1. 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, Atlanta, USA
Walden University Ph.D. Residency - Minneapolis, MN July 2008

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

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

4. 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.

5. 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.

6. 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, Morbidity and Mortality Weekly Report, 61, 671–677. Retrieved from /mmwr/preview/mmwrhtml/mm6134a3.htm
Walden University Ph.D. Residency - Minneapolis, MN July 2008

7. 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

8. 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

9. 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 PCABC.
Ngundue J, 2017

10. 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 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 –10567 _ PNAS _ September 2, 2003 _ vol. 100 _ no
Walden University Ph.D. Residency - Minneapolis, MN July 2008

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

18. 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)
% differences in adjusted average immunization rates
Interpretation of Findings
Immunization disparity existed between U.S adolescents and PCABC from
U.S. adolescents were more protected compared PCABC from against disease outbreaks for Hepatitis B, measles, mumps, rubella, and varicella
Ngundue J, 2017

19. Table 7 Adjusted Adolescent Vaccine Coverage Uptake Differences (as Percentages) Between Pulaski County, Arkansas Birth Cohort and United States, 2006–2008
Pulaski County, AR 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
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
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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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
Pertussis
Tetanus
Hepatitis B
Measles
Mumps
Rubella
Poliomyelitis
Varicella
Note. Pulaski County Arkansas Birth Cohort 1990 Data Analysis.
Ngundue J, 2017

27. 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

28. 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

29. 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

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

31. 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

32. Thank you!
Questions?
Ngundue J, 2017