Commentary--anatomy of racial disparity in influenza vaccination

The mediating effects of barriers to vaccination on the relationship between race/ethnicity and influenza vaccination status in a rural Southeastern Louisiana medical center

Introduction

Persistent disparities in influenza vaccination rates exist between racial/ethnic minorities and Whites. The mechanisms that define this relationship are under-researched.

Methods

Surveys assessing barriers to vaccination were administered to outpatients in a rural medical center in Southeastern Louisiana. Survey responses were matched to patient medical records. Likert-style statements were used to measure barriers to vaccination. A mediation analysis assessing the relationship between race and influenza vaccination mediated by vaccination barriers was conducted.

Results

The self-reported influenza vaccination rate in those surveyed was 40.4%. Whites (45.5%) were more likely than racial/ethnic minorities (36.3%) to report receipt of an influenza vaccination (p = 0.02). Racial/ethnic minorities reported significantly higher vaccination barrier scores (p < 0.01). The relationship between race/ethnicity and vaccination was mediated by vaccination barriers, when controlling for provider recommendation and having at least one comorbid medical condition (natural indirect effect [NIE] p-value = 0.02, proportion mediated = 0.71).

Conclusions

Barriers to vaccination mediates the relationship between race/ethnicity and vaccination status. Providers should focus on minimizing fears that the vaccine will cause illness and emphasize that the vaccine is safe and effective at preventing severe influenza-associated illness. Additional efforts should be made to improve accessibility of the influenza vaccine, including addressing costs of vaccination and expanding the number and types of settings where the vaccine is offered.

A Review of Racial and Ethnic Disparities in Immunizations for Elderly Adults

Vaccine preventable diseases are responsible for a substantial degree of morbidity in the United States as over 18 million annual cases of vaccine preventable disease occur in the U.S. annually. The morbidity due to vaccine preventable disease is disproportionately borne by adults as over 99% of the deaths due to vaccine preventable diseases occur within adults, and national data indicates that there racial disparities in the receipt of vaccines intended for elderly adults. A literature review was conducted by using the PubMed database to identify research articles that contained information on the vaccination rates among minority populations for selected vaccines intended for use in elderly populations including those for herpes zoster, tetanus, diphtheria, pertussis, hepatitis A, and hepatitis B. A total of 22 articles were identified, 8 of which focused on tetanus related vaccines, 2 of which focused on hepatitis related vaccines, and 12 of which focused on herpes zoster. The findings indicate that magnitude of the disparity for the receipt of tetanus and herpes related vaccines is not decreasing over time. Elderly patients having a low awareness of vaccines and suboptimal knowledge for when or if they should receive specific vaccines remains a key contributor to suboptimal vaccination rates. There is an urgent need for more intervention-based studies to enhance the uptake of vaccines within elderly populations, particularly among ethnic minorities where culturally sensitive and tailored messages may be of use.

The risk of racial bias while tracking influenza-related content on social media using machine learning

OBJECTIVE

Machine learning is used to understand and track influenza-related content on social media. Because these systems are used at scale, they have the potential to adversely impact the people they are built to help. In this study, we explore the biases of different machine learning methods for the specific task of detecting influenza-related content. We compare the performance of each model on tweets written in Standard American English (SAE) vs African American English (AAE).

MATERIALS AND METHODS

Two influenza-related datasets are used to train 3 text classification models (support vector machine, convolutional neural network, bidirectional long short-term memory) with different feature sets. The datasets match real-world scenarios in which there is a large imbalance between SAE and AAE examples. The number of AAE examples for each class ranges from 2% to 5% in both datasets. We also evaluate each model's performance using a balanced dataset via undersampling.

RESULTS

We find that all of the tested machine learning methods are biased on both datasets. The difference in false positive rates between SAE and AAE examples ranges from 0.01 to 0.35. The difference in the false negative rates ranges from 0.01 to 0.23. We also find that the neural network methods generally has more unfair results than the linear support vector machine on the chosen datasets.

CONCLUSIONS

The models that result in the most unfair predictions may vary from dataset to dataset. Practitioners should be aware of the potential harms related to applying machine learning to health-related social media data. At a minimum, we recommend evaluating fairness along with traditional evaluation metrics.

Disparities in influenza vaccination: Arab Americans in California

Background

Influenza vaccination among minoritized groups remains below federal benchmarks in the United States (US). We used data from the 2004–2016 California Health Interview Surveys (CHIS) to characterize influenza vaccination patterns among Arab Americans in California.

Methods

Influenza vaccination was self-reported by Arab American adults (N = 1163) and non-Hispanic Whites (NHW, N = 166,955). Differences in influenza vaccination prevalence and odds were compared using chi-squared tests and survey-weighted logistic regression, respectively.

Results

Across all years, 30.3% of Arab Americans self-reported receiving an influenza vaccine (vs. 40.5% for NHW, p < 0.05). After sequential adjustment by sociodemographic, health behavior, and acculturation variables no differences in odds of self-reported influenza vaccination were observed between Arab Americans and NHW (odds ratio: 1.02, 95% confidence interval: 0.76–1.38). Male and unemployed Arab Americans had higher odds of reporting influenza vaccination than female and employed Arab Americans.

Conclusions

Future work should consider specific barriers to influenza vaccination in Arab American communities.

Factors contributing to racial disparities in influenza vaccinations

Background

Racial/ethnic disparities in rates of influenza vaccinations in the US remain an issue even among those with access, no out-of-pocket costs, and after adjusting for confounders. We used an approach called the Oaxaca-Blinder (OB) decomposition method to ascertain the contribution of covariates individually and in aggregate to the racial disparity in influenza vaccination.

Methods

We included members > = 18 years of age as of 05/01/2014 with continuous enrollment through 04/30/2015. Influenza vaccination was defined by diagnosis, procedure, or medication codes, or documentation in the immunization table. Characteristics were reported by race. Logistic regression models estimated the odds of vaccination associated with: (1) race; and (2) covariates stratified by race. The Oaxaca-Blinder (OB) method calculated the contribution of covariates to the difference or disparity in vaccination between Blacks and Whites.

Results

We found that among adults, 44% were vaccinated; 55% were Black; and 45% were White. Black members have 42% lower odds of vaccination than White members. The contribution of the differences in the average value of the study covariates between Black and White members (the OB covariate effect) accounted for 29% of the racial disparity. The contributions to the total White-Black disparity in vaccination included: age (16%), neighborhood median income (11%), and registration on the online patient portal (13%). The contribution of the differences in how the covariates impact vaccination (OB coefficient effect) accounted for 71% of the disparity in vaccination between Blacks and Whites.

Conclusion

In conclusion, equalizing average covariate values in Blacks and Whites could reduce the racial disparity in influenza vaccination by 29%. For health system vaccine campaigns, improving registration on the patient portal may be a target component of an effective system-level strategy to reduce racial disparities in vaccination. Additional information on patient-centered factors could further improve the value of the OB approach.

Racial/Ethnic Disparities in Influenza Vaccination Coverage Among US Adolescents, 2010-2016

OBJECTIVE

Although research suggests racial/ethnic disparities in influenza vaccination and mortality rates, few studies have examined racial/ethnic trends among US adolescents. We used national cross-sectional data to determine (1) trends in influenza vaccination rates among non-Hispanic white (hereinafter, white), non-Hispanic black (hereinafter, black), and Hispanic adolescents over time and (2) whether influenza vaccination rates among adolescents varied by race/ethnicity.

METHODS

We analyzed provider-reported vaccination histories for 2010-2016 from the National Immunization Survey-Teen. We used binary logistic regression models to determine trends in influenza vaccination rates by race/ethnicity for 117 273 adolescents, adjusted for sex, age, health insurance, physician visit in the previous 12 months, vaccination facility type, poverty status, maternal education level, children in the household, maternal marital status, maternal age, and census region of residence. We calculated adjusted probabilities for influenza vaccination for each racial/ethnic group, adjusted for the same demographic characteristics.

RESULTS

Compared with white adolescents, Hispanic adolescents had higher odds (adjusted odds ratio [aOR] = 1.11; 95% confidence interval [CI], 1.06-1.16) and black adolescents had lower odds (aOR = 0.95; 95% CI, 0.90-1.00) of vaccination. Compared with white adolescents, Hispanic adolescents had significantly higher adjusted probabilities of vaccination for 2011-2013 (2011: 0.22, P < .001; 2012: 0.23, P < .001; 2013: 0.26, P < .001). Compared with white adolescents, black adolescents had significantly lower probabilities of vaccination for 2016 (2016: 0.21, P < .001).

CONCLUSIONS

Targeted interventions are needed to improve adolescent influenza vaccination rates and reduce racial/ethnic disparities in adolescent vaccination coverage.

Racial/Ethnic Differences in Receipt of Influenza and Pneumococcal Vaccination among Long-Stay Nursing Home Residents

OBJECTIVE/STUDY QUESTION

To examine racial/ethnic differences in influenza and pneumococcal vaccination receipt and nonreceipt among nursing home (NH) residents post implementation of federal vaccination policy. DATA SOURCES/STUDY SETTING/STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: An analysis of a merged national cross-sectional dataset containing resident assessment, facility, and community data for years 2010-2013 was conducted. Logistic regressions omitting and including facility fixed effects were used to examine the influence of race and ethnicity (black, Hispanic, white) and black concentration on vaccination status across and within NHs.

PRINCIPLE FINDINGS

Vaccination receipt of 107,874 residents in 742 NHs was examined. Blacks were less likely than whites to receive influenza and pneumococcal vaccinations (OR = 0.75; OR = 0.81, respectively, p-values <.001). The likelihood of not being offered the influenza vaccination was greater for blacks (OR=1.25, p = .004) and the likelihood of not being offered the pneumococcal vaccination was greater for Hispanics (OR = 1.65, p = .04) compared to whites. Fixed effects showed that within the same NH, Hispanics were more likely to receive both vaccinations compared to whites (OR=1.22, p = .004 (influenza); OR=1.34, p < .001 (pneumococcal)). Facilities highly concentrated with blacks accounted for large proportions of differences seen in vaccination receipt.

CONCLUSIONS

Racial/ethnic differences remain despite policy changes. Focused strategies aimed at NH personnel and racially segregated NHs are critical to improving vaccination delivery and eliminating disparities in care.

Trends in Influenza and Pneumococcal Vaccination Among US Nursing Home Residents, 2006-2014

BACKGROUND

Institutionalized adults are at increased risk of morbidity and mortality from influenza and pneumococcal infection. Influenza and pneumococcal vaccination have been shown to be effective in reducing hospitalization and deaths due to pneumonia and influenza in this population.

OBJECTIVE

To assess trends in influenza vaccination coverage among US nursing home residents from the 2005-2006 through 2014-2015 influenza seasons and trends in pneumococcal vaccination coverage from 2006 to 2014 among US nursing home residents, by state and demographic characteristics.

METHODS

Data were analyzed from the Centers for Medicare and Medicaid Services' (CMS's) Minimum Data Set (MDS). Influenza and pneumococcal vaccination status were assessed for all residents of CMS-certified nursing homes using data reported to the MDS by all certified facilities.

RESULTS

Influenza vaccination coverage increased from 71.4% in the 2005-2006 influenza season to 75.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage increased from 67.4% in 2006 to 78.4% in 2014. Vaccination coverage varied by state, with influenza vaccination coverage ranging from 50.0% to 89.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage ranging from 55.0% to 89.7% in 2014. Non-Hispanic black and Hispanic residents had lower coverage compared with non-Hispanic white residents for both vaccines, and these differences persisted over time.

CONCLUSION

Influenza and pneumococcal vaccination among US nursing home residents remains suboptimal. Nursing home staff can employ strategies such as provider reminders and standing orders to facilitate offering vaccination to all residents along with culturally appropriate vaccine promotion to increase vaccination coverage among this vulnerable population.

Racial/Ethnic Disparities in Influenza Vaccination of Chronically Ill US Adults: The Mediating Role of Perceived Discrimination in Health Care

BACKGROUND

Despite well-established programs, influenza vaccination rates in US adults are well below federal benchmarks and exhibit well-documented, persistent racial and ethnic disparities. The causes of these disparities are multifactorial and complex, though perceived racial/ethnic discrimination in health care is 1 hypothesized mechanism.

OBJECTIVES

To assess the role of perceived discrimination in health care in mediating influenza vaccination RACIAL/ETHNIC disparities in chronically ill US adults (at high risk for influenza-related complications).

RESEARCH DESIGN

We utilized 2011-2012 data from the Aligning Forces for Quality Consumer Survey on health and health care (n=8127), nationally representative of chronically ill US adults. Logistic regression marginal effects examined the relationship between race/ethnicity and influenza vaccination, both unadjusted and in multivariate models adjusted for determinants of health service use. We then used binary mediation analysis to calculate and test the significance of the percentage of this relationship mediated by perceived discrimination in health care.

RESULTS

Respondents reporting perceived discrimination in health care had half the uptake as those without discrimination (32% vs. 60%, P=0.009). The change in predicted probability of vaccination given perceived discrimination experiences (vs. none) was large but not significant in the fully adjusted model (-0.185; 95% CI, -0.385, 0.014). Perceived discrimination significantly mediated 16% of the unadjusted association between race/ethnicity and influenza vaccination, though this dropped to 6% and lost statistical significance in multivariate models.

CONCLUSIONS

The causes of persistent racial/ethnic disparities are complex and a single explanation is unlikely to be sufficient. We suggest reevaluation in a larger cohort as well as potential directions for future research.

The Impact of Vaccine Concerns on Racial/Ethnic Disparities in Influenza Vaccine Uptake Among Health Care Workers

OBJECTIVES

We explored whether collective concerns about the safety, effectiveness, and necessity of influenza vaccines mediate racial/ethnic disparities in vaccine uptake among health care workers (HCWs).

METHODS

We used a self-administered Web-based survey to assess race/ethnicity (exposure), concerns about influenza vaccination (mediator; categorized through latent class analysis), and influenza vaccine uptake (outcome) for the 2012 to 2013 influenza season among HCWs at St. Jude Children's Research Hospital in Memphis, Tennessee. We used mediation analysis to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the total, direct, and indirect effects of race/ethnicity on influenza vaccine uptake.

RESULTS

Non-Hispanic Blacks had lower influenza vaccine uptake than non-Hispanic Whites (total effect: PR = 0.87; 95% CI = 0.75, 0.99), largely mediated by high concern about influenza vaccines (natural indirect effect: PR = 0.89; 95% CI = 0.84, 0.94; controlled direct effect: PR = 0.98; 95% CI = 0.85, 1.1). Hispanic and Asian HCWs had modestly lower uptake than non-Hispanic Whites, also mediated by high concern about influenza vaccines.

CONCLUSIONS

Racial/ethnic disparities among HCWs could be attenuated if concerns about the safety, effectiveness, and necessity of influenza vaccines were reduced.

Determinants of healthcare provider recommendations for influenza vaccinations

OBJECTIVE

Investigate determinants of receiving healthcare provider (HCP) recommendations for seasonal and H1N1 influenza vaccinations.

METHODS

Using a United States national sample of adults 18 + from the National 2009 H1N1 Flu Survey, multivariate regression models estimated the likelihood of receiving a HCP recommendation. Covariates included demographics, socioeconomic status, and Advisory Committee on Immunization Practices (ACIP) priority groups.

RESULTS

Adults age 55-64 and 65 + were more likely to report a HCP recommendation when compared to adults age 18-34 (OR: 1.483, 95%CI: 1.237-1.778 and OR: 1.738, 95%CI: 1.427-2.116, respectively). Chronically ill adults had 58.0% (95%CI: 1.414-1.765) higher odds of receiving a HCP recommendation than non-chronically ill adults. Patients visiting a doctor once and twice had 28.7% (95%CI: 0.618-0.821) and 17.1% (95%CI: 0.721-0.952) lower odds of receiving a HCP recommendation when compared to adults visiting their doctor at least four times. And, compared to Non-Hispanic Whites, Non-Hispanic Blacks had 28.4% (95%CI: 1.064-1.549) higher odds of receiving a recommendation.

CONCLUSIONS

ACIP priority groups experienced higher rates of recommendations compared to non-ACIP groups. Racial differences in HCP recommendations cannot explain racial disparities in flu vaccination rates.

Trends in racial/ethnic disparities in influenza vaccination coverage among adults during the 2007-08 through 2011-12 seasons

BACKGROUND

Annual influenza vaccination is recommended for all persons aged ≥6 months. The objective of this study was to assess trends in racial/ethnic disparities in influenza vaccination coverage among adults in the United States.

METHODS

We analyzed data from the 2007-2012 National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS) using Kaplan-Meier survival analysis to assess influenza vaccination coverage by age, presence of medical conditions, and racial/ethnic groups during the 2007-08 through 2011-12 seasons.

RESULTS

During the 2011-12 season, influenza vaccination coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites among most of the adult subgroups, with smaller disparities observed for adults age 18-49 years compared with other age groups. Vaccination coverage for non-Hispanic white, non-Hispanic black, and Hispanic adults increased significantly from the 2007-08 through the 2011-12 season for most of the adult subgroups based on the NHIS (test for trend, P < .05). Coverage gaps between racial/ethnic minorities and non-Hispanic whites persisted at similar levels from the 2007-08 through the 2011-12 seasons, with similar results from the NHIS and BRFSS.

CONCLUSIONS

Influenza vaccination coverage among most racial/ethnic groups increased from the 2007-08 through the 2011-12 seasons, but substantial racial and ethnic disparities remained in most age groups. Targeted efforts are needed to improve coverage and reduce these disparities.

Coverage and predictors of vaccination against 2012/13 seasonal influenza in Madrid, Spain: analysis of population-based computerized immunization registries and clinical records

We aim to determine 2012–13 seasonal influenza vaccination coverage. Data were analyzed by age group and by coexistence of concomitant chronic conditions. Factors associated with vaccine uptake were identified. We also analyze a possible trend in vaccine uptake in post pandemic seasons.

We used computerized immunization registries and clinical records of the entire population of the Autonomous Community of Madrid, Spain (6 284 128 persons) as data source.

A total of 871 631 individuals were vaccinated (13.87%). Coverage for people aged ≥ 65 years was 56.57%. Global coverage in people with a chronic condition was 15.7% in children and 18.69% in adults aged 15–59 years.

The variables significantly associated with a higher likelihood of being vaccinated in the 2012–13 campaign for the age groups studied were higher age, being Spanish-born, higher number of doses of seasonal vaccine received in previous campaigns, uptake of pandemic vaccination, and having a chronic condition.

We conclude that vaccination coverage in persons aged &lt;60 years with chronic conditions is less than acceptable. The very low coverage among children with chronic conditions calls for urgent interventions. Among those aged ≥60 years, uptake is higher but still far from optimal and seems to be descending in post-pandemic campaigns. For those aged ≥65 years the mean percentage of decrease from the 2009/10 to the actual campaign has been 12%.

Computerized clinical and immunization registers are useful tools for providing rapid and detailed information about influenza vaccination coverage in the population.

Seasonal influenza vaccination coverage among adult populations in the United States, 2005-2011

The most effective strategy for preventing influenza is annual vaccination. We analyzed 2005-2011 data from the National Health Interview Survey (NHIS), using Kaplan-Meier survival analysis to estimate cumulative proportions of persons reporting influenza vaccination in the 2004-2005 through 2010-2011 seasons for persons aged ≥18, 18-49, 50-64, and ≥65 years, persons with high-risk conditions, and health-care personnel. We compared vaccination coverage by race/ethnicity within each age and high-risk group. Vaccination coverage among adults aged ≥18 years increased from 27.4% during the 2005-2006 influenza season to 38.1% during the 2010-2011 season, with an average increase of 2.2% annually. From the 2005-2006 season to the 2010-2011 season, coverage increased by 10-12 percentage points for all groups except adults aged ≥65 years. Coverage for the 2010-2011 season was 70.2% for adults aged ≥65 years, 43.7% for adults aged 50-64 years, 36.7% for persons aged 18-49 years with high-risk conditions, and 55.8% for health-care personnel. In most subgroups, coverage during the 2010-2011 season was significantly lower among non-Hispanic blacks and Hispanics than among non-Hispanic whites. Vaccination coverage among adults under age 65 years increased from 2005-2006 through 2010-2011, but substantial racial/ethnic disparities remained in most age groups. Targeted efforts are needed to improve influenza vaccination coverage and reduce disparities.

Influenza vaccination among cancer survivors: disparities in prevalence between blacks and whites

INTRODUCTION

Cancer survivors are at increased risk for influenza-related complications. Racial disparities in preventive health services have not been extensively studied among cancer survivors. Our objective is to compare influenza vaccination prevalence among black and white cancer survivors

METHODS

We performed a secondary data analysis of 41,346 white and black cancer survivors (excluding non-melanoma skin cancer) from the 2009 Behavioral Risk Factor Surveillance System survey. Respondents were asked whether they had received an influenza vaccination in the previous year. Multivariable logistic regression was used to estimate the odds of having influenza vaccine by race.

RESULTS

Sixty-five percent of whites reported receiving the vaccine in the last year compared to 50 % of blacks. Blacks had significantly lower odds of vaccination after controlling for covariates significantly associated with the odds of influenza vaccination. Higher education, having health insurance, having a primary care provider, and having a routine check-up in the last year increased the odds of receiving an influenza vaccine.

CONCLUSIONS

Our analysis supports that racial disparities in vaccine coverage persist among cancer survivors, a group strongly recommended to receive annual influenza vaccine, even when predictors significantly associated with increased vaccination are controlled for.

IMPLICATIONS FOR CANCER SURVIVORS

As a nationally representative survey with a large sample size, our study provides a picture of self-reported vaccine coverage among cancer survivors in the USA and the disparity that exists between blacks and whites in this population. Care teams can use these findings to better target follow-up care for cancer survivors.

Influenza vaccination coverage across ethnic groups in Canada

BACKGROUND

The success of influenza vaccination campaigns may be suboptimal if subgroups of the population face unique barriers or have misconceptions about vaccination. We conducted a national study to estimate influenza vaccine coverage across 12 ethnic groups in Canada to assess the presence of ethnic disparities.

METHODS

We pooled responses to the Canadian Community Health Survey between 2003 and 2009 (n = 437 488). We estimated ethnicity-specific self-reported influenza vaccine coverage for the overall population, for people aged 65 years and older, and for people aged 12-64 years with and without chronic conditions. We used weighted logistic regression models to examine the association between ethnicity and influenza vaccination, adjusting for sociodemographic factors and health status.

RESULTS

Influenza vaccination coverage ranged from 25% to 41% across ethnic groups. After adjusting for sociodemographic factors and health status for people aged 12 years and older, all ethnic groups were more likely to have received a vaccination against influenza than people who self-identified as white, with the exception of those who self-identified as black (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.88-1.15). Compared with white Canadians, Canadians of Filipino (OR 2.00, 95% CI 1.67-2.40) and Southeast Asian (OR 1.66, 95% CI 1.36-2.03) descent had the greatest likelihood of having received vaccination against influenza.

INTERPRETATION

Influenza vaccine coverage in Canada varies by ethnicity. Black and white Canadians have the lowest uptake of influenza vaccine of the ethnic groups represented in our study. Further research is needed to understand the facilitators, barriers and misconceptions relating to vaccination that exist across ethnic groups, and to identify promotional strategies that may improve uptake among black and white Canadians.

Despite small improvement, black nursing home residents remain less likely than whites to receive flu vaccine

Vaccination is a key deterrent to influenza and its related complications and outcomes, including hospitalization and death. Using 2006-09 data, we found a small improvement in vaccination rates among nursing home residents, particularly for blacks. Nonetheless, overall vaccination rates remained well below the 90 percent target for high-quality care, and black nursing home residents remained less likely to be vaccinated than whites. Blacks were less likely to be vaccinated than were whites in the same facility and were more likely to live in facilities with lower vaccination rates. Blacks were also more likely to be noted as refusing vaccination. Strategies are needed to ensure that facilities offer vaccination to all residents and to make vaccination more acceptable to black residents and their families.

How to improve influenza vaccination rates in the U.S

Annual epidemics of seasonal influenza occur during autumn and winter in temperate regions and have imposed substantial public health and economic burdens. At the global level, these epidemics cause about 3-5 million severe cases of illness and about 0.25-0.5 million deaths each year. Although annual vaccination is the most effective way to prevent the disease and its severe outcomes, influenza vaccination coverage rates have been at suboptimal levels in many countries. For instance, the coverage rates among the elderly in 20 developed nations in 2008 ranged from 21% to 78% (median 65%). In the U.S., influenza vaccination levels among elderly population appeared to reach a "plateau" of about 70% after the late 1990s, and levels among child populations have remained at less than 50%. In addition, disparities in the coverage rates across subpopulations within a country present another important public health issue. New approaches are needed for countries striving both to improve their overall coverage rates and to eliminate disparities.

This review article aims to describe a broad conceptual framework of vaccination, and to illustrate four potential determinants of influenza vaccination based on empirical analyses of U.S. nationally representative populations. These determinants include the ongoing influenza epidemic level, mass media reporting on influenza-related topics, reimbursement rate for providers to administer influenza vaccination, and vaccine supply. It additionally proposes specific policy implications, derived from these empirical analyses, to improve the influenza vaccination coverage rate and associated disparities in the U.S., which could be generalizable to other countries.

Association between quality of care and the sociodemographic composition of physicians' patient panels: a repeat cross-sectional analysis

BACKGROUND

Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients.

OBJECTIVE

To test for associations between quality of care and the composition of a physician's patient panel.

DESIGN

Repeat cross-sectional analysis

PARTICIPANTS

Nationally representative sample of US primary care physicians responding to a panel telephone survey in 2000-2001 and 2004-2005

MAIN MEASURES

Quality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians' patient panels.

KEY RESULTS

Across eight quality measures, physicians' quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points.

CONCLUSIONS

In a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians' quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.

Increasing inner-city adult influenza vaccination rates: a randomized controlled trial

OBJECTIVES

In a population of seniors served by urban primary care centers, we evaluated the effect of the practice-based intervention on influenza immunization rates and disparities in vaccination rates by race/ethnicity and insurance status.

METHODS

A randomized controlled trial during 2003-2004 tested patient tracking/recall/outreach and provider prompts on improving influenza immunization rates. Patients aged > or = 65 years in six large inner-city primary care practices were randomly allocated to study or control group. Influenza immunization coverage was measured prior to enrollment and on the end date.

RESULTS

At study end, immunization rates were greater for the intervention group than for the control group (64% vs. 22%, p < 0.0001). When controlling for other factors, the intervention group was more than six times as likely to receive influenza vaccine. The intervention was effective across gender, race/ ethnicity, age, and insurance subgroups. Among the intervention group, 3.5% of African Americans and 3.2% of white people refused influenza immunization.

CONCLUSIONS

Patient tracking/recall/outreach and provider prompts were intensive but successful approaches to increasing seasonal influenza immunization rates among this group of inner-city seniors.

Protection of racial/ethnic minority populations during an influenza pandemic

Racial/ethnic minority populations experience worse health outcomes than do other groups during and after disasters. Evidence for a differential impact from pandemic influenza includes both higher rates of underlying health conditions in minority populations, increasing their risk of influenza-related complications, and larger socioeconomic (e.g., access to health care), cultural, educational, and linguistic barriers to adoption of pandemic interventions. Implementation of pandemic interventions could be optimized by (1) culturally competent preparedness and response that address specific needs of racial/ethnic minority populations, (2) improvements in public health and community health safety net systems, (3) social policies that minimize economic burdens and improve compliance with isolation and quarantine, and (4) relevant, practical, and culturally and linguistically tailored communications.

Significant differences in the use of healthcare resources of native-born and foreign born in Spain

Background

In the last decade, the number of foreign residents in Spain has doubled and it has become one of the countries in the European Union with the highest number of immigrants There is no doubt that the health of the immigrant population has become a relevant subject from the point of view of public healthcare. Our study aimed at describing the potential inequalities in the use of healthcare resources and in the lifestyles of the resident immigrant population of Spain.

Methods

Cross-sectional, epidemiological study from the Spanish National Health Survey (NHS) in 2006, from the Ministry of Health and Consumer Affairs. We have worked with individualized secondary data, collected in the Spanish National Health Survey carried out in 2006 and 2007 (SNHS-06), from the Ministry of Health and Consumer Affairs. The format of the SNHS-06 has been adapted to the requirements of the European project for the carrying out of health surveys.

Results

The economic immigrant population resident in Spain, present diseases that are similar to those of the indigenous population. The immigrant population shows significantly lower values in the consumption of alcohol, tobacco and physical activity (OR = 0.76; CI 95%: 0.65–0.89, they nonetheless perceive their health condition as worse than that reported by the autochthonous population (OR = 1.63, CI 95%: 1.34–1.97). The probability of the immigrant population using emergency services in the last 12 months was significantly greater than that of the autochthonous population (OR = 1.31, CI 95%: 1.12–1.54). This situation repeats itself when analyzing hospitalization data, with values of probability of being hospitalized greater among immigrants (OR = 1.39, CI 95%: 1.07–1.81).

Conclusion

The economic immigrants have better parameters in relation to lifestyles, but they have a poor perception of their health. Despite the fact that immigrant population shows higher percentages of emergency attendance and hospitalization than the indigenous population, with respect to the use of healthcare resources, their usage of healthcare resources such as drugs, influenza vaccinations or visits to the dentist is lower.

Trust in the health care system and the use of preventive health services by older black and white adults

OBJECTIVES

We sought to find racial differences in the effects of trust in the health care system on preventive health service use among older adults.

METHODS

We conducted a telephone survey with 1681 Black and White older adults. Survey questions explored respondents' trust in physicians, medical research, and health information sources. We used logistic regression and controlled for covariates to assess effects of race and trust on the use of preventive health services.

RESULTS

We identified 4 types of trust through factor analysis: trust in one's own personal physician, trust in the competence of physicians' care, and trust in formal and informal health information sources. Blacks had significantly less trust in their own physicians and greater trust in informal health information sources than did Whites. Greater trust in one's own physician was associated with utilization of routine checkups, prostate-specific antigen tests, and mammograms, but not with flu shots. Greater trust in informal information sources was associated with utilization of mammograms.

CONCLUSIONS

Trust in one's own personal physician is associated with utilization of preventive health services. Blacks' relatively high distrust of their physicians likely contributes to health disparities by causing reduced utilization of preventive services. Health information disseminated to Blacks through informal means is likely to increase Blacks' utilization of preventive health services.