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MSc (Med) , Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2009

Health literacy is recognized as a contributor to health outcomes and maternal health literacy is important to the health and wellbeing of children and families. Of particular interest are mothers seeking immunization services for their children. The complexity of the recommended immunization schedule and the care management of children receiving immunizations have the potential to create negative health outcomes in the low health literate population. Assessment of maternal health literacy and provision of effective patient education adapted to the health literacy level of the individual is important for information transfer. The Teach-Back provides an opportunity to both assess understanding and reinforce teaching. This study used an experimental design to study two groups of women for a total of 90 participants in a public health department setting. The control group received the usual immunization patient education using Vaccination Information Sheets. The intervention group also received patient education in this manner plus use of the Teach-Back. Immunization knowledge was assessed prior to and after patient education. Immunization currency was assessed as well. The Newest Vital Sign was used to assess the maternal health literacy for 90 mothers bringing their children for immunizations. A demographic survey addressing both individual characteristics and social determinants of health variables was also administered. Most of the participants were low health literate (84%) and low health literacy was related to lower immunization knowledge and poor immunization currency. Social determinants of health variables were related to maternal health literacy, immunization knowledge and immunization currency. The results demonstrated an improvement of immunization knowledge scores with the use of the Teach-Back method of patient education. Additional research is needed in the area of patient education interventions specific to the low health literate population. The development of instruments to measure interactive and critical health literacy are needed and interventions to promote growth in health literacy are also needed. Clinically, improved patient education interventions for low health literate mothers has the potential to improve health outcomes and decrease health care costs of these women, their children and their families.

Background: Children are required by law to receive vaccinations to enter school. States and territories offer exemptions for parents who refuse to vaccinate their children. Types of exemptions vary by state or territory, as does the exemption claiming process. The purpose of this research was to identify the various education-related processes implemented by states and territories which allow parents to exempt children from vaccinations. Methods: A questionnaire was distributed to immunization managers in the 50 United States, District of Columbia, the United States Indian Health Service, and eight United States territories. Managers reported vaccination requirements for their jurisdiction (collectively referred to as "state"). Education-related questions, identified which states required parents to: 1) read and sign a vaccination risk/benefit statement prior to exemption; 2) complete mandatory vaccine education before obtaining vaccination exemption; 2a) complete education within a certain time period before school admission; and 2b) have parental vaccine education regulated. Results: A parent-signed risk/benefit statement was required by 25 states for religious exemptions, 12 states for personal exemptions, 10 states for medical exemptions, and 1 state for temporary medical exemptions. Thirteen states required mandatory parental vaccine education prior to obtaining an exemption. Vaccine education could be completed at various times prior to school admission. For most states, the mandated parental vaccine education prior to exemption was regulated by law, administrative rule, or policy. Conclusions: Implementing a risks/benefits statement prior to granting an exemption may not be helpful in reducing religious and personal exemption rates. The process of providing vaccine education prior to exemption varies greatly between states. Familiarity with various state vaccine education requirements may aid policymakers who are considering enacting mandatory vaccine education in his or her state.

Since 2010 the Center for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP) have recommended annual influenza vaccinations for all persons aged six months and up (ACIP, 2017). In December of the same year, the Agency of Health and Human Services (AHHS) unveiled Healthy People 2020, a series of health indicators and corresponding 10-year objectives. This newest iteration of the Healthy People program set target influenza vaccination levels for healthy adults 18 and older at 80% (AHHS, 2010). Aside from the inherent health benefits, multiple studies conducted over the past decade suggest there may be significant economic benefits to a highly-vaccinated population. Depending on the effectiveness of seasonal vaccines, the cost of vaccinating a U.S. adult can be outweighed by the health care savings from the resulting reduction in direct and indirect infection treatment costs. As the state of Vermont considers including influenza vaccinations in its state-mandated Vermont Vaccine Purchasing Program (VVPP), it presents a unique opportunity to conduct a state-wide case study on the potential cost-saving implications of a universally available influenza vaccination. This study takes a historical perspective and looks back at Vermont’s influenza cost, usage, and treatment information since the vaccine was recommended in 2010. Using data generated from Vermont’s immunization registry, de-identified claims data, CDC-reported statistics, and numerous published economic studies, this research answers the question: “What societal costs/savings would have been witnessed if the influenza vaccine was included in the VVPP since 2010?” and, more important, what policy changes can be made now to realize savings in the future? Using a dynamic transmission model embedded in cost-benefit analysis, this research concludes that influenza-related savings of 6.2% would have been experienced over the five flu seasons between fall 2010 and summer 2015. Most of the savings are generated by the increased vaccination rate associated with a universal vaccination program. Creation of such a program in the state of Vermont would likely be economically beneficial.

Globalization has brought health concerns to the forefront. Moreover, governments, policymakers, and health officials are paying more attention to these health concerns. With the increased cross-national interaction, diseases have more pathways to spread than ever. As countries attempt to ensure access to care and control health expenditure, monitoring and improving the quality of health care is a pressing issue. This paper uses linear regressions to analyze the relationship between prevention and public health expenditure and the rate of measles immunizations in member countries of the Organisation of Economic Co-operation and Development (OECD). There is a weak negative relationship between the expenditure and rates of measles immunizations for both private and public expenditure data, suggesting that the higher the expenditure the lower the rates of measles immunizations. Several possible reasons for this phenomenon is discussed in conjunction with the role of health educators as it relates to the use of theory based interventions to improve rates of measles immunizations.

Modern immunization’s role in health systems is threefold: it is simultaneously a pharmaceutical product, a personal health care intervention, and a public health measure, each constituting a distinct, yet overlapping set of governance arrangements. This thesis examines immunization policy change and governance at the federal-provincial interface over the last decade (1997-2008) in Canada, situated against broader trends in public policy and public health. The research is based upon a case study design and a discursive approach to policy analysis, using documentary sources, supplemented with archival information, direct observations, and decision-maker informants. Over time, structures and instruments used to deal with immunization at the federal-provincial interface have undergone adaptation. New decision-making structures include the Public Health Agency of Canada and the Pan-Canadian Public Health Network; new instruments include the National Immunization Strategy, accompanied by targeted federal funding. Consistent with other sectors, however, the decade also witnessed an ongoing emphasis on fiscal prudence, risk-based regulation, and informal networks to accomplish policy goals. This thesis concludes that effective federal governance and lasting policy change for immunization requires resolution of two major tensions in the policy ideas underlying national processes. First, the interpretation of federal authority over matters of national concern remains ambiguous. While the National Immunization Strategy reflected dominant ideas around equitable access to vaccines and a broad conception of the federal sharing community, persistent gaps, particularly linking national-level decisions, financing, and delivery, have reinforced the existing notion of the appropriate degree of federal influence for immunization, rather than expanding it. Second, an increasing focus on personal security dimensions of immunization amid structural changes intended to address public security concerns is in tension with a situation that predisposes the state to avoid an unjust application of compulsory measures rather than to protect from harm those individuals who consent freely to immunization. Immunization in Canada requires a new paradigm that expands the notion of the state’s role in prevention as it applies to immunization, that addresses specific needs for protection in the life of the individual, and that reasserts the importance of strong, substantive, and sustained federal contributions to matters of national concern.

This dissertation considers the economics of public health in the context of respiratory disease, a leading cause of morbidity and mortality. The pervasive nature of respiratory illness represents a significant reduction to health and longevity, but private actions to prevent illness may not consider the full-scale benefit of societal health improvement. In this thesis, I consider two determinants of respiratory illness: (1) the spread of influenza disease and (2) air pollution. In both cases, public policy aims to attenuate the effects of these factors by incentivizing or mandating preventative action. Because such interventions come at a cost, it is important to consider the magnitude of benefits associated with these actions. I consider each determinant in turn. First, I provide causal evidence on the health and economic consequences of an ongoing broad-scope vaccination program. The Ontario Influenza Immunization Campaign expanded the scope of vaccine coverage leading to a 20-percent increase in vaccination. Using the timing of this campaign and exogenous variation in vaccine quality, I link higher vaccination rates to decreases in lost-work-time, hospitalization, and death. Results indicate that, when vaccine quality is high, the program leads to higher gains for Ontario relative to other provinces and in short, an ounce of prevention is worth a pound of cure. Second, I provide evidence of the impact of air pollution on respiratory health. Recent changes in standards for air pollution are highly contentious and represent stringent constraints on economic activity. Evidence from this dissertation directly informs this debate. By linking daily pollution to hospital admissions for municipalities across Ontario, I study the impact of air pollution at levels below those historically considered. Results indicate that particulate matter has a significant effect on respiratory health of children but that ozone and carbon monoxide have little effect on respiratory hospitalizations for all age groups.

While the majority of school-aged children associate immunizations with low levels of anxiety, fear, and pain, there is a small subset for whom needles are highly distressing (Humphrey, et al., 1992). Poorly managed, these individuals may come to avoid medical treatment (Ollendick, King, & Muris, 2002). Using Lazarus and Folkmans (1984) transactional theory of coping and Reid and colleagues (1998) development and validation of the Pain Coping Questionnaire as frameworks, the present program of research elaborated on existing knowledge about how children cope with needles. As part of Studies 1 (N = 176) and 2 (N = 302), a Coping with Needles Questionnaire (CNQ) was developed and validated; both two- and three-subscale versions of the questionnaire were examined. The resulting CNQ was composed of and scored as two separate subscales: problem-focused and emotion-focused coping. Construct validity testing demonstrated that emotion-focused coping was robustly associated with more negative experience with needles (i.e., higher anxiety, fear, pain, and lower self-efficacy). There was no main effect of problem-focused coping but it tended to moderate the negative effect of emotion-focused coping when the two interacted. Study 3 (N = 78) was designed to investigate (1) the percentage of participants who are high on only one type of coping (i.e., dominant copers) and (2) how coping responses change over time in response to repeated presentations of the same stressor. Presently there are gaps in the existing literature regarding these two targeted areas of investigation. Results of this investigation indicated that most children engage in high amounts of both problem- and emotion-focused coping when initially queried about their experience with an immunization, with approximately 30% showing a pattern of coping dominance. When participants were followed and queried about a second experience with immunization, it was found that most of them engaged in low amounts of both types of coping. This pattern of change in the distribution of coping over time was not consistent with learning effects. In other words, participants did not seem to improve their coping with experience. However, lack of a clearly positive type of coping and a six-month time-lag may have inhibited the potential for learning to occur. The utility of the CNQ for screening purposes and implications of these findings for interventions are discussed.