{"id":60,"date":"2016-04-19T16:36:44","date_gmt":"2016-04-19T16:36:44","guid":{"rendered":"http:\/\/ctlsites.uga.edu\/hprb7010may2016\/?page_id=60"},"modified":"2016-06-07T21:32:48","modified_gmt":"2016-06-08T01:32:48","slug":"topic-2","status":"publish","type":"page","link":"https:\/\/ctlsites.uga.edu\/hprb7010may2016\/topic-2\/","title":{"rendered":"Vaccination – Community-Based Interventions Implemented in Combination"},"content":{"rendered":"

Community-Based Interventions Implemented in Combination to Improve Vaccination Rates<\/b><\/p>\n

Table 1. Summary of Recent Interventions<\/span><\/p>\n\n\n\n\n\n\n
Author & Year<\/strong><\/td>\nIntervention Setting, Description, and Comparison Group(s)<\/strong><\/td>\nStudy Population Description and Sample Size<\/strong><\/td>\nEffect Measure (Variables)<\/strong><\/td>\nResults including Test Statistics and Significance<\/strong><\/td>\nFollow-up Time<\/strong><\/td>\n<\/tr>\n
Aragones, Bruno, Ehrenberg, Tonda-Salcedo, & Gany, 2015<\/span><\/td>\nMexican-American parents attending the Health Window Program at the Mexican Consulate in New York City were recruited to participate in a study utilizing parental education and text message reminders to <\/span>increase HPV vaccination completion rates among Mexican American children.<\/span><\/p>\n

All study participants were given a one on one educational session with a trained health worker and then were either assigned to receive no text messages and or to receive text reminders \u00a0(in Spanish) regarding their child\u2019s vaccination status and eligibility. Messages were sent weekly until completion of 1st dose, and one month before due dates of the second and third doses. \u00a0Messages were sent weekly until dose completion was confirmed via telephone.<\/span><\/td>\n

\u00a0Eligible parents<\/span>\u00a0were selected, meeting the following criteria: <\/span>Mexican-American parent, \u00a018 years of age or older, speaking Spanish as a primary language, in possession of a text-capable cell phone, and who is\u00a0the primary caregiver of at least one child between the ages of 9-17 who has not received the HPV vaccine; n=69. (All received brief one on one educational session, 24 were assigned to control group, & 45 were assigned to intervention)<\/span><\/td>\n\u00a0Outcome measures included completion of full HPV vaccination course (3 doses) \u00a0for a parent\u2019s youngest eligible child.<\/span><\/td>\n\u00a0Parents receiving text message reminders were 15.5 times more likely to complete the HPV vaccination course than those in the group not receiving text messages (p<0.001). Variables shown to have no association with the outcome include gender of parent or child, parent age, English proficiency, or prior knowledge of the vaccine.<\/span><\/td>\nPhone call follow-ups (in Spanish) were conducted with parents to determine child vaccination status at:<\/span><\/p>\n

1) 6 weeks after failure to receive 1st dose or<\/span><\/p>\n

2) 4 months after completion of second dose to assess 3rd dose completion<\/span>
\n<\/span><\/td>\n<\/tr>\n

\u00a0Yoo, Humiston, Szilagyi, Schaffer, Long, & Kolasa, 2015 <\/span><\/td>\nElementary school children in Monroe County, New York during the fall seasons of 2009 and 2010 were enrolled in a community-based randomized controlled trial examining the effectiveness, cost, and cost-effectiveness of school-located vaccination against influenza (SLV). <\/span><\/p>\n

The study randomly assigned 21 elementary schools as the \u00a0intervention schools or intervention group for 2009 and 2010. Ten and eleven elementary schools were randomly assigned as the control group for 2009 and 2010 respectively. <\/span><\/td>\n

\u00a0 A total of 31 and 32 elementary schools in the Monroe County area were included in the 2009 and 2010 studies respectively. The intervention group included 21 schools and the control group included 10 and 11 in 2009 and 2010 respectively. There were 9027 students enrolled in the intervention schools in 2009 and 9145 students in 2010. The control group \u00a0had 4534 students enrolled in the 10 schools in 2009 and 4796 students enrolled in the 11 schools in 2010.<\/span><\/td>\n\u201cCost effectiveness analysis (CEA)\u201d –\u00a0<\/span>Measured as the cost effectiveness ratio. This was calculated by dividing the incremental cost (i.e. the difference in cost of intervention schools minus the cost of vaccination in control schools) by the incremental effectiveness (the number of additionally vaccinated students in intervention schools vs control schools)<\/span><\/p>\n

\u201cEffectiveness\u201d- measured by overall influenza vaccination rate. Defined as \u201cthe difference between the proportion of students who received <\/span>\u22651 seasonal influenza vaccine anywhere among students enrolled in the intervention vs the control schools.\u201d<\/span><\/p>\n

\u201cCosts\u201d – measured in U.S. dollars this was a total sum of the program costs broken down into school costs, project coordination costs, and vendor costs<\/span><\/td>\n

\u00a0 Overall, rates of influenza vaccination of \u00a0children in the intervention group were 40.7% and 40.4% in 2009 and 2010 respectively, while rates of influenza vaccination of the children in the control group were 29.8% and 28.4% in 2009 and 2010 respectively. This study found that children in schools with SLV programs are 1.5 times more likely to receive at least one seasonal influenza vaccine (p-value<0.0001). When averted costs were not taken into account, it was found that SLV vaccination programs are more costly than individual private practice administration. When averted costs were taken into account, the cost for SLV programs was comparable or lower than primary care practice. <\/span><\/td>\n\u00a0 No follow up.<\/span><\/td>\n<\/tr>\n
\u00a0Willis et al., 2016<\/span><\/td>\nCommunity Health Improvement for Milwaukee Children (CHIMC) launched educational, social marketing, and planned behavior interventions in an effort to reduce vaccination disparities among children age 19-35 months in lower socioeconomic families, using a \u00a0community-based participatory research (CBPR) approach. (Vaccinations in question: DTaP\/3HPV\/1MMR\/3HepB\/3Hib\/1VZV antigen series). \u00a0Participants were recruited from target communities and completed a survey consisting of demographics, immunization beliefs, and psychosocial factors. \u00a0An educational presentation was given to participants and pre- & post-knowledge surveys were obtained along with immunization rates. \u00a0Initial surveys were used to create a social marketing campaign, disseminated it throughout the communities, and conducted surveys to test the reach of the campaign. \u00a0Planned behavior change intervention worked to identify barriers to parents\u2019 keeping children up to date on vaccinations and demonstrated ways of navigating the healthcare system.<\/span><\/td>\n\u00a0565 parents\/caregivers and 1,533 children were enrolled and surveyed by CHIMC. (89.4% female, 91.4% African American, 63.5% unemployed, 70.5% single-headed households, 78.3% mother\/child relationship with child participant). \u00a0Of the households, mothers made the immunization decisions in 82.3% of them. <\/span><\/td>\nEducation interventions measured pre and post intervention attitudes and knowledge relating to child vaccination and compared changes in immunization status. \u00a0It also examined immunization status between children\u2019s age group and sought to identify factors influencing parents\u2019 perception of vaccination.<\/span><\/p>\n

The social marketing campaign measured the amount of people who had seen the CHIMC\u2019s messages and to what degree they were able to recall it, as well as their attitudes towards vaccinations.<\/span><\/p>\n

The planned behavior change intervention identified the most common perceived barriers to child vaccinations.<\/span><\/td>\n

\u00a0Baseline data was found to be different from that in <\/span>Healthy People 2020.<\/span><\/i> Educational interventions yielded a significant increase in both vaccination knowledge and increased immunization status from baseline (p<0.05). \u00a0Of the 408 participants surveyed about the social marketing campaign 51% recalled a message about children\u2019s health but only 2% were able to recall the CHIMC\u2019s message. The planned behavior change intervention identified the most commonly noted barrier to child vaccinations were hospital personnel (rhetoric, attitudes) and limited resources (time, transportation, insurance issues).<\/span><\/td>\nThe follow-up time for recall and immunization status of study participants occurred over 8 years.<\/span>\u00a0The CHIMC is ongoing and will continue to implement community-based approaches to develop interactive information dissemination about child vaccinations. \u00a0Resources will be compiled at www.chimcke.org.<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Community Guide Update and Rationale for Intervention<\/b><\/p>\n

Based on the selected strategies explored within these articles, the implementation of community based interventions, implemented in combination, to increase rates of vaccination are still strongly recommended<\/em> which is in agreance with the 2014 Task Force finding. Recent intervention programs such as text message reminders to increase HPV vaccine compliance, school located vaccine programs, and educational programs have shown statistically significant improvement in vaccination rates, especially in communities of lower socioeconomic standing where disparities are more pronounced.<\/p>\n

Intervention strategies implemented at the community level have shown to be effective at increasing vaccination rates. \u00a0Community-based combinations of interventions performed after the 2014 Task Force recommendations were published have proven to yield significant increases in vaccination compliance rates across various age groups and demographic groups. <\/span><\/p>\n

In their community based intervention involving an educational session on HPV vaccinations, followed by text message reminders, Aragones et al. found that parents receiving text message reminders were 15.5 times more likely to complete the HPV vaccination course than those in the group not receiving text messages. This study involved 69 Mexican American families with children under age 18 who had not received the HPV vaccine. \u00a0<\/span>After a brief one-on-one educational session, parents were assigned to groups that did and did not receive text message reminders about when their child was due for their next HPV vaccine booster. \u00a0They measured completion of full HPV vaccination course (3 doses) for a parent\u2019s youngest eligible child and found no other significant association (gender, age, English proficiency) between increased vaccination rates, other than having received text message reminders.<\/span><\/span><\/p>\n

Willis et al. employed textbook example of the Task Force\u2019s recommendation; a community level multi-component approach, incorporating voluntary educational sessions, a social marketing campaign, and a planned behavior change intervention. While the planned behavior interventions and the educational sessions were more effective than the social marketing campaign, all of these interventions produced significant results. This intervention targeted lower socioeconomic communities and was composed of mainly females and African Americans, including 565 adults and 1,533 children. \u00a0The Community Health Improvement for Milwaukee Children\u2019s educational campaigns yielded a significant increase in both vaccination knowledge and increased immunization status from baseline (p<0.05) (Willis et al.) \u00a0About 208 out of 408 people within the community were reached by the social marketing campaign and the planned behavior change intervention identified the most commonly noted barrier to child vaccinations included hospital personnel and limited resources such as time and money, providing the city of Milwaukee with valuable information on how to best provide community-based vaccination programs.<\/span><\/p>\n

Finally, Yoo et al. found results consistent with the recommendations outlined by the Task Force as well, with their study on the effectiveness of school-located vaccination against influenza. They found that vaccination rates among children in the intervention group were about 11-12% higher than children in the control group. \u00a0Children in schools with SLV programs are 1.5 times more likely to receive at least one seasonal influenza vaccine (p-value<0.0001) (Yoo et al.) \u00a0This study also found that SLV programs was comparable or lower than primary care practice when averted costs were taken into account. \u00a0The SLV program intervention study went on for two years and included a total of 31 and 32 two elementary schools in Monroe county in New York, either year. Slightly more 9000 students were enrolled at either school and roughly half of the children were placed in the intervention group, with the other half in the control group.<\/span><\/p>\n

Aragones et al.\u00a0targeted parents of Mexican-American children\u00a0and was greatly successful in increasing the rates of vaccination within the target population. Willis et al. improved attitudes concerning childhood vaccination among communities of low-socioeconomic standing. Yoo et al. found that children with access to school located vaccine clinics were much more likely to receive recommended vaccinations. All three of these studies exemplify the potential for community based combinations of interventions to increase vaccination among targeted communities.\u00a0<\/span><\/p>\n

Theoretical Framework\/Model<\/b><\/span><\/p>\n

The Health Belief Model and the Community Based Interventions Implemented in Combination to Increase Appropriate Vaccination<\/b><\/p>\n

The health belief model (HBM) is an explanatory model that, at the time of its conception, was primarily used as a technique for determining why many people do not participate in disease prevention programs (<\/span>Rimer & Glanz, 2005)<\/span>. \u00a0<\/span>The HBM approaches the desired behavior on an individual level, focusing on an individual\u2019s perception of health condition, the degree to which they feel the condition is a threat to them, and the marginal benefit of taking action once the cost of potential barriers to action are overcome. \u00a0These factors determine the likelihood of an individual making a behavior change. \u00a0<\/span>This was model excellently demonstrated by Willis et al. in the <\/span>Community Health Improvement for Milwaukee\u2019s Children Program, an ongoing community-based approach to identifying misinformation and barriers to early, childhood vaccination, and subsequently disseminating educational information and effective access to resources. \u00a0If we care able to effectively educate people on vaccinations we can correct any misinformation, quell some irrational fears, and provide information on effective methods of vaccination. \u00a0Education at the community level affords the opportunity to target specific groups who may be disproportionately affected by a preventable disease and who would benefit more from certain vaccinations. \u00a0Identifying perceived barriers to vaccination guides our objectives towards reducing those barriers and\/or revealing resources already available to people.<\/span><\/p>\n

Constructs<\/b><\/span><\/p>\n