Cover: Increasing Immunization Rates Among Inner-City, African American Children

Increasing Immunization Rates Among Inner-City, African American Children

A Randomized Trial of Case Management

Published in: JAMA, Volume 279, No. 1, pages 29-34 (January 1998). doi: 10.1001/jama.279.1.29

Posted on 1998

by David L. Wood, Neal Halfon, Cathy D. Sherbourne, Rebecca Mazel, Mark A. Schuster, Julie Hamlin, Margaret Pereyra, Patricia Camp, Mark Grabowsky, Naihua Duan


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.


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


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


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


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


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.


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.


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.

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. 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. 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. 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. 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.

Case management has been shown to be effective at providing information, influencing health beliefs, and helping clients access the health care system. 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.

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