to determine statistically significant differences in vaccination rates when analyzing matched or independent data, respectively.
A total of 1531 children from 630 families were enrolled in the study; 785 (51%) were boys. The number of children per family ranged from 1 to 8 (mean 2.4). There were 193 families with a single child and 437 had multiple children. Of the 1531 children, 1471 (96%) had medical insurance coverage and 1507 (98%) had an established medical home (Table 2).
We vaccinated 9 (16%) of the 55 eligible children with PCV-13, and 101 (10%) of the 1033 eligible children younger than 19 years, as well as an additional 362 adults between the ages of 19 and 96 years with TIV, including 6 pregnant women. Four children received both PCV-13 and TIV. Of the 101 children who received TIV on-site, 34 (15% of the eligible 229) were between 6 months and 3 years of age, 21 (9% of the eligible 228) were between 4 and 6 years, 21 (8% of the eligible 253) were between 7 and 10 years, 7 (6% of the eligible 114) were between 11 and 12 years, and 18 (9% of the eligible 210) were between 13 and 18 years.
Parent surveys were completed by 628 parents of 1529 children. Forty-three parents (7%) of 108 children stated that routine pediatric vaccines are unsafe, most commonly believing that vaccines cause illness (Table 3). Despite the expressed concerns, 610 (97%) parents of 1488 children stated that all children should receive routinely recommended vaccines. A total of 1415 (93%) of the children were believed by their parents to be vaccine-complete at study enrollment; however, only 599 (39%) were thought to have received a 2011–2012 influenza vaccine. The parents of 108 (7%) children refused 2011–2012 influenza vaccine for their child, most commonly because of the belief that influenza vaccine causes illness (Table 3).
Survey results indicated no differences in parental attitudes regarding vaccine safety and the belief that children should receive vaccines between vaccine-complete and vaccine-delayed children. Similarly, there were no differences in parental attitudes between the eligible children who received vaccine on-site and those who did not.
Preenrollment Immunization Records Updated in NYSIIS
At the time of study enrollment, immunizations were accurately entered into the NYSIIS registry for 1314 (86%) of the 1531 of the children, when compared with documentation provided by the primary care provider. Pediatric and family practice offices had accurate immunization records for 1041 (88%) of 1186 and 256 (81%) of 317 of their enrolled patients, respectively. Children younger than 3 years were more likely to have accurate NYSIIS records (369/403, 92%) when compared with adolescents 13 years and older (218/278, 78%). After contacting medical homes to ensure accuracy of the NYSIIS registry, 163 records were updated by our team (n = 1477).
Immunization Coverage Rates
Of the 1477 children with accurate immunization records documented in NYSIIS, only 416 (28%) were vaccine-complete, per Advisory Committee on Immunization Practices recommendations at the time of study enrollment. When we excluded the recommendation for annual influenza vaccine from the data analysis, 1034 (70%) of children were completely vaccinated. The contribution of influenza vaccine on reducing vaccine completeness was similar across all age groups (Table 4). On the other hand, excluding human papillomavirus (HPV) vaccine from the analysis had less impact on vaccine completion rates, with increases from 416 (28%) to 432 (29%) in the total population, and from 36 (13%) to 52 (19%) in the adolescent subpopulation (13–18 years old). At the time of study enrollment, 144 (52%) of the 278 adolescents had started the HPV series, whereas 118 (42%) had received all 3 doses.
Before our intervention, 1061 children from 502 families were vaccine-delayed. In the first month postintervention, 229 (22%) of the vaccine-delayed children received vaccine updates. The 454 families of the remaining 856 vaccine-delayed children were contacted and provided reminders regarding the need for vaccine updates. Subsequently, 41 of the remaining vaccine-delayed children received updates in the following 2 months. At 3 months postintervention, we again contacted 440 families of the remaining 816 vaccine-delayed children, after which an additional 71 children received vaccine updates.
Nine months after enrollment, the number of vaccine-complete children increased from 416 (28%) to 672 (45%). An increase in vaccine completion was seen in all age groups, although the most significant improvement occurred in the 0- to 3-year cohort, with an increase from 156 (40%) to 256 (65%) of 392 (95% confidence interval [CI] 21.2–29.8) (Table 5). Of the 100 children in this cohort who received vaccine updates postenrollment, we administered TIV to 27 on-site, whereas 73 children received updates at their medical home.
In the adolescent population, increases in coverage rates were highest for HPV and meningococcal vaccines. Among the 278 enrolled 13- to 18-year-olds, 3-dose HPV vaccine coverage increased from 118 (42%) to 162 (58%). Similarly, the number of those immunized against Neisseria meningitidis increased from 224 (81%) to 248 (89%).
As might be expected with a vaccine study beginning in mid-December, influenza vaccination rates increased across all age groups during the months after study enrollment. Among eligible enrollees (≥6 months of age and without an allergy to vaccine components; n = 1446), influenza vaccine coverage increased from 460 children (32%) in December 2011 to 713 (49%) in June 2012 (95% CI 15.5–19.5) (Table 6). When we reviewed NYSIIS at 1 and 3 months postenrollment, 8% and 9% of the eligible children had received influenza vaccine. This overall 17% increase was significantly higher compared with increases observed in all children 6 months to 19 years in Onondaga County, where only an 8% increase was achieved, and in New York State overall (excluding New York City, where a 5% increase was observed over the same period of time (Tables 7 and 8).
Improvement in influenza vaccine coverage was observed in children across all age groups. This increase was similar between the 0- to 3-year cohort (24%; 95% CI 20.1–29.1), 4- to 6-year cohort (17%; 95% CI 12.4–20.5), and 7- to 10-year cohort (16%; 95% CI 12.7–20.4), but lower in the 11- to 12-year-olds (14%; 95% CI 8.2–18.9) and 13- to 18-year-olds (13%; 95% CI 15.5–19.5), where the upper limit of the 95% CI did not overlap with the lower limit 95% CI for the 3 younger groups.
In this work, we describe the results of a program developed in collaboration with our county health department and a CBO to reach high-risk, resource-poor families to assess their vaccine concerns, and provide education regarding vaccine safety and importance. We found that pediatric vaccine completion rates increased from 28% to 45% in the 9 months after our educational intervention and that influenza vaccine rates increased from 32% to 49%. Most vaccine updates in our study occurred during the first month after our individualized educational intervention, whereas follow-up phone calls were less effective in increasing the rate of vaccine updates. These findings support previous studies describing the effectiveness of multicomponent community-based interventions in increasing pediatric immunization coverage rates.10
The most commonly adopted community-based immunization programs are school-based vaccination clinics, where vaccines are provided in a convenient manner at little or no cost to families. Interventions involving influenza vaccination of children in school-based clinics are highly effective, not only in efficiently immunizing a large number of children, but also in reducing influenza illness in children, their household contacts, and in the community.11–14 There are some limitations, however, to school-based clinics and influenza vaccine programs, as, by design, they do not capture preschool children or adults living in the same home. We note that the best incremental increase in influenza vaccine rates during our study occurred in children younger than 3 years. Although it is difficult to measure the contribution that parent counseling had on the change in vaccine coverage rates we observed, it is clear that direct parental education and discussion of vaccine safety and importance is more difficult to accomplish in a school setting because of minimal interaction between provider and parent. Engagement of the parent in influenza vaccination programs outside of the medical home also has a substantial impact on adolescent vaccine coverage rates. Sales et al15 demonstrated that adolescent children of parents who engaged in an educational influenza vaccination intervention were more likely to be immunized than the adolescent children of parents who did not.
Our program was able to overcome some of the limitations of the already highly successful school-based vaccine clinics by allowing us to interact directly with parents on-site, to answer their specific questions, and to educate them regarding vaccine safety and importance. Surprisingly, we found that the parents of 97% of the children supported the receipt of routinely recommended pediatric vaccines; however, only 93% felt that vaccines were safe, emphasizing that even parents whose children are immunized have vaccine concerns. Similarly, a 2009 HealthStyles survey found that whereas 93% of parents had or intended to have their children completely vaccinated, only 79% believed that vaccines were either safe or important for their children.16 Vannice and colleagues17 showed that mothers were more likely to respond positively to questions and statements supporting vaccine safety and importance after reading the vaccine information sheets, further illustrating the importance of engaging the parents in the vaccine discussion beyond providing the required written information. These and other related programs that allow for provider-parent interaction while providing vaccine education hold the promise of improving community confidence in immunizations.18
Ninety-three percent of parents in our study stated that they believed their children to be vaccine-complete at the time of enrollment; however, only 39% stated that they had received a 2011–2012 influenza vaccine. This observation illustrates that many parents do not consider annual influenza vaccine a routine recommendation. Furthermore, the parents of 108 (7%) children refused the influenza vaccine for reasons such as the belief that the vaccine causes illness, that healthy children do not need vaccine, or that the vaccine is not important.
Previous studies have shown similar parental concerns with influenza vaccine, including vaccine efficacy, safety, the presence of thimerosal, and/or the belief that vaccine causes influenza disease.18–23 Misperceptions regarding influenza infection and vaccine safety reduce public confidence in vaccines and contribute to poor vaccine uptake.23–25 Humiston and colleagues19 found that participants who believed that influenza infection was serious and that the vaccine did not cause disease had greater intent to vaccinate their children than those who did not, further supporting the importance of parental education in childhood immunization programs.
During our study enrollment period, we offered TIV to all eligible children and their family members on-site to provide a service that was convenient, and free-of-charge. We immunized 463 individuals during this 2-week time period and believe that providing vaccine on-site demonstrated to the participants that our study team believed in the safety and importance of influenza immunization. Offering influenza vaccine at community centers already used by low-income families for services reinforces the importance of influenza vaccine, improves this population’s access to vaccine, and captures both parents and children to increase influenza immunity in the community. Although some parents whose children had not yet received influenza vaccine opted for their child to be vaccinated on-site (n = 101), 152 children returned to their medical home during the study follow-up period to receive vaccine. Interval increases in influenza vaccine uptake across our county and across New York State were not as robust as we achieved in our study population.
Partnering with a CBO to reach resource-poor families at a location where they already access unrelated community services to address parental vaccines concerns was effective in improving local pediatric immunization coverage rates. Future programs should continue to focus on interactive vaccine education, with special attention on the risks of influenza infection and the benefit of influenza vaccination.
- Accepted April 23, 2013.
- Address correspondence to Manika Suryadevara, MD, Department of Pediatrics, SUNY Upstate Medical University 750 East Adams St, Syracuse, NY 13210. E-mail:
Dr Suryadevara contributed to study design, data acquisition, and data analysis, and drafted the initial manuscript; Ms Bonville contributed to data acquisition, and reviewed and revised the manuscript; Mr Ferraioli contributed to data acquisition; Dr Domachowske contributed to study design, data acquisition, and data analysis, and reviewed and critically revised the manuscript; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: Dr Domachowske performs clinical vaccine trials and consulting service with Sanofi-Pasteur, Novartis, Medimmune, Glaxo-Smith-Kline, Pfizer and Merck; Ms Bonville has stock in Pfizer; and the other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Support provided by Pfizer through the ASPIRE 2011 Junior Investigator Award in Pediatric Vaccine Research.
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- Copyright © 2013 by the American Academy of Pediatrics