A Multilevel Analysis to Understand the Role of the Federal
Transcript Of A Multilevel Analysis to Understand the Role of the Federal
City University of New York (CUNY)
CUNY Academic Works
Dissertations and Theses 6-1-2017
A Multilevel Analysis to Understand the Role of the Federal Vaccine Financing Program in Socioeconomic Disparities in Vaccination Coverage Among Children and Adolescents in New York City
Alexandra Ternier CUNY School of Public Health, [email protected]
How does access to this work benefit you? Let us know!
More information about this work at: https://academicworks.cuny.edu/sph_etds/14 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected]
A MULTILEVEL ANALYSIS TO UNDERSTAND THE ROLE OF THE FEDERAL VACCINE FINANCING PROGRAM IN SOCIOECONOMIC DISPARITIES IN VACCINATION COVERAGE AMONG CHILDREN AND ADOLESCENTS IN NEW YORK CITY
A DISSERTATION by
ALEXANDRA TERNIER Concentration: EPIDEMIOLOGY
Presented to the Faculty at the Graduate School of Public Health and Health Policy in partial fulfillment of the requirements for the degree of Doctor of Public Health
Graduate School of Public Health and Health Policy City University of New York New York, New York JUNE, 2017
Dissertation Committee: JENNIFER B. DOWD, PhD
GLEN JOHNSON, PhD HEIDI JONES, PhD
VASSILIKI PAPADOUKA, PhD
Copyrighted By ALEXANDRA TERNIER
2017 All rights reserved
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ABSTRACT
A Multilevel Analysis to Understand the Role of the Federal Vaccine Financing Program in Socioeconomic Disparities in Vaccination Coverage among Children and Adolescents in New York City
by Alexandra Ternier
Advisor: Heidi Jones, PhD
Objectives: The purpose of this study was to examine the role of the federal vaccine financing program, the Vaccines For Children (VFC) program, in vaccine series completeness among children and adolescents in New York City. In addition, we aimed to investigate possible effect measure modification by selected neighborhood variables to explain socioeconomic disparities in vaccination coverage.
Methods: We used data from the New York City (NYC) Citywide Immunization Registry (CIR) and the American Community Survey (ACS) to examine vaccine series completeness among children 19-35 months and adolescents 13-17 years of age, with VFC status as the main exposure controlling for selected individual- and neighborhood-level factors. Neighborhood poverty and VFC-facility concentration were explored as confounders and effect measure modifiers in the relationship between VFC status and vaccine series completeness. Data were analyzed using Poisson and multilevel log-binomial models. A separate spatial analysis was conducted using
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spatial scan statistics to identify clusters of undervaccination and ArcGIS to examine intersections between neighborhood vaccination coverage and neighborhood poverty.
Results: The effect of VFC status was minimal among children (prevalence ratio, PR=1.06, p<.0001). In contrast, the effect among adolescents was markedly higher than in the younger group (PR=1.72, p<.0001). Overall coverage in this group was suboptimal. When stratified by vaccine series, HPV was found to be a significant factor in the low overall coverage among adolescents. Disparities were also found within racial and ethnic sub-groups where Hispanic and Asian adolescents had superior coverage compared to non-Hispanic adolescents and those from other racial groups. In the spatial analysis, we identified geographic variations in coverage citywide and specific neighborhoods with low vaccination coverage.
Conclusion: Efforts to reduce vaccination coverage disparities based on VFC status should target primarily adolescents. Improving overall adolescent coverage must consider the barriers to HPV vaccination. For both children and adolescents, identifying the root causes of neighborhood coverage variations can help reduce disparities overall.
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ACKNOWLEDGEMENTS AND DISCLOSURE I would like to express my sincere gratitude to my advisor, Professor Heidi Jones, whose commitment to this work inspired me in so many ways. I am also thankful for my colleague, mentor, and my ‘shield’, Dr. Vassiliki Papadouka who provided professional and personal advice throughout this process. Additionally, I have a profound appreciation for Professor Glen Johnson and Professor Jennifer Dowd, for their time, guidance, and support. I am indebted to all of you
for agreeing to take on this journey with me and pulling me through. Most importantly, I thank my Father for His boundless love.
Anthony, my sunshine, I want you to know that I cannot wait for the day I read your doctoral dissertation.
The author has no conflict of interest and nothing to disclose. v
TABLE OF CONTENTS List of Tables.…………...………………………………………………………………………...2 List of Figures……………………………………………………….…………………………….4 Chapter One: Introduction……………………………………………………………………...…5 Chapter Two: Independent Effects of VFC Status on Vaccine Series Completeness among Children and Adolescents in New York City……………………………………………………21 Chapter Three: A Multilevel Model to Assess Effect Measure Modification by Neighborhood Factors on the Relationship between VFC Status and Vaccine Series Completeness…………………………………………………………………………….42 Chapter Four: Geographic Clustering Patterns of Vaccine Series Completeness in New York City………………………………………………………………………..………56 Chapter Five: Conclusion……………………………………………………………………….74 Bibliography………………………………………….…………………………………….…....84
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LIST OF TABLES
Table 2.1.1 Demographic characteristics of samples of children and adolescents by up-to-date (UTD) vaccination status…………………………………………………………...38 Table 2.2.1 Unadjusted and adjusted prevalence ratios for childhood vaccine series completeness by VFC status among children 19 to 35 months of age…………………………39 Table 2.2.2 Unadjusted and adjusted prevalence ratios for adolescent vaccine series completeness by VFC status among adolescents 13 to 17 years of age………………………..39 Table 2.3 Adjusted prevalence ratios for vaccine series completeness by selected covariates...40 Table 2.4.1 Adjusted prevalence ratios for HPV vaccine series completeness by VFC status among adolescents 13 to 17 years of age……………………………………………………….40 Table 2.4.2 Adjusted prevalence ratios for Tdap and meningococcal vaccine completeness and HPV initiation by VFC status among adolescents 13 to 17 years of age…………….…….41 Table 2.5 Adjusted prevalence ratios for meningococcal and HPV vaccine series initiation by VFC status among adolescents 13 to 17 years of age……………………………………….41 Table 3.1 Demographic and vaccination profile of sample of adolescents aged 13 to 17 years from the NYC CIR……………………………………………………………………………...54 Table 3.2 Prevalence ratios for mixed models of adolescent vaccine series completeness……55 Table 4.1 Census tract population and coverage profile by neighborhood poverty group- children and adolescents………………………………………………………………..66 Table 4.2 Characteristics of statistically significant clusters of low childhood vaccine series coverage……………………………………………………………………………….…66
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Table 4.3 Characteristics of statistically significant clusters of low adolescent vaccine series coverage…………………………………………………………………………………….…..67 Table 4.4 Characteristics of statistically significant clusters of low HPV vaccine series Initiation………………………………………………………………………………………..67 Table 5.1 States approaches to vaccine financing – 2013……………………………………...83 Table 5.2 The 2010 Affordable Care Act – Immunization Provision …………………………83
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LIST OF FIGURES Figure 1.1 The Health Belief Model (HBM)…………………………………………………….19 Figure 1.2 The Behavior Model (BM) of Health Care Utilization………………………………19 Figure 1.3 Adapted model of vaccine series completeness……………………………………...20 Figure 4.1 Low coverage clusters: children 4:3:1:3:3:1:4 series………………………………...68 Figure 4.2 Low coverage clusters: adolescent 1:1:3 series………………………………………69 Figure 4.3 Low coverage clusters: adolescent HPV initiation…………………………………...70 Figure 4.4 Childhood vaccine series completeness by neighborhood poverty ………………….71 Figure 4.5 Adolescent vaccine series completeness by neighborhood poverty…………………72 Figure 4.6 HPV series initiation by neighborhood poverty……………………………………..73
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CUNY Academic Works
Dissertations and Theses 6-1-2017
A Multilevel Analysis to Understand the Role of the Federal Vaccine Financing Program in Socioeconomic Disparities in Vaccination Coverage Among Children and Adolescents in New York City
Alexandra Ternier CUNY School of Public Health, [email protected]
How does access to this work benefit you? Let us know!
More information about this work at: https://academicworks.cuny.edu/sph_etds/14 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected]
A MULTILEVEL ANALYSIS TO UNDERSTAND THE ROLE OF THE FEDERAL VACCINE FINANCING PROGRAM IN SOCIOECONOMIC DISPARITIES IN VACCINATION COVERAGE AMONG CHILDREN AND ADOLESCENTS IN NEW YORK CITY
A DISSERTATION by
ALEXANDRA TERNIER Concentration: EPIDEMIOLOGY
Presented to the Faculty at the Graduate School of Public Health and Health Policy in partial fulfillment of the requirements for the degree of Doctor of Public Health
Graduate School of Public Health and Health Policy City University of New York New York, New York JUNE, 2017
Dissertation Committee: JENNIFER B. DOWD, PhD
GLEN JOHNSON, PhD HEIDI JONES, PhD
VASSILIKI PAPADOUKA, PhD
Copyrighted By ALEXANDRA TERNIER
2017 All rights reserved
ii
ABSTRACT
A Multilevel Analysis to Understand the Role of the Federal Vaccine Financing Program in Socioeconomic Disparities in Vaccination Coverage among Children and Adolescents in New York City
by Alexandra Ternier
Advisor: Heidi Jones, PhD
Objectives: The purpose of this study was to examine the role of the federal vaccine financing program, the Vaccines For Children (VFC) program, in vaccine series completeness among children and adolescents in New York City. In addition, we aimed to investigate possible effect measure modification by selected neighborhood variables to explain socioeconomic disparities in vaccination coverage.
Methods: We used data from the New York City (NYC) Citywide Immunization Registry (CIR) and the American Community Survey (ACS) to examine vaccine series completeness among children 19-35 months and adolescents 13-17 years of age, with VFC status as the main exposure controlling for selected individual- and neighborhood-level factors. Neighborhood poverty and VFC-facility concentration were explored as confounders and effect measure modifiers in the relationship between VFC status and vaccine series completeness. Data were analyzed using Poisson and multilevel log-binomial models. A separate spatial analysis was conducted using
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spatial scan statistics to identify clusters of undervaccination and ArcGIS to examine intersections between neighborhood vaccination coverage and neighborhood poverty.
Results: The effect of VFC status was minimal among children (prevalence ratio, PR=1.06, p<.0001). In contrast, the effect among adolescents was markedly higher than in the younger group (PR=1.72, p<.0001). Overall coverage in this group was suboptimal. When stratified by vaccine series, HPV was found to be a significant factor in the low overall coverage among adolescents. Disparities were also found within racial and ethnic sub-groups where Hispanic and Asian adolescents had superior coverage compared to non-Hispanic adolescents and those from other racial groups. In the spatial analysis, we identified geographic variations in coverage citywide and specific neighborhoods with low vaccination coverage.
Conclusion: Efforts to reduce vaccination coverage disparities based on VFC status should target primarily adolescents. Improving overall adolescent coverage must consider the barriers to HPV vaccination. For both children and adolescents, identifying the root causes of neighborhood coverage variations can help reduce disparities overall.
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ACKNOWLEDGEMENTS AND DISCLOSURE I would like to express my sincere gratitude to my advisor, Professor Heidi Jones, whose commitment to this work inspired me in so many ways. I am also thankful for my colleague, mentor, and my ‘shield’, Dr. Vassiliki Papadouka who provided professional and personal advice throughout this process. Additionally, I have a profound appreciation for Professor Glen Johnson and Professor Jennifer Dowd, for their time, guidance, and support. I am indebted to all of you
for agreeing to take on this journey with me and pulling me through. Most importantly, I thank my Father for His boundless love.
Anthony, my sunshine, I want you to know that I cannot wait for the day I read your doctoral dissertation.
The author has no conflict of interest and nothing to disclose. v
TABLE OF CONTENTS List of Tables.…………...………………………………………………………………………...2 List of Figures……………………………………………………….…………………………….4 Chapter One: Introduction……………………………………………………………………...…5 Chapter Two: Independent Effects of VFC Status on Vaccine Series Completeness among Children and Adolescents in New York City……………………………………………………21 Chapter Three: A Multilevel Model to Assess Effect Measure Modification by Neighborhood Factors on the Relationship between VFC Status and Vaccine Series Completeness…………………………………………………………………………….42 Chapter Four: Geographic Clustering Patterns of Vaccine Series Completeness in New York City………………………………………………………………………..………56 Chapter Five: Conclusion……………………………………………………………………….74 Bibliography………………………………………….…………………………………….…....84
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LIST OF TABLES
Table 2.1.1 Demographic characteristics of samples of children and adolescents by up-to-date (UTD) vaccination status…………………………………………………………...38 Table 2.2.1 Unadjusted and adjusted prevalence ratios for childhood vaccine series completeness by VFC status among children 19 to 35 months of age…………………………39 Table 2.2.2 Unadjusted and adjusted prevalence ratios for adolescent vaccine series completeness by VFC status among adolescents 13 to 17 years of age………………………..39 Table 2.3 Adjusted prevalence ratios for vaccine series completeness by selected covariates...40 Table 2.4.1 Adjusted prevalence ratios for HPV vaccine series completeness by VFC status among adolescents 13 to 17 years of age……………………………………………………….40 Table 2.4.2 Adjusted prevalence ratios for Tdap and meningococcal vaccine completeness and HPV initiation by VFC status among adolescents 13 to 17 years of age…………….…….41 Table 2.5 Adjusted prevalence ratios for meningococcal and HPV vaccine series initiation by VFC status among adolescents 13 to 17 years of age……………………………………….41 Table 3.1 Demographic and vaccination profile of sample of adolescents aged 13 to 17 years from the NYC CIR……………………………………………………………………………...54 Table 3.2 Prevalence ratios for mixed models of adolescent vaccine series completeness……55 Table 4.1 Census tract population and coverage profile by neighborhood poverty group- children and adolescents………………………………………………………………..66 Table 4.2 Characteristics of statistically significant clusters of low childhood vaccine series coverage……………………………………………………………………………….…66
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Table 4.3 Characteristics of statistically significant clusters of low adolescent vaccine series coverage…………………………………………………………………………………….…..67 Table 4.4 Characteristics of statistically significant clusters of low HPV vaccine series Initiation………………………………………………………………………………………..67 Table 5.1 States approaches to vaccine financing – 2013……………………………………...83 Table 5.2 The 2010 Affordable Care Act – Immunization Provision …………………………83
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LIST OF FIGURES Figure 1.1 The Health Belief Model (HBM)…………………………………………………….19 Figure 1.2 The Behavior Model (BM) of Health Care Utilization………………………………19 Figure 1.3 Adapted model of vaccine series completeness……………………………………...20 Figure 4.1 Low coverage clusters: children 4:3:1:3:3:1:4 series………………………………...68 Figure 4.2 Low coverage clusters: adolescent 1:1:3 series………………………………………69 Figure 4.3 Low coverage clusters: adolescent HPV initiation…………………………………...70 Figure 4.4 Childhood vaccine series completeness by neighborhood poverty ………………….71 Figure 4.5 Adolescent vaccine series completeness by neighborhood poverty…………………72 Figure 4.6 HPV series initiation by neighborhood poverty……………………………………..73
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