1. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Using Cluster Survey Methodology to Assess Current Immunization Coverage Levels Among African American Children 2-3 Years Old and Factors Influencing Completion Rose Wang, A. Nelson El Amin, Cheri Todoroff, Magda Shaheen, David Gambill Immunization Program, Los Angeles County Department of Health Services May 2004

2. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Background  Few sources of data available about African American IZ rates  California Kindergarten Retrospective Survey (CA KRS) –Annual random sampling of schools in CA –Determines percentage of kindergarten students who were up-to-date (UTD) with immunizations at different age checkpoints –UTD at 2 and 3 years old: 4 DTP, 3 Polio, 1 MMR

3. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Background  2001 CA KRS data shows IZ coverage level for LAC AA toddlers is lower than all other ethnic groups –24 months  52% (AA) vs. 71% (whites), 72% (Hispanic), 80% (Asian) –3 years old  65% (AA) vs. 84% (whites), 77% (Hispanic), 83% (Asian)

4. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Immunization Levels of LA County Toddlers at Two Years Old by Race (1996-2001) *Includes data from expanded sample of 46 schools in Los Angeles County

5. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Survey Objectives  Assess IZ coverage for AA children 2-3 years old in zip codes 90008, 90043, 90047, 90056, and 90305  Identify factors influencing IZ completion  Assess parents’ KAB related to childhood immunizations  Identify culturally appropriate ways to encourage timely childhood IZ

6. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Overlap of Selected African American Cluster Survey Zip Codes with proportion of Kindergarten Students UTD at 24 Months of Age, by Service Planning Area (1996/1999)

7. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Cluster Survey Sampling Scheme  Study population –Five zip codes divided into 170 clusters  Sample clusters –Clusters consist of blocks with households  Identify eligible children in households –African American children age 24-47 months old  Sample children

8. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Determining Clusters  5 zip codes divided into 170 clusters (groups of blocks) –Each had at least 20 eligible children identified by 2000 US Census data –Clusters created by using Map Info to determine spatial relationship of blocks to census data  Sampled 50 clusters with probability proportionate to the estimated size (PPS) of the eligible children

9. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Pre-Implementation  Pilot tested the survey instrument  Distributed flyers with local businesses, churches, daycare centers and advertised in local newspapers  Trained Staff –Safety and cultural sensitivity issues –Survey protocol

10. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Implementation Overview  July 2002 - December 2002  Collaborative effort with LACIP and Great Beginnings for Black Babies  Staff paired up in teams of 2 or 3  4 hour shifts  Six and a half days a week  5,579 total staff hours (54 total staff)

11. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM  Systematic documentation of all addresses on a given block and number of eligible children  Verify eligibility (2-3 yrs old) – Age = Date of Enumeration - Birthdate  Non-response households visited a maximum of 3 times, at least once on a weekend Phase 1: Enumeration

12. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Phase 2: Interview  Began when at least 10 kids found in a cluster  Objectives –Identify parental knowledge, attitudes, behaviors and other factors influencing completion of immunizations  5 page survey  Obtain parental consent –Determine child’s immunization status  Record abstraction form or  Medical release consent form

13. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Phase 2: Interview  August 27 – December 16  Randomly selected children  Appointments were made if necessary  Flyers were left if no response  No more than 10 attempts  No response, refusals, or “moved” households were replaced (if any)  $10 grocery gift certificate given upon completion

14. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Enumeration Results  48 clusters  Approximately 390 blocks (over 35,000 households)  Approximately 565 eligible children identified  More eligible children found in zip code 90008 – Crenshaw district –Predominantly apartments

15. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Types of Interview Responses n = 533 (362) (23) (15) (18) (5) (35) (75)

16. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Study Population Demographics  58% of children were 2 years old  99% of children were immunized  Parents’ age groups evenly distributed  56% of parents/guardians were never married or divorced  61% had income < $40,000 but 29% had a high school diploma and 58% had post-high school education

17. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Health Care Characteristics *multiple responses allowed

18. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Vaccine Coverage Levels DOSES OF VACCINE Cluster Survey 2002 (24-47 mos) NIS 2002 AA (19-35 mos)* NIS 2002 LAC (19-35 mos)* 3+ DTaP/DT88.7 ± 4.093.5 ± 1.893.1 ± 4.2 4+ DTaP/DT76.8 ± 4.375.8 ± 2.983.7 ± 5.3 3+ Polio85.6 ± 3.787.4 ± 2.188.3 ± 4.8 1+ MMR88.4 ± 3.790.3 ± 1.991.1 ± 4.0 3+ Hib81.8 ± 4.691.6 ± 1.989.7 ± 4.7 3+ Hep B81.8 ± 4.088.0 ± 2.190.4 ± 3.9 1+ Varicella84.3 ± 4.082.7 ± 2.588.1 ± 4.3 1+ Hep A61.3 ± 7.8N/A 2+ Hep A17.7 ± 3.7N/A 3+ PCV 721.3 ± 4.233.9 ± 3.134.4 ± 6.4 * National Immunization Survey 2002

19. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Combined Vaccination Series Coverage Levels COMBINED VACCINE SERIES Cluster Survey 2002 (24-47 mos) NIS 2002 AA (19-35 mos)* NIS 2002 LAC (19-35 mos)* 4:3:173.5 ± 4.071.6 ± 3.079.6 ± 5.6 4:3:1:370.4 ± 4.370.7 ± 3.077.1 ± 5.8 4:3:1:3:367.4 ± 4.367.7 ± 3.176.0 ± 5.9 National Immunization Survey 2002 4:3:1 – defined as 4 DTaP, 3 Polio, 1 MMR 4:3:1:3 – defined as 4 DTaP, 3 Polio, 1 MMR, 3 Hib 4:3:1:3:3 – defined as 4 DtaP, 3 Polio, 1 MMR, 3 Hib, 3 Hep B

20. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Usual Immunization Provider* * Multiple responses allowed

21. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM 4:3:1 Vaccination Coverage Levels by Provider

22. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Proportion With Immunization Card At Home (n = 362) 267 95

23. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM 4:3:1 Vaccination Coverage Levels by Immunization Card

24. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Potential Barriers

25. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Potential Barriers

26. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Main Sources of Health Information

27. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAMKnowledge

28. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Knowledge

29. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Knowledge

30. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Attitudes Toward Immunizations 325 279 (TRUE) 272 (TRUE) 312 (TRUE) 326 (TRUE) 281 (FALSE) 291 (FALSE) 230 (FALSE)

31. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Conclusions  Cluster Survey Methodology is time and staff intensive  –More racially homogenous or less mobile study areas maybe easier to implement  Selection bias in generalizing data   Useful for collecting KAB data  Face-to-face interaction is a plus  Community “buy-in”, build rapport

32. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Conclusions  Coverage levels were better than expected  Coverage levels comparable to NIS AA data, but still lower than other ethnic groups  Traditional health care providers still a major determinant of child’s immunization status –Reduce access barriers –Improve effective parent education

33. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Immunization Program 3530 Wilshire Bl. Suite 700 Los Angeles, CA 90010 Phone: (213) 351-7800 Fax: (213) 351-2780 www.lapublichealth.org/ip/ rwang@dhs.co.la.ca.us

34. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM How Much Parents Pay For Immunizations (n = 358) 259 4 95

35. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM 4:3:1 Vaccination Coverage Levels by Cost

36. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Proportion Who Make Appointments (n = 358) 37 20 299 2

37. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM 4:3:1 Vaccination Coverage Levels by Appointment Type

38. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Challenges  Staff safety & comfort  Ethnic/racial barriers  Neighbor’s saying “no kids”  Confusing maps & block diagrams  Locked apartment complexes, manager not available  No clear differentiation of a child’s temporary vs. permanent residence  Reduced daylight hours  Community program vs. research study

39. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM More Challenges  Parent/Legal guardian not home  Participant apathy  Enumeration errors (incorrect birthdate, incorrect race, no apt. # listed)  Responder differs at enumeration and interview phases  Residents moved  Big lag time between enumeration and interview phases  Staff morale and commitment  Distrust of survey

40. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Lessons Learned  Hire staff with transportation  Cell phones are great for emergencies  Knock on every door  Split up a block during enumeration if necessary  Avoid looking, sounding, or acting like the police  Incentives are always greatly appreciated  Persistence & patience can get you in

41. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM More Lessons Learned  Double check all maps and diagrams  Keep interview date as close to enumeration date  Ask for a contact name or phone number during enumeration  Weekends & evenings were productive –Weekends: Allowed staff to safely enter “gang” areas –Both: More residents were at home  Teams no more than 3 people

42. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Health Behavior n = 336 89 247

43. www.lapublichealth.org/ip/ County of Los Angeles Department of Health Services IMMUNIZATION PROGRAM Health Behaviors n = 87