Is there an association between local health department organizational and administrative factors and childhood immunization coverage rates?
Abstract: Background: Vaccines are valuable, cost-effective tools for preventing disease and improving community health. Despite the importance and ubiquity of vaccinations, childhood immunization coverage rates vary widely by geography, race, and ethnicity. These differences have been documented for nearly two decades, but their sources are poorly understood. Between 2005 and 2008, immunization staff of the National Association of County & City Health Officials (NACCHO) visited 17 local health department (LHD) immunization programs in 10 states to assess their immunization service delivery (ISD) practices and their impact on community childhood immunization coverage rates. Purpose: To qualitatively characterize LHD immunization programs and specific organizational factors underlying ISD performance challenges and successes related to community childhood immunization coverage rates.

Methods: Case studies were conducted in a convenience sample of 17 geographically and demographically diverse LHDs, predicated on each LHD's childhood immunization coverage rates per data from the National Immunization Survey and/or Kindergarten Retrospective Survey. NACCHO staff selected LHDs with high ([greater than or equal to] 80% up to date [UTD]), moderate ([greater than or equal to] 75% UTD but <80% UTD), and low (<75% UTD) coverage rates. All immunization staff members interviewed (n=112) were included in focus group interviews at each LHD per a standard semi-structured interview script developed by NACCHO staff. Supporting documents from each LHD immunization program were also collected for inclusion in the analysis. Content and thematic analyses of interview transcripts and supporting documents were conducted.

Results: Two thematic dimensions and six key factors emerged from the data. The dimensions of the themes were success and challenge elements. The organizational factors that were associated with success and/or challenges with regard to improving childhood immunization coverage rates included 1) leadership: organizational leadership and management related to aligning ISD with other child-focused services within the LHD; 2) resources: organizational efforts focused on aligning federal and state ISD financing with local ISD needs; 3) politics: political advocacy and partnering with local community stakeholders, including local political entities and boards of health to better organize ISD; 4) community engagement/coalitions and partnerships: partnerships, coalitions, and community engagement to support local immunization-related decision-making and prioritization; 5) credibility: agency credibility and its ability to influence community attitudes and perspectives on the health department's value in terms of child health; and 6) cultural competency of LHD staff: LHD staff members' perceptions and understandings of its community's cultural, economic, and demographic attributes shaped their responses to and understandings of the community and how they interacted with it in terms of service delivery.

Discussion: Public health researchers are in a nascent stage of understanding how health department organizational factors may contribute to specific community health outcomes, such as childhood immunization coverage rates. An implicit challenge to LHD immunization programs is to implement strategies that lead to equitable and high vaccination coverage among children, despite shrinking resources and community demographic differences. Community-specific attributes (e.g., poverty, lack of health insurance, or geographic isolation) affect childhood immunization coverage rates, but internal LHD aspects such as leadership and organizational culture also likely have a significant impact.
Article Type: Report
Subject: Immunization (Finance)
Child health services (Finance)
Health insurance industry (Management)
Health insurance industry (Services)
Authors: Ransom, James
Schaff, Katherine
Kan, Lilly
Pub Date: 03/22/2012
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2012 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Spring, 2012 Source Volume: 34 Source Issue: 4
Topic: Event Code: 250 Financial management; 200 Management dynamics; 360 Services information Computer Subject: Company financing; Company business management
Product: Product Code: 8000187 Maternal & Child Health Care; 9105264 Maternal & Child Health Programs NAICS Code: 621999 All Other Miscellaneous Ambulatory Health Care Services; 92312 Administration of Public Health Programs SIC Code: 8099 Health and allied services, not elsewhere classified; 6321 Accident and health insurance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 304050533
Full Text: INTRODUCTION

According to available data, 20-25% of children <3 years old do not receive their Advisory Committee on Immunization Practices (ACIP)-recommended vaccinations on time (Luman, 2004, 2005; Child Trends, 2010; NIS, May 2010). State laws requiring children to be fully vaccinated before entering school have been successful in ensuring that children are protected; however, even those who are fully vaccinated by school entry may have been undervaccinated for much of their first four years of life, the time during which they are most susceptible to severe morbidity and mortality from these diseases (Hinman, 2002; Schor, 2004).

Governmental public health plays a critical role in delivering vaccines to children <3 years old. Nearly half of this population receives ACIP-recommended vaccines purchased with public funds (Lindley, 2009). Health departments face numerous immunization service delivery (ISD) challenges in the public sector (Szilagyi, 2002). The activities associated with public health ISD are outlined in Table 1. New vaccines prevent an ever-expanding number of infectious diseases, chronic diseases, and certain cancers (Hamlin, 2008) but eventually lead to an increasingly crowded and complex schedule of recommended vaccinations (Ackerman, 2008). Consequently, health departments must conduct more quality assessment visits to providers enrolled in the Vaccines for Children (VFC) program, and sustain all the responsibilities that come with additional recommended vaccines (Beitsch, 2006).

These conditions, in combination with budget cuts, compromise the ability of LHDs to provide the full spectrum of ISD and other services. As a result, local immunization coverage rates vary widely and the extent to which LHDs that provide ISD implement existing and new vaccination recommendations depends on how highly ISD is prioritized in a given LHD.

Given the documented variations in immunization coverage rates of recommended vaccines in this age group and that approximately half of this cohort receives doses of vaccine purchased with public funds, it is critical to more broadly examine the factors that contribute to these variations. An intensive review of these multiple facets--public health funding, outreach and education to providers and the public, provider enrollment in VFC, evolving epidemiology of the diseases, evolving demographics of communities, rates of insurance coverage, ease of access to preventive care, economic decision making by vaccine manufacturers, interactions of all levels of governmental public health, health care providers, and insurers--may help public health professionals better understand the predicates to the variations in childhood immunization coverage rates. While repeated studies have examined many of these variables and their impact on community childhood immunization coverage rates, few have focused on the role that LHD organizational factors and how ISD is administered play in variations among community childhood immunization coverage rates. Given that immunization coverage rates are a key indicator of overall community health (Healthy People 2010), we examined whether and how LHD organizational factors affect community childhood immunization coverage rates.

Overarching Research Questions

The case study research was shaped by the following key questions:

1. How do immunization program ISD operations compare from one city or county health department to another?

2. Do LHD organizational factors contribute to variations in community childhood immunization coverage rates? If so, how?

Our goal was to use this method to create a kaleidoscope of local immunization programs-a collection of data, experiences, artifacts, and observations that, when examined together, might offer more insight into why childhood immunization coverage rates vary by locality--even though these local programs are working toward a shared goal and implementing many of the same ISD activities.

Organizational Factors

The organizational aspects of health departments are important to study because organizations influence the individuals who work within them by patterning their perceptions, thoughts, feelings, expectations, and behaviors (Suchman, 2001). According to Edgar Schein (1985), organizations imprint a pattern of shared basic assumptions learned by a group as it works through its problems and challenges. The successes and lessons learned from working through past problems and challenges lay groundwork and provide the basis for practice standards. These past successes serve as a template for future decisions, actions, and activities. Strategies that have effectively solved problems are considered valid by public health practitioners and subsequently used as examples to teach new members ways to perceive, think, and feel in relation to those problems, irrespective of current outcomes. The part of Schein's study of organizational factors and organizational culture most relevant to public health is that "if an occupation involves an intense period of education and apprenticeship, there will certainly be a shared learning of attitudes, norms, and values that eventually will become taken-for-granted assumptions for the members of those occupations."

LHDs serve as a logical observation point for gaining an understanding of organizational factors that affect childhood immunization coverage rates across the country. Two-thirds of the nation's LHDs are units of local government while the others function as part of state governments

(NACCHO Profile, 2008). Differing organizational governmental structures allow great freedoms in how LHDs interpret and implement immunization policy and organize ISD activities. It is these organizational and regional variations that this research characterizes.

Knowledge Gap

In public health, there is an impetus to improve service delivery (Boe, 2009), but there is little empirical evidence on the most effective strategies for doing so. There is scant evidence on the value of characterizing organizational factors within LHDs, despite the need for guidance on specific internal changes that can contribute to improved service delivery and community health measures. Characterizing LHD organizational factors can provide a profile of specific successes and challenges that help to inform recommendations for change (Schneider, 1996). The need for this type of information was articulated by one of the LHD staff members interviewed:

[Y]ou have a little bit of your project that you post on your website, but there's not enough operational detail to know how much did that cost, how did you really do this? And then you start calling people and the person who actually ran the program left three years ago. They don't know how they got to where they [are]. You can't even compare local health department [immunization programs], one to another, because mine might include human services. Different things are considered [ISD] in one city or another. So it's really hard to advocate to say that we are not in line [operationally] with other communities, because there is no benchmark.

[Immunization Manager, Midwestern urban LHD]

METHODS

Site & participant selection

To help characterize the spectrum of LHD ISD experiences and begin understanding the childhood coverage variations across jurisdictions, teams of 2 staff members from the National Association of County and City Health Officials (NACCHO) examined a convenience sample of LHDs with a mix of high, moderate, and low coverage rates (Table 2). We relied on National Immunization Survey (NIS) data for those jurisdictions that were urban immunization action plans (IAPs) and local data sources for those who had never been oversampled as part of the NIS.

The LHDs included in this research were convenient in that we were conducting other activities at the LHDs. From this group of LHDs, we looked at those jurisdictions that were local participants in the NIS from 2002-2004 or had local immunization coverage rate data available through the kindergarten retrospective survey (KRS) for the same time periods. Of those LHDs with NIS or other local immunization coverage data, we selected a cross sample of jurisdictions with low, moderate, or high immunization rates, based on functional definitions for immunization coverage: high: ([greater than or equal to] 80% up to date [UTD]) 4:3:1:3:3; moderate: (>75% UTD but <80% UTd) 4:3:1:3:3; low: ([greater than or equal to] 75% UTD) 4:3:1:3:3. The case study sites were spread across the country, with some geographic clustering toward counties in western states. This clustering was due to the fact that many of the fastest growing populous counties in the country are located in the western states (Census Data 2010), but many of those counties had never been oversampled as part of the NIS; thus these areas were an important sub-section to the research.

We recognize that the LHDs are not a representative sample of LHD immunization programs, which limits the conclusions that we can draw from the data. Nonetheless, the data can give us clues as to specific questions other researchers may want to explore when examining the association between organizational and administrative operations of health departments and the impact on a specific community health outcome. We targeted LHD immunization staff only and excluded external partners (e.g., providers, representatives of local medical societies) in order to better focus on internal LHD immunization program operations and the staff members responsible for them.

We determined that a case study approach would be the most effective method for characterizing the multiple factors affecting community childhood immunization coverage rates (Higginbottom, 1998; Hofmeyer, 2006). In practice-based settings, LHDs simultaneously use numerous methods to improve and sustain immunization rates. At the same time, there is a flux of contextual factors, such as staffing, funding, immunization guidelines, program administration, and media around vaccines and childhood immunizations that may make it difficult for LHDs to pinpoint which factors, especially administrative and organizational factors, are critical to influencing immunization rates. By comparing case study data from numerous LHDs, it is possible to pull out key overlapping themes in LHD ISD and identify which factors tend to cluster in areas with high immunization rates, moderate rates, or persistently low rates.

Interview guide & data collection

This part of the research involved three key actions:

1. Designing a semi-structured interview guide to conduct group interviews with health department staff members responsible for planning, administering, and implementing immunization activities. Interviews were structured to answer the research questions and help further characterize the concepts of high quality community involvement and successful public health intervention.

2. Analysis of documentation, resources, and other items that describe different aspects of an LHD's immunization program and its activities. Examples of documentation include retrospective data-collection tools; summary notes of the LHD's participation in a community health coalition; press releases; marketing materials targeting parents and providers; meeting agendas and minutes; and planning and progress reports.

3. Observation of the group dynamics during the group interviews. These observations provided us with data on the interactive patterns within the immunization program (e.g., power relationships, how leadership is exercised, and whether staff seemed free or restrained to speak their opinions in such a forum). Direct observation of these relevant events allowed the identification of important individual and group behaviors and environmental conditions.

Conducting case studies on multiple LHDs provided information about how characteristics such as geographic location or jurisdiction size might influence variability in outcomes. To assure reliability, we used the same protocol and instrument for each case study. At least 2 NACCHO staff members attended each interview-one to lead the interview dialogue and one to take notes and digitally record the interview. Interviews lasted on average 4 hours.

Each case study involved group interviews with as many LHD immunization staff as possible to cover every related job category and engage every individual who has a role in sustaining the immunization program. The key questions asked during each interview are outlined in Table 3. Such a big tent approach minimized the chances that we missed a key person in the program, as often title does not necessarily correlate with "importance" to a particular program (Heifetz, 1994; Demaio, 1998; Kusy, 2008). The interviews were conducted face-to-face, with follow-up via teleconference and e-mail, in terms of clarifying or expanding on comments. The group interviews and discussions were preferred over individual interviews because it was an opportunity for the researchers to observe interactive processes (e.g., organizational power relationships) among the participants (Kitzinger, 1994; Duggleby, 2005). This was also part of the overall research goal in terms of characterizing the particular LHD's organizational culture and dynamics.

We also collected secondary data--LHD immunization program web page content, brochures, press releases, evaluation reports, pamphlets, any media files (e.g., public service announcements), and other immunization outreach, education, and/or marketing materials that may provide insight into the culture of the LHD immunization program and how they view their roles, interact with their community, interact with each other as colleagues, views on departmental leadership, and how/whether they engage external partners to affect ISD. These secondary data are the material symbols of the LHD's ISD practices (Rafaeli, 1987; Pratt, 1997).

Analysis

The interviews were transcribed and uploaded to the NVIVO qualitative data software for content analysis. The analysis searched and coded for repeating key words and phrases to see if the LHDs' reports about their efforts to improve coverage were converging in a specific direction. This first wave of analysis allowed us to break up, separate, and disassemble hundreds of pages of data into manageable pieces that we could later sort and categorize. We did not engage in intensive data coding. We did not think it was the most appropriate strategy for the types of data we collected. This process of analysis (limited data coding) fit with our goals of: 1) making sense of data generated from each case study; 2) identifying patterns and relations within each case study and then across all LHD case studies; and 3) making general discoveries about the phenomena (LHD organizational and administrative factors) we were researching. After identifying the key pieces through the key word and phrase searches, we engaged in micro-level work by looking repeatedly at detailed passages (those that contained the key words and phrases) and applying thorough analysis on these pieces to discern the interviewee's meanings (Seidel, 1998). We went through all the interviews and looked for these key items. These key items were sorted into 2 dimensions: success elements--factors that helped to improve or sustain good immunization coverage rates; and challenge elements--factors that seemed to be associated with low or declining coverage rates.

RESULTS

After analyzing the content of the transcripts from the in-depth interviews and the materials the programs gave us; six key concepts emerged (Table 4). ISD, immunization service delivery. LHD, local health department.

Leadership

Among all the LHDs, leadership was the most crucial aspect to improving childhood immunization coverage in their community-this leadership extended from the health department, to the community, to schools, and to partners such as hospitals and providers. Respondents viewed effective internal leadership as a key component to shaping and guiding public health's visions and actions. Those LHD immunization programs with better coverage rates stated that exercising leadership at every level within the agency was a means to promote agency psychological empowerment--a belief that each worker in the program had the ability to influence a larger system of which they are a part of. One LHD, which had a shift in agency leadership, noted the impact that new leadership had on staff morale.

[H]e came [here] with a whole new vision, which was really nice. [W]e were very, very siloed with our previous director. [He] is big on immunizations and immunization rates and not missing opportunities, and looking for ways to make the best use of what we're doing, because we've done a lot of stuff with WIC [the Women, Infant, Children Program]. I mean we had done some when he got here, but he really encouraged them and we've done a lot more. Every year we pick one WIC office and do a random selection of days, and try to get 80% of the records of the kids scheduled on those days, and look at their actual rate and see how they're doing.

[Immunization Nurse Manager, Western urban LHD]

What was most evident in LHDs with weaker coverage rates was that they often articulated words associated with powerlessness--an inability to change the cards that they had been dealt in regard to funding, staffing, and local political support for immunization initiatives. [We] are having a problem with [the] third dose. They are trying everything. They cannot locate most of the babies and moms. The numbers are very low compared to previous years. Serological testing for infants is very low and has dropped from 80% to 60%.

[Immunization Program Manager, Western metro-urban LHD] We just simply don't have the people to really get out there and do it. I mean, this is the biggest I think the immunization program has been, but we still don't have nearly the resources we need to consistently work with the city schools. [Immunization Program Manager, Midwestern urban LHD]

The LHDs with better coverage rates, in addition to communicating in words associated with "action" also reported that they felt like "champions." These staff reported that they led efforts to control, modify, and challenge potentially detrimental external forces so that they could sustain their coverage rates. These staff members articulated a clear connection between their actions and the health of children in their communities. And so [there] have been obstacles and challenges for sure. But at the point where they say it's up to us, we can make the schedule, decide about the delivery, packing the clinics in the bag, getting them out there, doing a schedule of who's [going to] work at those clinics.

I do feel like I am a champion. People bring up obstacles and all sorts of things. And, "Don't do this, " and, "Be careful of this," and that kind of [thing]. But then I sat there and thought, Wow, they're giving this stuff away. Isn't there anything that we can do with it? [Immunization Nurse, Mid-Atlantic suburban LHD]

Secondly, we've got also an immunization taskforce with the Medical Society. That is aimed more at providers and getting providers to do a better job on immunizations. I think that's been a little slow to get started, but has a lot of potential. I think we see that as one of the solutions, too. That's [going to] help us to move more actual provision of immunization to the medical home and help [improve coverage]. [Immunization Program Manager, Midwestern urban LHD]

Credibility

Immunization programmatic staff members are tremendously concerned about their agency's credibility with the public, because trust is a linchpin for sustaining their community relationships (Eisenman, 2004). The data indicated LHD staff feel that the challenges they face, such as parental hesitancy regarding the safety of vaccine ingredients, are eroding that credibility. Credibility is also closely related to the aforementioned leadership factor. Those we interviewed articulated the importance of multiple levels of leadership in building that credibility--from their health officials, to their political leaders, as well as the leadership exercised by those they partner with providers, entities like birthing hospitals, and community health centers; and they all listed the importance of that broad concept of 'resources' as related to credibility--mentioning local and state staff reductions, retiring workers, and new work demands that do not come with funds attached.

More and more people are coming to rely on the health department for clinical services, when the push has been to put them in medical homes. This is complicated by the fact that [we are] functioning with ~1/3 of its staff. [We] are collaborating with primary care providers, hospitals, and any other community partners to work on these problems. [Medical Director, Southern urban LHD]

They were not only concerned with their credibility with individuals and families in the community, but also with their partner organizations. All LHDs, irrespective of coverage rates, indicated that one of their top priorities was to maintain a high public profile of their agency ensure that individuals in their community viewed the LHD as accessible to the public and a good place to get help or answers or information that they and their families need. The interviewees mentioned that even one bad experience can have a much more lasting impression on the community than thousands of good experiences. Well, we did some outreach to hospitals about birth dose of hepatitis B. We actually came up to the barrier that some of them thought that it would impact their accreditation if they had standing orders, that the Joint Commission wouldn't allow it.

So it's just this perception out there-and we actually went to the Joint Commission person and their answer was just as confusing as where we started with. So there is the misconception out there that that's an acceptable practice. [Immunization Program Manager, Southern multi-county urban LHD]

Community Engagement/Coalitions & Partnerships

Among those LHDs with better coverage rates, the interviewees emphasized sustaining strong ties to the community, engaging the community in decision-making and program implementation, and pulling partners together into health-related coalitions. Those LHDs with better coverage rates articulated a clear connection between how their agency is organized, how ISD is administered, and how it works and how it interacts with its external environment-community members, schools, providers, and other partners.

[T]hey look at all the information and see what's out there. If there was an additional more formal process for sharing what's working. When you're trying to formulate your idea you look at what others have done. It may not be easy to articulate, but anything that helps you understand what others have done that was successful; you get to ask if that would work for us. The more common the issues that come up, the national issues, you get to identify it as a priority that CDC needs to address. [Immunization Nurse, Western suburban LHD]

The high rates are also because a combination of other activities: Media campaigns; school trainings; working with providers; doing assessments; providing [technical assistance]; [medical assistant] trainings; and satellite trainings. Everything happens simultaneously. They also have nice multi-lingual materials. Their immunization campaign is constant and non-stop, going all year. They are planning on doing workshops with schools. They are going down to the nitty-gritty details that need to be addressed to increase rates. There are 33 school districts and they are going to be working with the people checking records. [Health Officer, Northeastern urban LHD]

I mean, the first [community] meeting that I went into, there was so much yelling and finger pointing-oh, it was awful. The District Attorney was there. Things were said. I mean, after a lot of the yelling got done, I think in the last year or so, we've really turned it around. Everybody's agreed that there's things we have to do. We're going to follow statute. We are going to work together. We've seen these large increases in our compliance rates and the number of kids that meet the minimum requirements. [Immunization Manager, Midwestern urban LHD]

LHDs have to have partners, but the strength of those partnerships are along a continuum-some are much stronger than others. Those LHDs with strategic and robust partnerships (evidenced by having regular meetings, standing and operating joint health and immunization coalitions were doing a much better job of collaborating to improve coverage rates. There should have been more public education about [the immunization program]-but the budget was limited so those resources were earmarked for educating the WIC staff. There should have been more focus on educating the management at each WIC-Health Center site. More communication was needed with the sites, and [t]he partnerships could have been stronger. There was a need to get someone on site to "own" the project. [Immunization staff member, Southern urban LHD]

All LHDs articulated that community partnerships (external) were part of their agency's mission and that an integral part of their job of health promotion was to create and sustain effective community partnerships. They recognized that much of what they are tasked with doing by statute could not be done without the help and collaboration of community partners, particularly providers, community health centers, schools, and other entities that interact with families and children. A difference in their responses occurred when discussing how to overcome specific barriers to form, sustain, and strengthen partnerships and ties throughout the community. Those with better coverage rates doubled-down on their partnerships and developed effective coalitions to make sure that they obviated barriers. The coalitions provided forums for all partners to air issues and come up with solutions.

They have worked a lot with providers and on getting them trained. [Children aged] zero to 2[years] are still the most difficult population to get to because they are not in school and some not in day care. [Immunization nurse manager, Northwestern city-county LHD]

[We have] a hospital-based Maternal/Infant Education Program. [We] visit new moms in the hospital. [Health department] clerks do the visits.

They have a gift bag. They pass out information on immunization and WIC, and some other issues. The importance of getting your child immunized and when they should get immunized. Many parents believe the doctor will take care of it and will let them know what to do. They are informed that they need to know as much as their doctor with regard to their child's immunization requirements. This program helped the parents become informed consumers. [Immunization nurse, Southeastern multi-county urban LHD]

These LHDs also communicated that their internal subunits (internal partnerships and collaborations) and subsystems continually interact because they recognize that they are mutually dependent on one another for their work to be successful. There was some difference (in terms of the strength of these internal collaborations) between larger and smaller LHDs, with smaller LHDs noting that they had smaller staff numbers and less bureaucracy to wade through to get things done.

LHDs with high coverage rates mentioned that collaborations with their colleagues in other agency divisions was a key ingredient to any successes within their immunization program. This increased internal collaboration was predicated on effective agency-wide communication and provided a means of vertical and horizontal sensitization of all agency staff, irrespective of division affiliation. These efforts helped improve agency communication and enhance line staff and leadership awareness of community health issues and increased staff roles and contributions to decision-making and development and implementation of specific activities. One reason for high rates might be that the units under the [community health] program really work collaboratively. They have merged everything into one program and work closely with the community. [Immunization manager, Western urban LHD]

One of the good things of having [immunization and epidemiology] within one division is that as more things become vaccine preventable there is overlap and sharing of expertise. During large outbreaks and crises, the whole division can be leveraged. [We] have weekly joint meetings of all the epi[demiology] staff-lots of cross-training. One division makes it easier and sometimes [we] subdivide diseases. [They] really work together and they have joint protocols for surveillance for [certain diseases]. [Medical Director, Northeastern urban LHD]

Politics

Data from the interviews of LHDs with high coverage rates showed that maintaining good relationships with local political structures were key elements to success. Staff noted that an absence of strong relationships with politicians and policy makers would hamper their ability to address inequities and lobby for special projects or increased funding to address disparities.

Actually it was the legislature. It's state money that finally got reinstated when [we were] at [number] 50 [of 50 states] two years in a row [for NIS], and then there's always that time line. So we've probably had--this is probably the third year we're applying for it, and it's to do something with a partnership of some kind or to do something in an office that's not your own, or try to be creative with what you 're doing. We were actually allowed to use it to help fund our fire station [pediatric vaccination] clinic. [Immunization program manager, Western suburban LHD] [B]ecause the mayor has taken such a big interest in making sure kids are properly immunized for school, we've done clinics, we've tracked our costs. [Immunization medical director, Midwestern urban LHD]

From the data, it appears that those programs with better political support, which seem to have better community engagement, and have more robust investments of local sources of funds-attribute those positives to their relationships with community political leaders and decision-makers (e.g., boards of health, mayor, and council members)-had better coverage rates. This local fiscal investment allowed them a measure of flexibility to exercise certain innovative and creative concepts. There were exceptions to this, but it was a dominant interconnected concept across the board-those reporting stronger community engagement, robust community partnerships, and stronger coalitions also reported more political support and sustained local funding streams and thus did a better job of figuring out ways to improve coverage rates.

Resources

The amount of LHD resources dedicated to immunization programs (per capita) fall along a wide spectrum, usually predicated on the size of the LHD and its jurisdiction's population profile. The LHDs focused on the changing resources landscape that they have to build their ISD on. However, those with less successful coverage rates focused on what they did not have, with minimal discussion on solutions to those resource changes. The problem with VFC is that the 2 VFC coordinators cannot handle the number of providers out there. Pediatric up-to-date rates are only 40% for VFC, based on AFIX numbers. [Immunization nurse, Western urban district LHD] We went from over 400 staff and well over 100 public health nurses to now, we have 250 staff and, I don't know, maybe 30 district nurses or something like that. [Immunization program manager, Western urban district LHD]

But if you look at public health funding in the [state] as a whole, state funding for public health, we're 50th. Federal funding for public health, we're 50th. [Immunization nurse, Western suburban LHD]

Those with better coverage rates changed and adapted with the changing resource landscape and figured out ways to sustain good coverage rates-and talked at length about what they had tried.

One of the things we've done through a taskforce that is between the health department, [the] public schools, the district attorney's office, and the State Division of Public Health, [is that] we've gotten [the schools] to finally actually comply with the school immunization law. So they're doing a better job with that now. When a parent is faced with a letter of exclusion, it's sometimes easier for them to just check the philosophical exemption box than it is to go and get shots. [W]hen we've looked at records and looked at the schools and talked to parents, they're not anti-vaccine.

[Immunization manager, Midwestern urban LHD]

This factor emerged as a key success element--staff members were focused on implementing innovative ideas instead of focused on how proposed solutions would not work in practice. The data generated from these successful LHDs can help develop guidance on how to move practice groups or teams from negatively focusing on barriers to positively creating,

implementing, and sustaining solutions and improving community health outcomes.

LHD staff member perceptions of community demographic attributes. Staff perceptions of cultural practices of racial and ethnic populations influenced the immunization programs and practices within the health departments. While all LHDs provided services to diverse communities, specific community demographic attributes were seen as barriers to service delivery for many of the LHDs included in the study. The statements provided by staff members show that public health organizations are rooted in systemic inequities, as are other institutions. Consequently, it may be that these notions, grounded in the staff members' experiences of interaction with specific communities, may function as processes of reproducing the very marginalization and inequities they are committed to addressing and correcting. In discussing low IZ rates, by locating the problem in perceived cultural attributes of certain groups, this also limits the potential solutions because immunization staff focus on trying to change community cultural norms and practices rather than changing programs to fit the needs of various groups. Seeing cultural differences as a barrier to high rates rather than an opportunity for innovative program planning and collaboration with diverse groups was a reoccurring pattern in many of the LHDs. For many of those interviewed, they noted the pressure to change practices and programs to accommodate the dramatic changes in the characteristics of the clientele accessing LHD immunization services, and the strain placed on staff resources, skills, and the structures of the LHD. Many of the comments made by interviewed staff members show the need for building staff capacity around cultural competency, cultural humility, and understanding how cultural bias affects decision-making (Hunt, 2001). The starting point for such an approach may not necessarily be an examination of the community's belief systems or cultural practices. The starting point should be consideration by public health practitioners of the assumptions and beliefs that may be embedded in their own understandings and goals in how they encounter and interact with community members. Training and cultural competency, with its emphasis on promoting the understanding of the "cultural" community, seems to have neglected study and consideration of the practitioners' cultural values.

In Asian and Hispanic cultures, you don't go to the doctor unless you are sick, so it is hard to convince them to get vaccinated or to bring their children in to the clinics. [For the] Hep B program--they are having a problem with third dose. They are trying everything. They cannot locate most of the babies and moms. The numbers are very low compared to previous years. Serological testing for infants is very low and has dropped from 80% to 60%. [Immunization nurse, Western urban district LHD]

One problem is that the population moves in and out of insurance coverage, and [in areas with better coverage] income distribution may have something to do with high rates.

[Immunization program manager, Midwestern urban LHD]

Childhood practices--the ones discussed before, have been successful-but we are still struggling with the barriers. We need to educate the public. Some minorities are leery about vaccines. There is a wide disparity in the rates.

[Immunization program manager, Midwestern urban LHD]

The parents [here] are go-getters for information, which may not be the case in all counties. [We] have large disparate populations. In the Hispanic culture, you do exactly what your doctor says and you follow their directions, so their rates are dependent on private providers.

[Immunization program manager, Western urban LHD]

Applying norms from one's own cultural understandings and practices can cause tensions when the "others" are expected to behave and think and act as "we" do within our own cultures. If staff do not have time, flexibility, leadership support, and staff development support to work with diverse cultures as needed, it is hard to work in a way that values and leverages cultural, social, and economic differences instead of seeing them as a barrier.

DISCUSSION

This research examined local ISD perceptions and its relation to a specific outcome-childhood immunization coverage rates. An examination of individual perceptions is not just the domain of psychologists. The goal was not to examine the inner workings of their brains, but to identify and characterize how staff perceptions about their organizations impact staff members' behaviors and how they practice, administer, and deliver immunization services. It is their perceptions that matter. W.I. Thomas (1966) noted that "if people define situations as real, they are real in their consequences." Therefore, if staff members see themselves as champions and see obstacles as motivators and guidelines as goals instead of burdens, then how they practice will be altered and that will impact the outcome.

In every organization-public or private sector--there is the formal organization that is manifested through structure, systems, and strategies (Garmestani, 2009) and then there is the "informal" one-the organic but equally vital mix of human psychology, organizational culture, social networking, and communities of practice that make the organization work (Harrison & Carroll, 2006). This article presents a small step toward understanding how organizational and administrative factors converge within LHD immunization programs to play a role in community childhood immunization coverage rates.

The LHDs that served as case studies for this research did not make decisions in a vacuum, and each recognized that they were not surprised when their ability or inability to execute and deliver ISD was successful or fell short of goals and expectations. Those LHDs with persistently low coverage rates indicated that the goals articulated by ACIP and Healthy People 2010 are not grounded in reality-the realities of local capacity, knowledge of community and partner needs, or based on their real resources, realistic time frames, or over stressed resources. Those LHD immunization programs with better coverage rates said that those types of goals were motivators-providing them with a target to aim at and work toward-instead of unattainable barriers due to lack of resources. Again, a key factor here was an organizational culture that allowed staff to act as champions and exercise leadership to improve practice. The staff members who saw themselves as champions were not stating that they just felt that way. Their feelings of effectiveness were grounded in data from programmatic measures they used to evaluate their agency's ISD. These measures included number of provider visits to gauge pediatric coverage levels, number of in-services with providers and other stakeholders, as well as participation in local, regional, and statewide health coalitions.

Although preliminary, our findings suggest that organizational and administrative factors, based on leadership, management, and culture; play a significant role in community health outcomes. The study had methodological limitations, including that it included a convenience sample of LHDs that are not necessarily representative of local immunization programs throughout the U.S. Also, a quantitative assessment of LHD organizational factors could give a clearer idea of how organizational factors interact with external community aspects to affect community health outcomes. Our qualitative method, however, was an effective tool for developing a preliminary understanding of the complexities of health department organizational factors and how they impact public health practice and community health outcomes.

Understanding how organizational culture within LHD immunization programs can be shaped and modified by its leadership and management will be a critical aspect of determining how and where to intervene to affect the most change. Conversely, examining the role of agency in community health outcomes, in their roles as gatekeepers to resources, services, and opportunities of access as well as their role in perpetuating or dismantling power structures, is critical to understanding how agency organizational culture and structure impacts community health, well-being, and health outcomes. Assumptions about the local leg of the governmental public health system are widespread and largely anecdotal. There is a need to move beyond the anecdotes and better define the root causes and the magnitude of the problem with hit-or-miss childhood immunization coverage rates (Smith, 2009). A clearer picture of operations and documentation of the common elements of exemplary LHD ISD will help local programs apply model organizational practices to improve their internal practices and, theoretically, affect a community health outcome like childhood immunization coverage rates.

Separating out the interconnectedness of all of these items will require some more work, more interviews, and more site visits to determine which themes are predicated on other themes. Does having robust political support for your activities improve or enhance community partnerships? Do better interagency collaborations do it? Do strategic collaborations help? If so, how? How does agency leadership and management affect organization culture within public health departments? What impact do appointed or elected board of health members have on local public health organizational culture and practice? What impact does organizational leadership and staff perception of themselves as practitioners instead of employees have on the agency's culture and practice environment and, ultimately, on community health outcomes? These are a few questions to consider when attempting to draw associations between the qualitative points and coverage rates.

An understanding of how various aspects of health department organizational factors impact community health outcomes is an important aspect of transforming public health practice and thus the public health system's infrastructure (Rowitz, 2003). Knowledge derived from these case studies can fill gaps in understanding the ways that an LHD depends on specific leadership and management styles to shape its organizational culture and how that culture contributes to the quality of ISD in a health jurisdiction. This study will help begin the establishment of an empirical basis for evaluating "how" LHD organizational factors operate in LHDs that can inform internal planning and improvements in a specific health outcome.

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JAMES RANSOM

Antioch University

KATHERINE SCHAFF

Alameda County Public Health Department

LILLY KAN

National Association of County & City Health Officials

Washington, DC
Table 1
Activities Associated with Public Sector Immunization Service Delivery
(ISD)

                 Roles
ISD              Local             State             Federal
Component

Vaccine Supply   Ordering and      Procurement       Regulatory
                 supply planning   Timely ordering   authority
                 Delivery of       Supply planning   Purchase price
                 vaccine to        Accountability    contracts
                 community         Supply            Financial
                 partners and      management        security for
                 providers                           purchase
                 Logistics                           Supply planning
                 Community                           Accountability
                 outreach and                        Supply
                 education                           management
                 Provider                            Management of
                 outreach and                        central storage
                 education                           facility
                 Lot quality
                 assessments

Surveillance     Monitoring        Laboratory        Policy
                 adverse events    services          Standards and
                 Vaccine-          Data              guidelines
                 preventable       management        Case definitions
                 disease (VPD)     systems           VPD outbreaks
                 monitoring and    Improving         Monitoring of
                 reporting         information       adverse events
                 sources           gathering,
                 Immunization      storage,
                 registry          analysis
                 reporting         Registry

Advocacy and     Coalitions        Technical         Technical
communication    Interactions      documents         documents
                 with local        Guidelines        Guidelines
                 political         Capacity          Capacity
                 structures        building          building
                 Community         resources         resources
                 partnerships      Customizing       Developing
                 Interaction       consistent and    consistent and
                 with local        credible          credible
                 medical           messages          messages
                 societies                           Interaction
                 Social                              with federal
                 mobilization                        political
                 Immunization                        structures
                 campaigns

Logistics        Supply            Policy            Policy
                 management        development       statement
                 Transport         Regulation of     development
                 Disbursement of   vaccine-          Guidance on
                 vaccine to        receiving         safe injection
                 community         facilities        practices
                 providers         Supply            Supply
                                   management        management

Table 2
Case Study Sites

                                            Population
                                            Size
                                            of LHD
                                            Juris-
                    Type of        Type     diction *
Site    Region      jurisdiction   of LHD   (rounded)

LHD     Mid-        Urban-         County   400,000
1       Atlantic    Suburban

LHD     North       Urban          City-    2 million
2       west                       county

LHD     West        Urban-         County   2 million
3                   Suburban

LHD     West        Urban          Distr-   2 million
4                                  ict

LHD     West        Urban          County   1.5 million
5

LHD     Midwest     Urban-         County   2.5 million
6                   suburban

LHD     Southeast   Urban          City-    2 million
7                                  county

LHD     West        Urban          City     700,000
8

LHD     West        Urban          City     500,000
9

LHD     Midwest     Urban          City     600,000
10

LHD     West        Urban-         Multi-   1 million
11                  suburban       county

LHD     Northeast   Urban          County   700,000
12

LHD13   West        Urban          County   9 million

LHD14   West        Rural          County   200,000

LHD15   Midwest     Urban          City     3 million

LHD16   Northeast   Urban          City     600,000

LHD17   South       Urban          City     2 million

        Coverage
        Rate
        Classific            # people
        ation                intervie
        (2002 -              wed at
Site    2004)       Source   LHD

LHD     Moderate    KRS      11
1

LHD     Moderate    NIS,     9
2                   KRS

LHD     High        NIS      4
3

LHD     Low         KRS      7
4

LHD     Moderate    KRS      5
5

LHD     Low         KRS      6
6

LHD     Moderate    NIS      7
7

LHD     Moderate    KRS      8
8

LHD     Low         KRS      7
9

LHD     Low         KRS      4
10                  NIS

LHD     Low         KRS      3
11

LHD     Moderate    KRS      9
12

LHD13   High        NIS      7

LHD14   Low         KRS      6

LHD15   Moderate    NIS      4

LHD16   High        NIS      8

LHD17   Low         NIS      7

* Based on U.S. Census Data, 2000.
LHD, Local Health Department.
NIS, National Immunization Survey.
KRS, Kindergarten Retrospective Survey.

Table 3
Key Discussion Points for Case Study Interviews

Item             Key Discussion Terms/Questions
Organizational   What is the general organizational structure of
functions        your immunization program? (Pleaseprovide an
                 organisation chart if one is available.) How are
                 duties divided, sorted, or assigned? How would you
                 describe your agency's work environment?
                 Please describe your program's relationship with
                 other programs within your agency.

Activities       Explain the action steps your agency took to
                 improve or sustain your community's childhood
                 immunization coverage rates. What are the
                 strengths/weaknesses of your agency's immunization
                 program? (This may include assessments,
                 immunization promotion, education, and outreach
                 efforts.) Please describe any special projects
                 your immunization program has taken part in to
                 improve childhood coverage rates.

Resources        Does your agency provide childhood immunizations
                 in LHD clinics? Do you charge a fee or do third-
                 party billing? What is the source of funding for
                 vaccinations when parents of children cannot afford
                 to pay? Are there state and federal mandates that
                 your health agency have not been able to meet, due
                 to budget constraints? Have resource challenges
                 affected your efforts toward developing and
                 sustaining community partnerships?

Health equity    Does your agency engage in activities that address
                 racial, ethnic, and sociodemographic disparities
                 in childhood immunization coverage rates?

Community        Do you collaborate with other public health
engagement       agencies and community partners on immunization
                 promotion/outreach efforts?
                 If yes, what are those activities?
                 If no, are you interested in collaboration?

Political        How closely does your immunization program work
advocacy         with your local government (e.g., city or county
                 council, mayor, board of health)?

Partnerships     Please describe your department's relationship
                 with your state health department and/or with
                 other LHD immunization programs.

Table 4
Emergent Dimensions and Themes

                   Dimensions

                   Challenge                Success
Key Factors

Leadership &       Agency leadership        Agency leadership is
organizational     is top-down, with        participatory and
alignment          minimal input from       inclusive of staff
                   staff for decision-      opinions and
                   making ISD is not in     perspectives ISD is
                   sync or aligned with     aligned with other
                   other LHD programs       child-health-focused
                   focused on child         programs
                   health and well-being

Resources          Limited innovative       Organizational efforts
                   efforts to identify      to leverage various
                   and leverage various     streams of revenue
                   and/or new streams of    (e.g., preparedness
                   revenue to expand and    funding) to expand and
                   enhance ISD with the     enhance child health
                   LHD                      programs, especially
                                            immunizations

Politics           Limited and/or           Strong relationship
                   adversarial              with local political
                   relationship with        leadership (e.g.,
                   local political          commissioners, boards
                   leadership               of health) that is
                                            leveraged to help
                                            improve flow of
                                            resources

Community          Weak external            Active immunization
engagement/        partnerships,            and/or health
coalitions &       coalitions, and          coalitions, agency
partnerships       community engagement     requires community
                   efforts; minimal         health assessments
                   relationships with
                   community stakeholders

Credibility        Uncertainty of           Agency focus on
                   credibility and trust    sustaining credibility
                   community has in the     with various community
                   LHD and its programs     groups and trust with
                                            a spectrum of community
                                            partners and
                                            stakeholders

LHD perspectives   Limited cultural         Cultural competency
on its community   competency and           integrated into staff
                   cultural humility of     training; immunization
                   staff; limited LHD       efforts considered part
                   infrastructure for       of agency's health
                   supporting focus on      equity efforts.
                   staff development and
                   growth in cultural
                   humility and cultural
                   competency; limited
                   activities focused on
                   health equity
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