Achieving Equity in Childhood Vaccination: A Mixed-Methods Study of Immunization Programs, Policies, and Coverage in 3 US States

Abstract

Objective: In this study, we sought to understand patterns of childhood vaccinations in the United States across socioeconomic and racial/ethnic groups over a 12-year period to identify interventions that improve immunization equity and inform public health practice.

Design: We conducted an explanatory, sequential, mixed-methods study. US state- and county-level immunization data were analyzed to understand trends in immunization coverage among racial/ethnic groups. Qualitative interviews with public health and community leaders were used to explain trends, gain insight into routine childhood immunization interventions, and understand local contexts and data limitations.

Participants and setting: Secondary data were used from the National Immunization Survey-Child (NIS) public use data sets (2007 and 2019). Eligible participants for qualitative interviews were routine childhood immunization stakeholders from selected counties in North Carolina, Washington, and Arizona.

Main outcome measure: Our integrated findings report trends and probability of children aged 19 months to 3 years being fully vaccinated (measles-mumps-rubella [MMR], diphtheria and tetanus toxoids and acellular pertussis [DTaP], hepatitis B [Hep B]), interventions, and recommendations to improve routine childhood immunization coverage and equity.

Results: Vaccination coverage remained high and relatively stable between 2007 and 2019; however, there were differences across racial/ethnic groups. Public health leaders identified key interventions that effectively improved vaccine equity and coverage, including data quality improvement, tailored interventions for specific populations, multisector partnerships, addressing common barriers, and data limitations. Participants also identified the critical role of state policies, public health funding, and community vaccine norms.

Conclusions: Variability persists in vaccination coverage and equity across states, race/ethnicity, and socioeconomic status despite decades of interventions. Vaccine stakeholders should use our findings to improve coverage and reduce disparities. Equitable improvements can be realized through policy change, data tracking/infrastructure improvements, and tailored interventions. Furthermore, local partners are critical in improving vaccine coverage and equitable interventions to disrupt disparities that long hold true for vaccine-preventable diseases.