2nd World Congress on Medical Sociology & Community Health Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. 2nd World Congress on Medical Sociology & Community Health Disparities in Arkansas Mandated Immunization Coverage Among Natural Home and Foster-Care Adolescents Jerome E. Ngundue, Ph.D., MHSA September 25-26, 2017 Atlanta, USA Walden University Ph.D. Residency - Minneapolis, MN July 2008

Establish the background State the problem OBJECTIVES Establish the background State the problem Explain methodology and analysis Discuss results Identify implications Ngundue J, 2017

Pulaski County, Arkansas Missouri Oklahoma Tennessee Mississippi Texas Louisiana Ngundue J, 2017

Low Immunization Coverage Rates Section 1 Background Low Immunization Coverage Rates School Absenteeism Hospitalization Societal Burdens Lost Work Productivity Economic Stress Increased Vaccine Preventable Diseases Outbreaks and Resurgences Immunization Triad CDC, 1991; Gould et al., 2009; Lee et al., 2008b, & Lopez et al., 2006. Gould et al., 2009; Parker et al., 2006; Safi et al., 2012; Thompson et al., 2007; Wheeler et al., 2004.

Section 1 Background Immunization Cascade Low Immunization Rates Vaccine Preventable Diseases Outbreaks and Resurgences Societal Burdens School Absenteeism Hospitalization CDC, 1991; Gould et al., 2009; Lee et al., 2008b, & Lopez et al., 2006. Gould et al., 2009; Parker et al., 2006; Safi et al., 2012; Thompson et al., 2007; Wheeler et al., 2004.

Section 1 Problem Statement Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 1 Problem Statement Reported immunization rates and uptake coverage for routinely required recommended five vaccines for school entry (FVSE) among adolescents in Pulaski County Arkansas (PCA) were persistently low compared to the U.S. average (CDC, 2012e). Centers for Disease Control and Prevention. (2012e). National and state vaccination coverage among adolescents aged 13–17 years—United States, 2011. Morbidity and Mortality Weekly Report, 61, 671–677. Retrieved from http://www.cdc.gov /mmwr/preview/mmwrhtml/mm6134a3.htm Walden University Ph.D. Residency - Minneapolis, MN July 2008

Section 1 Purpose Statement Assess adolescent immunization-rates disparity among the 1990 Pulaski County, Arkansas birth cohort (PCABC). Examine game theory in vaccination coverage among the 1990 PCABC Pulaski County, Arkansas Ngundue J, 2017

Section 1 Quantitative Research Questions Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 1 Quantitative Research Questions Research Question 1: Are the calculated 2006–2008 adolescent percent vaccination uptake for FVSE among the 1990 PCABC significantly different from the FVSE reported 2006–2008 U.S. national adolescent estimated immunization rates? Research Question 2: Are there differences in percentage of FVSE vaccine coverage uptake between natural home (NHA) and foster care adolescent (FCA) among adolescents in the 2003–2008 PCABC? Research Question 3: Is the association between home of resident (HOR) defined as NHA and FCA, and up to date (UTD) of FVSE coverage mediated through sociodemographic characteristics, which include age, race, ethnicity, and gender in PCABC? Research Question 4: Will differences in individual vaccine payoff, measured by avoidance of disease development as a result of vaccine receipt, affect group interest, measured by deaths as a result of non-vaccination for the FVSE among the PCABC? Ngundue J, 2017 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Section 1 Hypothesis Ho1: Null Hypothesis: There is no difference between the 2006–2008 PCABC calculated percent VCU for the FVSE and the reported 2006–2008 U.S. adolescent national immunization teen (NIS-Teen) estimated percent VCU for the FVSE Ho2: Null Hypothesis: There is no significant difference in FVSE coverage uptake between the HOR defined as NHA and FCA in the 2003–2008 PCABC Ho3: Null Hypothesis: The associations between HOR, as defined as NHA or FCA, and UTD FVSE in PCABC is not mediated through sociodemographic characteristics, including age, race, ethnicity and gender Ho4: Differences in individual vaccine payoff, measured by avoidance of disease development as a result of vaccine receipt, will not affect group interest, measured by deaths as a result of non-vaccination, for the FVSE among the 1990 PCABC. Ngundue J, 2017

Section 1 Theoretical framework Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 1 Theoretical framework Theory of games (TOG) John von Neumann & Oskar Morgenstern, 1944 John Nash Equilibrium. 1994 Nobel Prize Economics Bauch, C.T, Galvani, A.P., & Earn, D. J. D., 2003 Game theory and vaccination Group optimum Individual equilibrium Bauch, C.T, Galvani, A.P., & Earn, D. J. D. (2003). Group interest versus self-interest in smallpox vaccination policy. 10564–10567 _ PNAS _ September 2, 2003 _ vol. 100 _ no. 18. www.pnas.org_cgi_doi_10.1073_pnas.1731324100 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Section 2 Quantitative Method Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 2 Quantitative Method Quantitative Method Analysis of retrospective secondary data Four statistical tools Cross-sectional Research Design Examine immunization rates at a point in time Sample size 3,371 adolescents Eligibility data collection criteria Four criteria Ngundue J, 2017 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Section 2 Data Source and Collection Plan Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 2 Data Source and Collection Plan Arkansas immunization registry Retrospective archived registry data Institutional research board IRB Arkansas Department of Health Completed IRB requirements Ngundue J, 2017 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Section 2 Data Analysis Plan Research Question 1: Are the calculated 2006–2008 adolescent percent vaccination uptake for FVSE among the 1990 PCABC significantly different from the FVSE reported 2006–2008 U.S. national adolescent estimated immunization rates? Adjusted up-to-date UTD immunization rates Conducted direct standardization based on 2010 U.S. census Research Question 2: Are there differences in percentage of FVSE vaccine coverage uptake between natural home (NHA) and foster care adolescent (FCA) among adolescents in the 2003–2008 PCABC? Conducted chi square analysis Assessed association between UTD FVSE and home of residence HOR Ngundue J, 2017

Section 2 Data Analysis Plan Research Question 3: Is the association between home of resident (HOR) defined as NHA and FCA, and up to date (UTD) of FVSE coverage mediated through sociodemographic characteristics, which include age, race, ethnicity, and gender in PCABC? Performed logistic regression analysis Determined mediation variable between HOR and UTD FVSE Research Question 4: Will differences in individual vaccine payoff, measured by avoidance of disease development as a result of vaccine receipt, affect group interest, measured by deaths as a result of non-vaccination for the FVSE among the PCABC? Operationalized vaccination TOG equation parameters Calculated estimated payoff deaths applied the individual equilibrium and group optimum behavior Ngundue J, 2017

Section 3 Results Summary Overview United States adolescents had higher adjusted immunization rates compared to Pulaski County Adolescent Birth Cohort (PCABC) Foster care adolescents had higher immunization rates compared to natural home adolescents. Race mediated the associations between home of residence and UTD for FVSE in PCABC. Individual equilibrium estimated deaths were higher compared Group optimum estimated deaths. PCABC did not achieve immunization rate threshold Ngundue J, 2017

Table 5 Pulaski County 1990 Birth Cohort Vaccine-Coverage Uptake, 2008 Ngundue J, 2017

FVSE vaccine UTD status by race Table 6 Pulaski County, Arkansas 1990 Birth Cohort Population and Five Vaccines for School Entry FVSE Coverage Uptake By Race FVSE vaccine UTD status by race Total   No Yes Race N % χ2 p-value 3,371 100.0 2,840 84.3 531 15.7 25.93 < .0001 African American 1,792 53.2 1,456 81.3 336 18.7 Caucasian 1,036 30.7 907 87.5 129 12.5 Other 543 16.1 477 87.8 66 12.2 Note. Statistically significant, p < .05. Ngundue J, 2017

Section 3 Results 1 and Interpretation of Findings United States (US) adolescents had higher adjusted immunization rates compared to Pulaski County Adolescent Birth Cohort (PCABC) 11.6 -70.2% differences in adjusted average immunization rates Interpretation of Findings Immunization disparity existed between U.S adolescents and PCABC from 2006-2008. U.S. adolescents were more protected compared PCABC from 2006-2008 against disease outbreaks for Hepatitis B, measles, mumps, rubella, and varicella Ngundue J, 2017

Table 7 Adjusted Adolescent Vaccine Coverage Uptake Differences (as Percentages) Between Pulaski County, Arkansas Birth Cohort and United States, 2006–2008 Pulaski County, AR. 1990 birth cohort   U.S. National Immunization Survey Vaccine 2006 2007 2008 Average t-test p-value Td/Tdap 84.0 83.8 83.9 58.2 72.3 72.1 67.5 3.51 .025 Hep B 77.9 75.6 74.2 75.9 82.1 87.6 87.9 85.9 4.59 .01 MMR 77.7 87.1 88.9 89.3 88.4 15.86 .000009 OPV/IPV 86.2 86.0 82.8 85.0 N/A NA VAR 17.0 17.4 28.8 21.1 89.4 91.8 92.7 91.3 17.59 .000006 Note. Td/Tdap = tetanus-diphtheria/tetanus-diphtheria-acellular pertussis; Hep B = hepatitis B; MMR = measles-mumps-rubella; OPV/IPV = poliomyelitis; VAR = varicella; Pulaski County, AR birth cohort 1990 Data Analysis, p < .05 statistically significant; *Standardized to 2010 U.S. population. Ngundue J, 2017

Section 3 Results 2 and Interpretation of Findings FCA had higher immunization rates compared to NHA for FVSE (Tdap/Td, Hep B, MMR, OPV-IPV, and VAR) from 2003–2008. Significant differences existed in Hep B, MMR, OPV-IPV, and VAR coverage uptake between FCA and NHA from 2003–2008. Tdap/Td differences between FCA and NHA for FVSE was not significant (X2 =1.55; p = 0.21) Interpretation of Findings Differences exist in percentage of FVSE coverage between NHA and FCA FCA higher immunization rates contradicts findings from published literature Attributable to factors outside scope of this study but published in the literature Ngundue J, 2017

Table 8 Home of Residence Vaccine Coverage Uptake Comparison, 1990 Pulaski County, Arkansas Birth Cohort   Foster care Natural home N % Vaccine Yes No χ2 p-value Td/Tdap 103 15 87.3 12.7 2,694 555 82.9 17.1 1.55 .21 Hep B 96 22 81.4 18.6 2,172 1,077 66.9 33.1 10.89 .001 MMR 107 11 90.7 9.3 2,509 740 77.2 22.8 11.89 .0006 OPV/IPV 108 10 91.5 8.5 2,737 512 84.2 15.8 4.61 .0318 VAR 43 75 36.4 63.6 619 2,330 19.1 80.9 21.79 < .0001 FVSE 35 83 29.7 70.3 2,630 18.5 Note. Td/Tdap = tetanus-diphtheria/tetanus-diphtheria-acellular pertussis; Hep B = hepatitis B; MMR = measles-mumps-rubella; OPV/IPV = poliomyelitis; VAR = varicella; p < .05 statistically significant. Ngundue J, 2017

Section 3 Results 3 and Interpretation of Findings Race mediated the associations between home of residence HOR and UTD of five vaccines for school entry FVSE among PCABC. African American adolescents were 1.8 times more likely to have UTD for FVSE compared to Whites adolescents. Interpretation of Findings Findings revealed differences in odds of UTD for FVSE among PCABC race categories. Improved immunization among African Americans in this cohort offers future possibilities exist to sustain vaccination gain among historic low performing races. Ngundue J, 2017

Variable and covariate Table 9 Logistic Regression Examining the Association Between Five Vaccines for School Entry and Home of Residence Controlling For Univariates Variable and covariate Odds ratio (OR) 95% confidence limits p-value Home-Residence Foster-care adolescent 1.02 0.67–1.56 .91 Natural-home adolescent 1 Gender Male 0.86–1.17 .99 Female Race African American 1.77 1.49–2.09 < .0001 Other 0.54 0.43–0.67 Caucasian Ethnicity Hispanic 1.21 0.78–1.87 .4005 Non-Hispanic Note. p < .05 statistically significant. Ngundue J, 2017

Table 10 Bivariate Logistic Regression Results for Examining Possible Variable in the Association Between FVSE and HOR Variable and covariate Odds ratio 95% confidence limits p-value Home Residence (NHA and FCA) Mediated by Race Association between HOR and Race African American 1.23 0.85–1.88 .2422 Other 0.19 0.07–0.53 .0016 Caucasian 1.00 Association between Race and UTD for All FVSE 1.79 1.51–2.12 < .0001 0.48 0.39–0.59 Home Residence Mediated by Gender Association between Gender and HOR Male 1.29 0.90–1.85 .1716 Female Association between Gender and UTD for FVSE 0.98 0.85–1.14 .8072 Home Residence Mediated by Ethnicity Association between HOR and ethnicity Hispanic 1.07 0.61–1.88 .806 Not Hispanic Association between Ethnicity and UTD for FVSE 1.12 0.64–1.96 .6984 Note. p < .05 statistically significant. Ngundue J, 2017

Section 3 Results 4 and Interpretation of Findings Varicella deaths 12.9 (individual equilibrium) and 9.7 (group optimum) Hepatitis B deaths 5.4 (individual equilibrium) and 1.8 deaths (group optimum) Tetanus deaths 3.4 (individual equilibrium) and 0.6 deaths (group optimum) Interpretation of Findings Individual equilibrium was a high-risk behavior. Group Optimum is protective against potential disease risks, exposures, and outbreaks Ngundue J, 2017

Individual equilibrium deaths Table 11 Pulaski County Arkansas 1990 Birth Cohort Estimated Payoff Comparison Deaths Vaccination Game Theory Individual equilibrium deaths Group optimum deaths Diphtheria 2.610000 0.441000 Pertussis 1.300000 0.220000 Tetanus 3.390000 0.570000 Hepatitis B 5.440000 1.780000 Measles 0.001000 0.000200 Mumps 0.000095 0.000021 Rubella 0.222000 0.050000 Poliomyelitis Varicella 12.030000 9.660000 Note. Pulaski County Arkansas Birth Cohort 1990 Data Analysis. Ngundue J, 2017

Section 3: How Findings Relate to the Literature Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 3: How Findings Relate to the Literature Support findings from other studies US adjusted immunization rates are higher than PCABC. Game theory group optimum lower payoff deaths compared to individual equilibrium (Bauch et al., 2003). Contradicted findings of other published studies Stable home adolescents had higher immunization rates African Americans had lower immunization rates Ngundue J, 2017 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Section 4 Limitations of the study Generalizable to Pulaski County adolescent birth cohort. Validity and reliability of results interpretations applicable and specific to Pulaski County adolescent birth cohort. Ngundue J, 2017

Section 4 How Data Relates to Professional Practice Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Section 4 How Data Relates to Professional Practice Public Health and Clinical Practice Health providers School nurses Contributed evidence of increased vaccination Research Examine benefits of immunization-registry data Future research on other Arkansas cohorts Ngundue J, 2017 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Conclusion Implications for Social Change Low immunization rates Preventable diseases incidence Diphtheria Hepatitis B Measles Mumps Pertussis Polio Rubella Tetanus Varicella

Conclusion Implications of Data for Social Change Designing and Implementing a High Quality Research Project: Best Practices, Training and Practice Robert Kilmer, Ph.D. and Wade Smith, Ed.D. Conclusion Implications of Data for Social Change Individual Protect vulnerable unvaccinated NHA and FCA Encourage parents to accept to vaccinate adolescents Public Health, Physicians, and Community Stakeholders Health providers enhance vaccine communication with PCABC hesitant parents Social media strategies to increase immunization rates Direct vaccine communication build trust between providers and parents Ngundue J, 2017 Walden University Ph.D. Residency - Minneapolis, MN July 2008

Thank you! Questions? Ngundue J, 2017