Literature Review on Childhood Immunization

RESEARCH AND PRACTICE

Indigenous Farmworkers Project, partners will promote leadership among indigenous farm- workers by directly involving the farmworkers as promotores/as (health promoters) to develop educational materials and advocate for healthier occupational environments. The changing de- mographics of the agricultural workforce require development of suitable services and materials for indigenous farmworkers, as well as greater attention to this population's basic ri^ts. •

About the Authors Stephanie Farquhar and Nancy Goffare with the School of Community Health, Portland State University, Portland, OR. Nargess Shadbeh, Julie Samples, and Santiago Ventura are with the Oregon Law Center, Woodbum.

Requests for reprints should be sent to Stephanie Farquhar, PhD, Portland State University, School of Community Health, PO Box 751, Portland, OR 97207 (e-mail, [email protected]).

This brief was accepted February 4, 2008.

Contributors S. Farquhar facilitated development and implementation of research instruments and protocol, data analyses and interpretation, and article preparation. N. Shadbeh con- ceptualized the study and supervised all aspects of im- plementation and evaluation. N. Shadbeh, J. Samples, and S. Ventura provided expertise on farmworker com- munities in Oregon, contributed to development of instruments, conducted focus groups, administered sur- veys, interpreted data, and edited the article. N. Goff managed, analyzed, and interpreted the data, and con- tributed to article preparation and editing.

Acknowledgments This research was supported by a grant fix)m the National Institute for Occupational Safety and Health (grant R25- OH008334-01).

The authors express their appreciation for Linda McCauley of the University of Pennsylvania School of Nursing, who served as project consultant

Human Participant Protection Human participant approval for this research was obtained from the institutional review board at Portland State University.

References 1. u s Department of Labor. Findings from the National Agricultural Workers Survey (NAWS) 2001-2002. A Demographic and Employment Profile of United States Farm Workers. Washington, DC: US Dept of Labor; 2005. Research report no. 9.

2. McCauley L, Stickler D, Bryan C, Lasarev MR, Scherer JA. Pesticide knowledge and risk perception among adolescent Latino farmworkers./>lgric Saf Health. 2 0 0 2 ; 8 : 3 9 7 - 4 0 9 .

3. Stephen L. Mixtee farmworkers in Oregon: linking labor and ethnidty through farmworker unions and

hometown associations. In: Fox J, Rivera-Salgado G, eds. Indigenous Mexican Migrants in the United States. San Diego: University of California, San Diego; 2 0 0 4 : 1 7 9 - 202.

4. McCauley L Work characteristics and pesticide exposures among migrant agricultural families: a community-based research approach. Environ Health Perspect. 2 0 0 1 ; 1 0 9 : 5 3 3 - 5 3 8 .

5. Larson A. Migrant and seasonal farmworker enumeration profiles study: Oregon. Portland, OR: Department of Human Services Migrant Health Office; 2 0 0 2 .

6. Arcury TA, Quandt SA, Cravey A], Elmore RC, Russell GB. Farmworker reports of pesticide safety and sanitation in the work environment Amf ¡nd Med. 2 0 0 1 ; 3 9 : 4 8 7 - 4 9 8 .

7. McCauley LA, Shapiro SE, Scherer JA, Lasarev MR. Assessing pesticide safety knowledge among Hispanic migrant farmworkers in Oregon, f Agrie Saf Health. 2004; 10:177-186.

8. Salazar MK, Keifer M, Negrete M, E s t i v a F, Synder K. Occupational risk among orchard workers: a descriptive study. Fam Community Health. 2005;28: 2 3 9 - 2 5 2 .

9. Holmes SM. An ethnographic study of the sodal context of migrant health in the United States. PLoS Med 2 0 0 6 ; 3 : 1 7 7 6 - 1 7 9 3 .

10. Israel B, Schulz A, Parker E, Becker A Review of community-based research: assessing partnership ap- proaches to improve public health. Annu Rev Public Health. 1998;19:173-202.

11. Farquhar S, Samples J, Ventura S, et al. Promoting the occupational health of indigenous farmworkers. /Immigr Minor Health. 2008; 10(3):269-280.

12. Centers for Disease Control and Prevention. Be- havioral Risk Factor Surveillance System (BRFSS). Available at: http://www.cdcgov/brfss/indexhtm. Accessed November 12, 2 0 0 7 .

13. Cardenas E. Portrait of a laborer: Indigenous farmworkers in Santa Barbara County. Santa Barbara, CA: Centi-al Coast Environmental Health Project; 2006.

Effectiveness of a Community Coalition for Improving Child Vaccination Rates in New York City Sally E. Rndley, PhD, Matilde Irigoyen, MD, Martha Sanchez, MA, Melissa S. Stockwell, MD, Miriam Mejia, BA, Letty Guzman, BA, Richard Ferreira, MSW, Oscar Pena, JD, Shaofu Chen, MD, PhD, and Raquel Andres-Martinez, PhD

We used a retrospective, match- ing, birth cohort design to evaiuate a comprehensive, coaiition-led child- hood immunization program of out- reach, education, and reminders in a Latino, urban community. After we controlled for Latino ethnicity and Medicaid, we found that children en- rolled in the program were 53% more likely to be up-to-date (adjusted odds ratio=1.53; 95% confidence interval = 1.33, 1.75) and to receive timely immunizations than were chil- dren in the control group (t=3.91). The coalition-led, community-based immunization program was effec- tive in improving on-time childhood immunization coverage. (-4m J Pub- lic Health. 2008;98:1959-1962. doi:10.2105/AJPH.2007.121046)

The most effective strategies for improving community-vdde childhood immunization rates combine reminders, tracking, and out- readi.''^ Most evidence about these strate- gies derives from provider-driven programs, with very little from community-driven pro- grams.^® Our immunization program. Start Right, is community driven, but until recently, we have not had community-spedfic data for demonstrating its effectiveness, relying in- stead on comparisons to national datsJ'^ In this study, we re-examined the program's effectiveness with a comparison cohort in our own community.

METHODS

Prior to the intervention, our Latino, low- income community in New York City had childhood immunization rates of 57%—well below dty and national rates.^ To address this problem. Start Right, our 23-partner coalition, adapted national and dtywide materials for its own package of bilingual and community- appropriate immunization-promotion mate- rials; trained peer health educators; imple- mented personalized immunization outreach and promotion within sodal service and educational programs; provided outreach, ed- ucation, and reminders to parents; and sup- ported provider immunization

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RESEARCH AND PRACTICE

(Table 1), Enrollment, tracking, and account- ability were shared among partners,^°'^' Participants were recruited through the Special Supplemental Nutrition Program for Women, Infants, and Children (27%), facili- tated State CMdren's Health Insurance Pro- gram enrollment program (20%), childcare and Head Start centers (20%), parenting assistance programs (19%), and housing and tenant associations (9%), The refusal rate was 2%,

Study Design

We used a quasi-experimental, retrospec- tive, birth cohort design^ -̂̂ ^ with 10857 chil- dren bom between Apdl 1999 and September 2003 at the primary community hospital (76% of community births) who resided in the com- munity's zip codes. Following National Im- munization Survey methodology, we created 4 annual cohorts of children, aged 19 to 35 months as of April 1 of each year, 2002 to 2005 (n=2879, 2788, 2653, and 2577,

respectively). The annual cohorts were divided into intervention and control groups. The study was conducted retrospectively in 2006 to 2007,

The hospital database was used for demo- graphics; the New York Citywide Immunization Registry (CIR) for immunization records, CIR is a population-based registry with mandated provider reporting. Most children (88%) had a record in CIR (n=9511; 93,9% of the Start Right group, 87,0% of the control group).

Outcome measures were up-to-date immu- nizations for the 4:3:1:3:3 series (4 diphtheria- tetanus-pertussis [DTaP]; 3 polio; 1 measles- mumps-mbella; 3 Haemophilus influenza b; and 3 hepatitis B *̂) and timeliness of the last DTaP dose, known as DTaP4, measured by elapsed days between the date a child became overdue and the immunization date for chil- dren with a DTaP4 dose (n=5059),^^ Signifi- cance of differences in coverage and timeliness were assessed with the x^ test and the unpaired

2-sample Student's í test Logistic regression was used to estimate adjusted odds ratios (AOR) for the intervention effect on immuni- zation status, controlling for Latino ethnidty and Medicaid enrollment (n=10231).^*' We used Stata 9.0 (StataCorp, College Station, TX) for statistical analysis,

RESULTS

Across all birth cohorts, 8,2% (n=895) enrolled in Start R i ^ t Compared with control groups, children in Start Right were similar in c^e (mean=27.4 months) but were more likely to have Medicaid (85,1% vs 78%; x^=27,8; df=2\ P<,001) and be Latino (92% vs 85.1%; X^=39,l; d/=2; PK.OOÍ).

Children in Start Right achieved significantly higher (11,1%) immunization coverage than did control children (x^=44,6; P<,001; Figure 1) and completed the immunization series ear- lier, by 11 days (<=3.91)! After controlling for ethnicity and Medicaid, children in Start Rigjit

TABLE 1-Community-Based Immunization-Promotion Program Components

Strategy Implementation Result

Membership A total of 23 community organizations: sociai seivices, housing, faith-based,

childcare providers, primaiy care providers, the city health department.

Leadership Shared ieadership, academic, 2 community organizations.

Program design Used community organization needs and experiences and provider perspectives to

select evidence-based best practices and to develop bilingual and community-

specific outreach and educational materials.

Integration into Immunization promotion designed as an "add-on" to 5 basic community social

existing seivices service and education programs: parenting assistance, childcare, facilitated

enrollment for SCHIP, housing assistance, and WIC. Implementation guide

tailored the intervention to each type of program.

Staff/peer training Social seivice and educational staff or peers trained in immunization

outreach, education, reminders and traci<ing with our own bilingual

materials and curriculum, including Immunization 1 0 1 , Card Reading,

Tips on Educating Parents, and Methods for Reminding and Tracking

Families,

Parental empowerment Parents learn about immunizations, immunization cards, and the immunization

schedule from peers or trusted staff through one-on-one and group sessions.

Use of coalition-developed, bilingual, low-literacy materials.

Reminders and recall Parents given calendar dates for when shots are due, reminder phone

calls and cards before each immunization due date, and recall

phone call, card, or visit if missed.

Tracking Decentralized immunization tracking at each member

organization, consolidating data from parents'

cards and electronic registries.

Broad-based constituency.

Enhanced coordination and community ownership.

Blend of own experience and national evidence-based

insights; enhanced community ownership and

relevance of immunization materials.

Immunization promotion not stand-alone, but incorporated

into ongoing programs working with parents of young children.

A total of 9 9 8 community staff trained in 2 0 0 0 to 2 0 0 7 , with

150 to 2 0 0 active at any given time; enhanced outreach

and sustainability through the long-term presence of

trained staff in the community,

A total of 1 0 2 5 1 parents participated, with 60% receiving one-on-one

education, and 40% receiving both group and one-on-one education.

Parents like the program and recommend it to friends.

Average of 2,7 calls, reminders, or visits per child.

A total of 1 8 4 8 9 6 immunization records in the consolidated

coalition database, including 24% recorded only on the

child's vaccination card.

Note. SCHIP=State Children's Health Insurance Program; WIC=Special Supplemental Nutrition Program for Women, Infants, and Children,

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RESEARCH AND PRACTICE

40 n

20

í O)

I b I b a o

3 -20

-40

5%

. - • 1

- 5 %

1

6%

_ •

• Intervention

1 , -6%

D Control |

6%

m - 6 %

4%

— ^ 1 ^ 1 1

- 4 %

2002 2003 2004

Year 2005

FIGURE 1-Dlfferences In registry-reported Immunization coverage rates from the community average: New York City, 2 0 0 2 - 2 0 0 5 .

were 5 3 % more likely to be uf>-to-date than were control children (AOR=1.53; 9 5 % con- fidence interval [CI]=1.33,1.75). Neither La- tino ethnidty (AOR=1.07; 9 5 % CI=0.93, 1.24) norMedicaid (AOR=1.05; 95% 0 = 0 . 9 5 , 1.16) significantly influenced immunization coverage.

DISCUSSION

Despite similarities at birth and control for ethnicity and Medicaid insurance, less than 3 years later, the children in the Start Right intervention had significantly higher immuni- zation coverage rates than did the rest of their birth cohort The community birth cohort control further validates our earlier findings regarding the effectiveness of our community- driven, comprehensive immunization- promotion intervention.̂ '® The observed in- creased coverage is not the result of a higher community-wide immunization level, but of the immunization-promotion program year after year. This improvement in coverage is well within the range expected for reminder- recall interventions and other community- based programs.^

The major limitation to this study was incom- plete data reporting to the CIR.̂ '̂̂ ® In contrast to our previous reports, which included parent- held vaccination card datci, we only included

registry data in this study. Incomplete provider reporting of immunizations to the CIR, esti- mated at 85%, may have downwardly biased immunization coverage.^^ As indicated in Table 1, including only immunizations reported to the CIR excluded 24% of immunizations recorded on the intervention children's vacci- nation cards.

We attribute the success of the program to a number of factors, including community ovwi- ership of the program, integration of immuni- zation promotion into social service and educational programs, training of a large cadre of peer educators, intense parental education and empowerment, and culturally appropriate reminders arising out of the con- text of our intervention. We hope that this study helps others seeking ways to embed health care promotion into community programs. •

About the Authors Sally E. Findley, Martha Sanchez, and Raquel Andres- Martinez are with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY. At the time ofthe study, Matilde Irigoyen, Melissa S. Stockwell, Oscar Pena, and Shaofu Chen were with the Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York Miriam Mejia and Letty Guzman are with Alianza Dominicana, Inc, New York, NY. Richard Ferreira is with Harlem Congregations for Community Improve- ment, New York.

Reprint requests should be sent to Sally E. Findley, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B-2, New York. NY 10032 (e-mail: seß@ columbia.edu).

This brief was accepted March 2, 2008.

Contributors All authors except R. Andres-Martinez (who joined the team later) participated in the design of the study. M. Irigoyen and M.S. Stockwell obtained the control sample data, and S. Chen and R. Andres-Martinez assembled and analyzed the data. L. Guzman helped develop the Start Right database and, with 0 . Pena, assured high-quality data inputs from partners. The article was drafted by S. E. Findley, M. Irigoyen, M. Sanchez, and M. S. Stockwell, with assistance in devel- oping the program summary in Table 1 from M. Mejia and R. Ferreira, who also reviewed the final draft ofthe article.

Acknowledgments Support for this project has been provided by the Centers for Disease Control and Prevention (cooperative agree- ment U50/CCU222197) and the Bank of America Foundation.

We have many to thank, but none more than the families who participated in the study and our com- munity partners: Alianza Dominicana, Ine; Dominican Women's Development Center; Fort George Commu- nity Enrichment Program; Northern Manhattan Im- provement Corporation; Columbia-Presbyterian Special Supplemental Nutrition Program For Women, Infants, and Children. New York Presbyterian Hospital Ambula- toiy Care Network; New York City Bureau of Immuniza- tion; and Mailman School of Public Health. The study team is particularly indebted to Amy Metroka, Director of the Citywide Immunization Registry, New York City De- partment of Health and Mental Hygiene, who graciously provided the data for the cohort samples per the speci- fications provided by the Start Rijjit team. We also thank Frank Chimkin, who originally developed the Start Right database and specified the initial immunization registry record requests.

Human Participant Protection This study was approved by the Columbia University Medical Center institutional review board.

References 1. Szilagyi PG, Bordley C, Vann JC, et al. Effect of patient reminder/recall interventions on immunization rates: a review, fAMA. 2 0 0 0 ; 2 8 4 : 1 8 2 0 - 1 8 2 7 .

2. Wood DL; American Academy of Pediatrics Com- mittee on Community Health Services; American Acad- emy of Pediatrics Committee on Practice and Ambulatory Medidne. Increasing immunization coverage. American Academy of Pediatrics Committee on Community Health Services. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine. Pediatrics. 2 0 0 3 ; 1 1 2 : 9 9 3 - 9 9 6 .

3. Browngoehl K, Kennedy K, KrotM K, Mainzer H. Increasing immunization: a Medicaid managed care model. Pediatrics. 1997;99:E4.

4. Wood D, Halfon N, Sherboume DC, et al. Increasing immunization rates among inner-dty, Añican American

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children. A randomized trial of case management/AAM. 1 9 9 8 ; 2 7 9 : 2 9 - 3 4 .

5. Briss PA. Rodewald LE. Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. AmfPrev Med. 2 0 0 0 ; 1 8 : 9 7 - 1 4 0 .

6. Mayer JP, Housemann R, Pipenbrok B. Evaluation of a campaign to improve immunization in a rural head start program. / Community Health. 1999;24; 1 3 - 2 7 .

7. Findley S, Irigoyen M, Sanchez M, et al. Community empowerment to reduce childhood immunization dis- parities in New York City. Ethn Dis. 2004; 14(3 suppl. 1):S134-S141.

8. Findley SE, Irigoyen M, Sanchez M, et al. Community- based strategies to reduce childhood immunization dis- parities. Health Promot Pract. 2006;7(suppl 3):191S- 200S.

9. Eng E, Parker E, Harlan C. Lay health advisor intervention strategies: a continuum from natural helping to paraprofessional helping. Health Educ Behav. 1997; 2 4 ; 4 1 3 - 4 1 7 .

10. Lewin S, Dick J, Pond P, et al. Lay health workers in primary and community health care. Cochrane Database SystRev. 2005;25(l):CD004015.

11. Brach C, Fraser L Can cultural competency re- duce radal and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2 0 0 0 ; 5 7 : 1 8 1 - 217.

12. Barnes K, Friedman SM, Namerow PB, Honig ]. Impact of community volunteers on immunization rates of children younger than 2 years. Arch Pediatr Adolesc Med. 1 9 9 9 ; 1 5 3 : 5 1 8 - 5 2 4 .

13. Israel B, Checkoway B, Schulty A. Health education and community empowerment: conceptualizing and measuring perceptions of individual, organizational and community control. Health Educ Q. 1994;21 : 1 4 9 - 1 7 0 .

14. Hoekstra EJ, LeBaron CW, Megaloeconomou Y, et al. Impact of a large-scale immunization initiative in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)./4J\«. 1998;280:l 1 4 3 - 1147.

15. Wood D, Halfon N. Reconfiguring child health services in the inner áty.fAMA. 1 9 9 8 ; 2 8 0 : 1 1 8 2 - 1 1 8 3 .

16. van Ryn M, Heaney CA. Developing effective helping relationships in health education practice. Health Educ Behav. 1997;24:683-702.

17. Green LW, Kreuter MW. Health Promotion Plan- ning: An Educational and Ecological Approach. 3rd ed. Mountain View, CA: Mayfield Publishing Co; 1999.

18. Kapore T, Moore A, Acosta R. Developing part- nerships with family home day care providers to improve immunization rates in the dty of Long Beach. Paper presented at: 34th National Immunization Conference; July 5, 2000; Washington, DC

19. Minkler M, Wallerstein N. Improving health through community organization and community building. In: Glanz K, Rimer BK, Lewis FM., eds. Health Behavior and Health Education: Theory, Research and Practice. 2nd ed. San Frandsco, CA: Jossey-Bass Publishers; 1 9 9 7 : 2 4 1 - 269.

20. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership

approaches to improve public health. Annu Rev Public Health. 1998;19:173-202.

2 1 . Institute of Health Promotion Research. Guidelines for Participatory Research in Health Promotion Vancou- ver: University of British Columbia; 1997.

22. Cook TD, Campbell DT. Quasi-Experimentation: Design and Analysis Issues for Field Settings. Boston, MA: Houjjiton Mifilin Company; 1979.

2 3 . Rossi PH, Freeman HE. Evaluation: A Systematic Approach. 3rd ed. Beverly Hills, CA: Sage; 1985.

24. Centers for Disease Control and Prevention. Na- tional, state, and urban area vaccination coverage among children aged 1 9 - 3 5 months-United States, 2005. MMWR Morb Mortal Wkly Rep. 2 0 0 6 ; 5 5 : 9 8 8 - 9 9 3 .

25. Luman ET, Barker LE, Shaw KM, McCauley MM, Buehler JW, Pickering LK. Timeliness of childhood vac- cinations in the United States, fAMA. 2 0 0 5 ; 2 9 3 : 1 2 0 4 - 1 2 1 1 .

26. Pagano M, Gauvreau K. Principles of Biostatistics. 2nd ed. Padfic Grove, CA: Duxbury Thomson Learning; 2000.

27. Kolasa MS, Chilkatowsky AP, Qarke KR, Lutz JP. How complete are immunization registries? The Phila- delphia story. Ambul Pediatr. 2 0 0 6 ; 6 : 2 1 - 2 4 .

28. Kempe A, Beaty BL, Steiner JF, et al. The regional immunization registry as a public health tool for im- proving clinical practice and guiding immunization de- Uvery policy. Am f Public Health. 2 0 0 4 ; 9 4 : 9 6 7 - 9 7 2 .

29. Papadouka V, Zucker ], Balter S, Reddy V, Moore K, Metroka A. New York City Department of Health and Mental Hygiene. Impact of Childhood Hepatitis A Vacci- nation: New York City. Paper presented at: 41st National Immunization Conference; March 5—8, 2 0 0 7 ; Kansas City, MO.

Readings in Global Health Omar A. Khan, MD, MHS, FAAFP-Editor

Readings in Global Health gathers com- phensive, cross- disciplinary research and commentary on a broad range global health topics including HIV/AIDs,

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1962 I Research and Practice | Peer Reviewed | Findley et al. American Journal of Pubiic Heaith | November 2008, Voi 98, No. 1 1