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Immunization Disparities Among Adolescents in Pulaski County, Arkansas

This study aims to assess the disparities in adolescent immunization rates among the 1990 Pulaski County, Arkansas birth cohort. It will also examine the influence of sociodemographic characteristics and individual vaccine payoff on vaccination coverage among adolescents in this population.

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Immunization Disparities Among Adolescents in Pulaski County, Arkansas

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  1. 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

  2. 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. Section 1 Background 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 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 1Problem 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

  7. Section 1Purpose 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 1Quantitative 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

  9. Section 1Hypothesis • 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

  10. Section 1Theoretical 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

  11. Section 2Quantitative 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

  12. Section 2Data 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

  13. Section 2Data 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 2Data 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? • Performedlogistic 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 3Results 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 5Pulaski County 1990 Birth Cohort Vaccine-Coverage Uptake, 2008 Ngundue J, 2017

  17. Table 6Pulaski County, Arkansas 1990 Birth Cohort Population and Five Vaccines for School Entry FVSE Coverage Uptake By Race Note. Statistically significant, p < .05. Ngundue J, 2017

  18. Section 3Results 1 and Interpretation of Findings Results • 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

  19. Table 7Adjusted Adolescent Vaccine Coverage Uptake Differences (as Percentages) Between Pulaski County, Arkansas Birth Cohort and United States, 2006–2008 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 3Results 2 and Interpretation of Findings • Results • 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 8Home of Residence Vaccine Coverage Uptake Comparison, 1990 Pulaski County, Arkansas Birth Cohort 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 3Results 3 and Interpretation of Findings Results • 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. Table 9Logistic Regression Examining the Association Between Five Vaccines for School Entry and Home of Residence Controlling For Univariates Note. p < .05 statistically significant. Ngundue J, 2017

  24. Table 10Bivariate Logistic Regression Results for Examining Possible Variable in the Association Between FVSE and HOR Note. p < .05 statistically significant. Ngundue J, 2017

  25. Section 3Results 4 and Interpretation of Findings Results 4 • 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. Table 11Pulaski County Arkansas 1990 Birth Cohort Estimated Payoff Comparison Deaths Vaccination Game Theory Note. Pulaski County Arkansas Birth Cohort 1990 Data Analysis. Ngundue J, 2017

  27. 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

  28. Section 4Limitations 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 4How 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

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

  31. ConclusionImplications 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

  32. Thank you! Questions? Ngundue J, 2017

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