Increasing immunization rates among inner-city, African American children. A randomized trial of case management.
BACKGROUND
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.


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


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


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


METHODS
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.


METHODS
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.
Wood
D
D
RAND, Santa Monica, CA, USA. dwood@gte.net
Halfon
N
N
Donald-Sherbourne
C
C
Mazel
R M
RM
Schuster
M
M
Hamlin
J S
JS
Pereyra
M
M
Camp
P
P
Grabowsky
M
M
Duan
N
N
D001741:Black or African American / Q000706:statistics & numerical data*; D019090:Case Management / Q000191:economics; D003362:Cost-Benefit Analysis; D006302:Health Services Research / Q000379:methods; D006801:Humans; D007223:Infant; D016015:Logistic Models; D015141:Los Angeles / Q000453:epidemiology; D011203:Poverty; D011446:Prospective Studies; D014505:Urban Population / Q000706:statistics & numerical data; D014611:Vaccination / Q000191:economics / Q000706:statistics & numerical data*