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Original Contribution |

Increasing Immunization Rates Among Inner-City, African American Children:  A Randomized Trial of Case Management FREE

David Wood, MD, MPH; Neal Halfon, MD, MPH; Cathy Donald-Sherbourne, PhD; Rebecca M. Mazel, MA; Mark Schuster, MD, PhD; Julie Shea Hamlin, MA; Margaret Pereyra, PhD; Patricia Camp, MS; Mark Grabowsky, MD, MPH; Naihua Duan, PhD
[+] Author Affiliations

From RAND, Santa Monica, Calif (Drs Wood, Halfon, Schuster, Donald-Sherbourne, Duan and Mss Camp and Mazel); the Department of Pediatrics, Shriners Hospitals, Tampa, Fla (Dr Wood and Ms Hamlin); Department of Community Health, School of Public Health (Drs Halfon and Pereyra), and Department of Pediatrics, School of Medicine (Drs Halfon and Schuster), University of California, Los Angeles; and Vaccine and Prevention Research Branch, Division of AIDS, National Institutes of Health, Bethesda, Md (Dr Grabowsky).


JAMA. 1998;279(1):29-34. doi:10.1001/jama.279.1.29.
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Published online

Context.—  Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in inner-city areas have been largely untested.

Objective.—  To assess the effectiveness of case management in raising immunization levels among infants of inner-city, African American families.

Design.— Randomized controlled trial with follow-up through 1 year of life.

Setting.— Low-income areas of inner-city Los Angeles, Calif.

Patients.— A representative sample of 419 African American infants and their families.

Interventions.—  In-depth assessment by case managers before infants were 6 weeks of age, with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed.

Main Outcome Measures.—  Percentage of children with up-to-date immunizations at age 1 year, characteristics associated with improved immunization rates, and cost-effectiveness of case management intervention.

Results.—  A total of 365 newborns were followed up to age 1 year. Overall, the immunization completion for the case management group was 13.2 percentage points higher than the control group (63.8% vs 50.6%; P=.01). In a logistic model, the case management effect was limited to the 25% of the sample who reported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 percentage points. Although for the case management group intervention was not cost-effective ($12022 per additional child immunized), it was better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits.

Conclusions.—  A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city, African American infants. The intervention was demonstrated to be particularly effective for subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.

Figures in this Article

RECENT SURVEYS of immunization coverage conducted by the Centers for Disease Control and Prevention (CDC), Atlanta, Ga, have shown increasing rates of immunization coverage for the population as a whole.1,2 However, children who are poor, live in urban areas, or are members of minority groups are less likely to be up-to-date in their immunizations than the general population.3,4 When multiple risk factors converge, as they do in many urban areas, immunization rates may be much lower than they are in other parts of the United States.5 New strategies need to be developed to reach out to inner-city populations and raise immunization rates.

In previous work, we examined access to immunizations for African American preschool children in inner-city Los Angeles, Calif. We found that 50% were fully immunized at 12 months of age, and only 25% were fully immunized by 24 months of age.6 Late immunizations were more common in children who were not consistently connected to the health care system. For example, the families frequently lacked referrals from the birth hospital to a child health care provider. In addition, we found that African American mothers' beliefs regarding immunizations were likely to inhibit them from seeking immunizations. For example, one third of mothers did not believe that the vaccines for measles or pertussis were effective.7

Case management has been shown to be effective at providing information, influencing health beliefs, and helping clients access the health care system.810 We hypothesized that a case management intervention would be effective at improving receipt of immunizations in the first year of life. To test this hypothesis, we conducted a prospective, randomized controlled trial of case management in a representative sample of African American women–infant pairs in inner-city Los Angeles.

Sample

After enrollment in the first weeks of life, a cohort of 419 mother-infant pairs was randomized to an intervention (case management and a health passport) or control group (health passport only) and followed through an average of 15 months of life. The health passports given to all participants were produced by the state of California and contain information on the recommended visits for well-child care and the childhood immunization schedule approved by the CDC.11

The sample was geographically based in 10 ZIP codes predominantly inhabited by low-income, African American families that we had surveyed in previous studies. On a biweekly basis, we obtained lists with names and addresses from the Los Angeles County Vital Statistics Branch for all births to African American women residing in the 10 target ZIP codes. Using a reverse directory, we contacted them by telephone, and then a trained RAND interviewer interviewed them in their homes. The average age of the child at the enrollment interview was 17.8 days, with a range of 0 to 42 days. We enrolled the 419 mother-infant pairs over a 3-month period between February and early May 1994.

Of the total of 606 children born into the 10 ZIP codes during the enrollment period, 84 were not eligible for various reasons (baby died, caretaker no longer at the current address, etc). Of the 522 eligible births, 419 (80.3%) agreed to participate. We compared the participants and those that did not participate on 29 characteristics obtained from the birth certificate. The 2 groups differed only on rate of minor complications of labor and on insurance coverage.12 The mother-infant pairs were randomized in blocks of 4 (ABBA, ABAB, etc) by RAND survey staff in advance of the baseline interview and assigned to interviewers in advance, so the group assignment was balanced both in temporal sequence and by interviewer. A total of 209 pairs were randomized to the case management group, and 210 were randomized to the control group.

To track the control group, the RAND survey group made 1 contact when the infants were aged 4 to 5 months to update the mothers' addresses and telephone numbers. After randomization to the case management group, 32 refused to participate. At the end of the intervention period (the average age of the children was 15.5 months), we interviewed 181 (86%) of the 210 passport group participants and 186 (89%) of the 209 participants in the case management group, including 29 of 32 who had initially refused to participate in case management (Figure 1). The case management refusals are maintained in the case management group in the analysis, consistent with an intention-to-treat analysis.

Graphic Jump Location
Profile of the trial of African American mother–infant pairs in inner-city Los Angeles, Calif.
Intervention

The case managers conducted in-depth assessments in the home of the child before the infant was 6 weeks of age, with subsequent home visits scheduled 2 weeks prior to when the next immunizations were due. In a family that received all well-child care visits and immunizations on time, home visits would occur when the infants were approximately 3.5 and 5.5 months of age, with a fourth visit being optional. Case managers also followed up by telephone or by home visit after scheduled well-child visits to determine if the family kept the appointment and if the child received the appropriate care. Case managers scheduled more follow-up visits with families that had difficulty in keeping appointments or whose children fell behind in their immunizations. Therefore, the families that were compliant received fewer home visits and had fewer telephone or mail contacts initiated by the case manager. The mean number of home visits was 4.0 (SD, 2; range, 0-13), and the mean number of telephone contacts was 7.0 (SD, 4.1; range, 0-23). Over the 1 year, the mean number of minutes spent by the case managers in face-to-face contact with a family member was 85 minutes (SD, 75), and the mean number of minutes on the telephone with a family member was 29.8 (SD, 39).

The case management intervention included the following components: assessment of client health and other needs, development of a service plan and goals in collaboration with the client, brokering and coordination of services for the client, advocacy with larger institutions and public assistance programs (such as Medicaid), and monitoring and follow-up. At each visit the case manager documented that the client understood the immunization schedule and which immunizations were still remaining, had an appointment with a provider for the next immunization, and was planning on keeping the appointment. The case managers sought to reduce misconceptions regarding false contraindications to vaccination and encouraged clients to be proactive and request immunizations from their providers. Furthermore, the case managers sought to identify and help resolve problems or barriers in the receipt of well-child care, such as lapses in Medicaid insurance or problems with transportation.

Data Collection

Information collected from both groups at baseline and at the end of the intervention period by face-to-face interviews is presented in Table 1.

Table Graphic Jump LocationTable 1.—Information Collected in the Baseline and Exit Interviews
Up-to-Date Measure

Of the 365 mother-infant dyads successfully contacted at the end of the trial, 259 (71%) produced written, handheld records with valid immunization information at the exit interview. In addition, we successfully abstracted provider chart immunization information from an overlapping subgroup of 299 children (82%). For each child we combined the 2 written sources of information and eliminated redundant immunizations, resulting in written documentation of immunization for 89% of our final sample. Being up-to-date at 12 months of age was defined as having received 3 appropriately spaced diphtheria-tetanus-pertussis (DTP) vaccinations, 2 appropriately spaced oral poliovirus (OPV) vaccinations, and 3 appropriately spaced Haemophilus influenzae type B (HIB) vaccinations.11

At the initial interview, after recording immunization information from the handheld record, we asked the parents if the record contained all the immunizations the child had received. If they responded "no," we took them through a series of prompts to solicit their recall of the specific vaccines received and the specific dates on which they were received. Recalled immunizations were accepted for inclusion only if they had both complete dates, and the specific vaccination was identified. For each child for whom there was recall data, vaccine type and date were compared with both the handheld record and the provider record; 7.4% of respondents recalled at least 1 immunization that was not recorded on either record.

The 29% of respondents who could not produce a handheld record at the initial interview were taken through a more comprehensive series of prompts to solicit recall of their children's immunizations in the first year of life. The interviewer first established the child's age at each health visit at which they received any immunizations. Then, for each health visit, the interviewer asked the parent to indicate which immunizations the child had received using prompts such as the following: "Did [child's name] receive the shot (vaccination) for Haemophilus influenzae B (HIB) or the meningitis immunization?" Recalled immunizations were accepted for inclusion only if they had both complete date information, and the specific vaccination was identified.

Of the 106 respondents that gave full recall information, more than half (66) had their recall validated by provider records. For 40 children, provider records were either incomplete or unavailable. For 17 children (or 4.7% of the total sample), recalled immunization information met the criteria for acceptance, and the standard up-to-date criteria were applied to the reported immunizations. For 23 children (6.3% of the total sample), parental recall did not meet the criteria for acceptance, and those children were classified as not up-to-date.

Data Analysis

We first examined the bivariate or unadjusted relationships between each of the independent variables and immunization status at 12 months; χ2 tests were used for categorical variables, and t tests were performed for continuous variables. We evaluated correlations among independent variables for evidence of potential multicollinearity. In the 2 cases in which variables were highly correlated (the number of people in the household and the number of siblings), we chose to include only 1 in subsequent multivariate analyses.

We entered a comprehensive set of variables into a logistic regression model that predicted being up-to-date at 12 months, including (1) the variable "living with a partner" to correct for differences at baseline between the 2 groups; (2) demographic and health system variables identified as significant from the bivariate analyses; and (3) any additional variables that were associated with immunization receipt in our previous studies.7 A forward stepwise elimination procedure was conducted, resulting in a final, parsimonious model that included only statistically significant predictors. We tested key variables for interaction with case management and found that only the interaction between the 2-part well-child visit variable (0-3 visits and ≥4 visits) was significant at the .05 level. The interaction terms were included in the final model. We performed our analyses using the STATA 3.0 software package (STATA Corp, Santa Monica, Calif).13

Cost-effectiveness Analysis

We calculated the total costs of implementing the case management program, including personnel, supplies, travel, office space costs, and orientation costs. We divided those costs by the total number of participants to get an average cost per participant. The overall cost-effectiveness ratio was calculated by dividing the mean costs by the absolute percentage increase in up-to-date immunization. We further determined the proportionate costs for each individual participant through the following approach. (1) Case managers documented by client both the frequency and the time required to complete each of their client contact–related tasks. (2) We calculated the mean times for each category of task and used this time in minutes as a resource weight. (3) For each client, by task category, we multiplied the recorded number of tasks by the task-specific weight in minutes and summed the task-minutes for each client and across all clients. (4) The total cost of the intervention was divided by total task-minutes to arrive at a cost for each task-minute. This cost was then multiplied by each client's number of task-minutes to get a total cost per individual client. This calculation allocates indirect costs associated with case management in the same proportion as direct costs. The cost-effectiveness ratio was then calculated by adding the costs of individuals within a group and dividing the mean costs consumed by the particular group by the absolute percentage increase in immunization completion for that same group.

Table 1 presents the names and descriptions of the variables collected in the baseline and follow-up interviews and used in this analysis. In Table 2, the case management and control groups are compared and found to be similar on almost all characteristics, except whether the mother reported she was currently "living with a partner." Examining bivariate associations with being up-to-date at 1 year of age (Table 3), the case management group's up-to-date rate was 13.2 percentage points higher than the passport group's rate (P=.01). Children receiving private insurance were more likely to be up-to-date than children on both continuous and discontinuous Medicaid. Children with 4 or more well-child visits or whose mother did not report missing a well-child visit were much more likely to be up-to-date. First-born children were more likely to be up-to-date than later-born children, and children whose mothers reported having worked in the past year were also more likely to be up-to-date. Children from families reporting fewer life difficulties and children of mothers who were not smokers were also more likely to be up-to-date. Increased knowledge of the immunization schedule and immunization contraindications were associated with a higher immunization up-to-date rate. Immunization status was not significantly associated with maternal education level, maternal age, level of family support, or whether the mother was currently living with a mate.

Table Graphic Jump Location Table 2.—Characteristics of the African American Women Randomized to the Case Management (Intervention) and Passport (Control) Groups
Table Graphic Jump Location Table 3.—Level of Association Between Up-to-Date Immunization Status at 1 Year and Selected Population Characteristics

A logistic regression model without reported well-child visits demonstrated that children receiving case management had an odds ratio (OR) of 1.9 (95% confidence interval [CI], 1.18-3.05; P=.008) for being up-to-date at 1 year of age compared with children not receiving the intervention. We eliminated the visits variable to see the main effect of case management free of interactions or intervening variables. After reported well-child visits were added into the model with interaction terms, the case management effect was predominantly within the group of children with low reported well-child visits (Table 4) (OR, 3.43; 95% CI, 1.26-9.35). The logistic model also demonstrated that better knowledge of the immunization schedule (OR, 1.33; 95% CI, 1.0-1.77) was associated with increased odds of being up-to-date. Parental report of ever having missed a well-child visit greatly reduced the odds of being up-to-date (OR, 0.33; 95% CI, 0.19-0.56), as did increasing birth order (OR, 0.71; 95% CI, 0.58-0.86). An interesting and as yet unexplained finding was that increasing family support was associated with a decreased odds of being immunized at 12 months of age (OR, 0.72; 95% CI, 0.59-0.90).

Table Graphic Jump Location Table 4.—Logistic Regression Predicting Being Up-to-Date at 12 Months of Age*

We calculated the percentage of children that were up-to-date at 12 months for the 2 intervention groups by level of well-child care visits reported (Table 5). Two independent effects associated with case management are evident. First, case management moved approximately 20 of 50 children (or 40% of the expected number of case management children in the low-visit group) from the 0 to 3 well-child care visits group to the 4 or more visits group. This also effectively raised their immunization levels by 35 percentage points (30% to 66%). In addition, among those who reported 0 to 3 well-child visits, 58% of the case management group was up-to-date compared with only 30% of the control group.

Table Graphic Jump Location Table 5.—Percentage Up-to-Date at 12 Months by Intervention Group and Reported Number of Well-Child Care Visits*

Table 6 reports the cost-effectiveness analysis. The total cost of the intervention was $293662, for an average cost per participant in case management of $1587. The cost-effectiveness of this intervention was $1587 divided by 0.132, or $12022, which is the cost of moving each additional child from being underimmunized to being fully immunized at 12 months of age for the entire intervention cohort, using an intention-to-treat analysis. The cost-effectiveness ratio for the group of children retrospectively identified with a reported 0 to 3 well-child visits was $1273 divided by 0.28, which equals $4546.

Table Graphic Jump Location Table 6.—Cost-effectiveness Analysis for Case Management Intervention for Full Sample and for Subgroup With 0 to 3 Well-Child Visits

In this randomized, prospective study of case management for an inner-city, African American population, we found that 63.8% of the case management group and 50.6% of the control group were up-to-date at 1 year of age. The intervention raised immunization rates in the population group that had low immunization levels and was a focus of the 1989-1991 measles epidemic in Los Angeles.14,15 The main effect of case management persisted in significance in a comprehensive, multivariate model that adjusted for demographic characteristics and health system utilization covariates.

The cost of the intervention, however, was high at $1587 per child, and the overall cost-effectiveness ($12022 per additional child immunized) compares unfavorably with other medical interventions16 and is prohibitively high for universal implementation among inner-city populations. The cost-effectiveness ratio from our study, however, most likely underestimates the true cost-effectiveness of an ongoing case management program in this setting because of increased start-up costs for a single-year project and because the intensive evaluation component raised program costs an estimated 5% to 10%. Moreover, a single-year trial may be an inadequate amount of time for a community-based program to be accepted and to demonstrate its potential level of effectiveness.

An important finding of our study is the low overall up-to-date immunization levels in the study population. Recent surveys have demonstrated rising national immunization levels; however, these rates obscure very low rates in many urban and rural subpopulations. The National Immunization Survey estimated 1-year up-to-date rates (using 3 DTP, 2 OPV) to be 83.2% (95% CI, 80.5%-85.9%) for the nation and 85.8% (95% CI, 80%-91.7%) for Los Angeles County (CDC, written communication, April 29, 1997). Using comparable methods, we calculated the 19951-year up-to-date rate for our control sample, which is representative of an inner-city population with no intervention, at 57% (95% CI, 50%-66%), which is almost 30 percentage points lower than the rate for greater Los Angeles County.17 The annual National Immunization Survey and other state-based immunization surveys do not attempt to identify and develop estimates for pockets of high-risk, underimmunized populations.18 The states and the CDC could use census data to design surveys that geographically target poor inner-city or rural populations. This would be an important first step at quantifying the problem.

Another important finding is that the intervention was not equally effective across the sample population. For 25% to 30% of the sample that retrospectively reported fewer than 3 well-child health visits in the first year, immunization levels were particularly low. Fortunately this group was also much more responsive to case management, and immunization up-to-date levels were raised from 30% to 58%. For the other 70% of the sample, case management was much less effective, raising immunization levels only 6 percentage points. Therefore, applying an intensive intervention such as case management broadly, even among an inner-city population with generally low immunization levels, may not be an effective or cost-effective strategy. Identification of subpopulations with low immunization levels that both need and will benefit from more intensive interventions such as case management must be made a high priority. We attempted to do this using birth certificate and entry questionnaire data, but we were unsuccessful at identifying characteristics with sufficient sensitivity and specificity to be useful in targeting.

Immunization registries are the most promising method for accomplishing this objective and are in development in more than 34 states and many localities in the United States.19,20 Immunization registries have been developed in collaboration with WIC (Women, Infants, and Children) and other community-based agencies that see a majority of children in poor inner-city areas.21 An immunization registry could be used to identify children falling behind in their immunizations as early as 2.5 to 3 months of age and to target them for additional interventions such as case management. Moreover, immunization registries are commonly linked to birth registry data, providing an ideal, real-time data set of sufficient size to build and refine predictive models of immunization delay or other adverse outcomes.22 The Seattle immunization registry, the Child Health, Immunization Linkage, and Development (CHILD) Profile,23 used this approach to build a model based on birth certificate data that predicts social risk, such as being reported to protective services. Many of the predictors in their model of social risk have been associated with immunization delay in previous studies, such as high parity,6,2428 Medicaid insurance,6,29 inadequate receipt of prenatal care,6,20,24 and single-parent household.20,24 They are currently testing the sensitivity and specificity of this model to predict immunization receipt as well as other outcomes.

The limitations of our study should be acknowledged. First, the study was conducted in an inner-city, African American population served by a particular health service system. The results of this study may not be generalizable to all inner-city, high-risk populations. Second, a small portion of the immunization records were reconstructed from parental recall—4.7% were reconstructed from recall only, and recall contributed some immunizations to an additional 7.4%. Parental recall of past events can be faulty.30 However, studies show that specific strategies or cues can be used to improve recall.31 Based on our prior work with parental recall of immunization and a review of the cognitive psychological literature, we designed a series of prompts to promote more accurate recall and minimize recall bias. To investigate the potential confounding effect of recall bias, we assessed the immunization levels between recalled immunizations and documented immunizations and found that the rate of being up-to-date among children with documentation was 57.2%, and, among children dependent on recall, the rate was 58.8% (P=.89) (merging control and case management groups). Furthermore, individuals with "recall only" information were equally distributed across the 2 groups, with 9 in the case management group and 8 in the control group (P=.85). Based on these results, we are confident that the use of recall information did not bias our results.

In summary, a case management intervention in the first year of life was effective at raising immunization levels in inner-city, African American children. Case management was particularly effective among families that were identified retrospectively as not having accessed well-child visits adequately. To be effective, case management should be targeted to high-risk groups that will benefit from the intervention, potentially through the use of immunization registries in low-income urban and rural areas.

Centers for Disease Control and Prevention.  Vaccination coverage for 2-year-old children—United States, 1993.  MMWR Morb Mortal Wkly Rep.1994;43:705-709.
Centers for Disease Control and Prevention.   State and national vaccination coverage levels among children aged 19-25 months—United States, April-December, 1994.   MMWR Morb Mortal Wkly Rep.1995;44:613, 619-623.
US General Accounting Office.  Vaccines for Children: Critical Issues in Design and Implementation .  Washington, DC: US General Accounting Office; July 1994:7. GAO/PEMD-94-28.
Williams IT, Milton JD, Farrell JB, Graham NMH.  Interaction of socioeconomic status and provider practices as predictors of immunization coverage in Virginia children.   Pediatrics.1995;96:439-446.
Zell ER, Dietz V, Stevenson J, Conchi S, Bruce RH. Low vaccination levels of US preschool and school-age children.  JAMA.1994;271:833-839.
Wood DL, Sherbourne CD, Halfon N.  et al.   Factors related to immunization status among Latino and African American inner city preschoolers.   Pediatrics.1995;96:295-301.
Wood DL, Halfon N, Sherbourne C.  et al.   Increasing Immunizations for African American and Latino Preschool Children in the Inner City of Los Angeles .   Atlanta, Ga: Centers for Disease Control and Prevention; 1993. Contract 200-91-0942.
Olds DL, Kitzman H.  Review of research on home visiting for pregnant women and parents of young children.   Future Child.1993;3(3):53-92.
Selby-Harrington M, Sorenson JR, Quade D, Stearns SC, Tesh AS, Donat PLN. Increasing Medicaid child health screenings.  Am J Public Health.1995;85:1412-1417.
Colombo TJ, Freeborn KD, Mullooly JP, Burnham VR.  The effect of outreach workers' educational efforts on disadvantaged preschool children's use of preventive services.   Am J Public Health.1979;69:465-468.
Centers for Disease Control and Prevention.   General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP).   MMWR Morb Mortal Wkly Rep.1994;43(RR-1):1-38.
Wood DL, Halfon N, Sherbourne C.  et al.   A Randomized Trial of Case Management to Raise Immunization Rates Among African American Children in Inner-City Los Angeles .   Atlanta, Ga: Centers for Disease Control and Prevention; 1996. Contract 200-91-0942.
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California Dept of Health Services.  Immunization Update .   Sacramento, Calif: Immunization Branch, Dept of Health Services; 1996.
Tengs TO, Adams ME, Pliskin JS.  et al.  Five-hundred life-saving interventions and their cost-effectiveness.  Risk Anal.1995;15:369-390.
Wood DL, Mazel B, Schuster M, Halfon N.  Immunization levels for children 12 months of age in 1992 and 1995 in inner city Los Angeles compared to the US and metropolitan Los Angeles.   In: Program and abstracts of the 31st Centers for Disease Control and Prevention Immunization Conference; May 6, 1997; Detroit, Mich.
US General Accounting Office.   CDC's National Immunization Survey: Methodological Problems Limit Survey's Utility .  Washington, DC: US General Accounting Office; 1996. GAO/PEMD-96-16.
Watson WC, Nicholson-Saarlas K, Hearn R, Russell R. The All Kids Count national program: immunization registries.  Am J Prev Med.1997;13(suppl):3-6.
Cordero F, Orenstein WA. The future of immunization registries.  Am J Prev Med.1997;13(suppl):122-125.
Gubernick RS, Boclair L, DeAngelo-Cashman S.  Community partnerships: a key factor in the deployment of an immunization registry.   Am J Prev Med.1997;13(suppl):86-89.
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Baker BJ, Applebaum D, Hinds W.  et al.  CHILD profile: development of an immunization registry.  Am J Prev Med.1997;13(suppl):42-46.
Lieu TA, Black SB, Ray P, Chellino M, Shinefield HR, Adler NE. Risk factors for delayed immunization among children in an HMO.  Am J Public Health.1994;84:1621-1625.
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Wood DL, Halfon N, Sherbourne CD, Farris H, Grabowsky M, Duan N.  Assessing the accuracy of parental recall of child immunizations in an inner city population.   Ambul Child Health.1997;4:319-328.
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Figures

Graphic Jump Location
Profile of the trial of African American mother–infant pairs in inner-city Los Angeles, Calif.

Tables

Table Graphic Jump LocationTable 1.—Information Collected in the Baseline and Exit Interviews
Table Graphic Jump Location Table 2.—Characteristics of the African American Women Randomized to the Case Management (Intervention) and Passport (Control) Groups
Table Graphic Jump Location Table 3.—Level of Association Between Up-to-Date Immunization Status at 1 Year and Selected Population Characteristics
Table Graphic Jump Location Table 4.—Logistic Regression Predicting Being Up-to-Date at 12 Months of Age*
Table Graphic Jump Location Table 5.—Percentage Up-to-Date at 12 Months by Intervention Group and Reported Number of Well-Child Care Visits*
Table Graphic Jump Location Table 6.—Cost-effectiveness Analysis for Case Management Intervention for Full Sample and for Subgroup With 0 to 3 Well-Child Visits

References

Centers for Disease Control and Prevention.  Vaccination coverage for 2-year-old children—United States, 1993.  MMWR Morb Mortal Wkly Rep.1994;43:705-709.
Centers for Disease Control and Prevention.   State and national vaccination coverage levels among children aged 19-25 months—United States, April-December, 1994.   MMWR Morb Mortal Wkly Rep.1995;44:613, 619-623.
US General Accounting Office.  Vaccines for Children: Critical Issues in Design and Implementation .  Washington, DC: US General Accounting Office; July 1994:7. GAO/PEMD-94-28.
Williams IT, Milton JD, Farrell JB, Graham NMH.  Interaction of socioeconomic status and provider practices as predictors of immunization coverage in Virginia children.   Pediatrics.1995;96:439-446.
Zell ER, Dietz V, Stevenson J, Conchi S, Bruce RH. Low vaccination levels of US preschool and school-age children.  JAMA.1994;271:833-839.
Wood DL, Sherbourne CD, Halfon N.  et al.   Factors related to immunization status among Latino and African American inner city preschoolers.   Pediatrics.1995;96:295-301.
Wood DL, Halfon N, Sherbourne C.  et al.   Increasing Immunizations for African American and Latino Preschool Children in the Inner City of Los Angeles .   Atlanta, Ga: Centers for Disease Control and Prevention; 1993. Contract 200-91-0942.
Olds DL, Kitzman H.  Review of research on home visiting for pregnant women and parents of young children.   Future Child.1993;3(3):53-92.
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