Which factors make a difference when
identifying pockets of
under-immunization? Gayle Moxness
Hennepin County Community Health DepartmentMinneapolis, MN
October 2002
Agenda
Identify Sources and Tools Plan the Analysis Analyze the Data -
Look for Patterns/Relationships See the Results -
Hennepin County Analysis
Identify Sources/Tools
ImmuLink Immunization Registry
2000 Census Data
CASA (Clinic Assessment Software Application)
GIS (Geographic Information System)
What is ImmuLink?
Immunization Registry serving
the Minneapolis/St. Paul Metro Region (population 2.6 million)
History Behind ImmuLink
Retrospective studies• Conducted by the Minnesota Department of
Health • Identified pockets within Hennepin County
that had very low immunization rates ImmuLink launched in 1995
• Hennepin County launched ImmuLink in response to these research results
ImmuLink Today
Nearly 600,000 records (people of all ages with shots)
Over 4 million shots
111 Participating Sites (public and private clinics, including large clinic systems, and schools)
Plan the Analysis
Focus on Hennepin County
Develop hypotheses
Determine geographic areas
Analyze the data
Focus on Hennepin County, MN
Minneapolis and Suburbs
Population: 1.1 million
Increasingly diverse
Develop Hypotheses: Do any of these factors relate to
immunization UTD rates?
Poverty level Inability to speak English well Gender Race/ethnicity Immigrant density Population density Single parent household
Possible Geographic Areas
Urban/Suburban Cities (47 in Hennepin County)
Communities/Planning Districts (11 in Minneapolis)
Neighborhoods (34 in Minneapolis)
Census Tract (298 in Minneapolis)
Zip Code
Analyze the DataExtract Data from ImmuLink
From ImmuLink, extract immunization data for children who:
Live in Hennepin CountyAre 24-35 months old
For each child:Vaccinations given/datesStreet addressGender (if available)Race (if available)
Result: 7023 records
Analyze the Data
Match Addresses Match children’s addresses from ImmuLink with
defined Census geographic areas
Test for sufficient sample size
Result: • “Communities” for Minneapolis• “Cities” for suburban areas
-
Analyze the DataCASA
Use CASA to analyze ImmuLink data to determine UTD rates
Total Hennepin County- Gender- Race
Each geographic area
Analyze the Data
Census Analyze Census 2000 data by
geographic area:• Population density, poverty, etc.• Above/below County average
Integrate with CASA analysis• Look for patterns: UTD rates and Census
Hennepin County Analysis Census and UTD Rates
Calculate indices to easily compare above/below the County average for different types of data Example: • If Hennepin County has average HH income of $30,000 per year• City XYZ has an average HH income of $60,000• We see that the city has above average income City XYZ = 60,000 = 200% (index County 30,000 of 200)
Hennepin County Analysis Total Hennepin County
Does Gender make a difference?
6,926 kids had a “gender” code in ImmuLink (only 97 records without gender code)
Compare UTD rates for M & F
Is the rate for one gender above average, the other below average?
Hennepin County AnalysisHennepin County ImmuLink Data
Index to County Avg.%UTD* (49.8%=100)
Female 49.8 100 Male 50.4 101
*includes MOGEs
Conclusion: Gender doesn’t make
a difference
Hennepin County AnalysisHennepin County ImmuLink Data
Does race make a difference?
2486 kids with “race” code in ImmuLink
( Nearly 2/3 of all records lack the optional “race”code)
Compare UTD rates for differentracial groups
Hennepin County Analysis Hennepin County ImmuLink Data
Index to County Avg. %UTD (49.8%=100)
White 36.2 73Black 45.8 92Asian 41.7 84Am. Indian 42.5 85No race code 55.3 111
Results: Inconclusive. Questionable whether samples represent
each racial group since all groups are below the County average
Hennepin County Analysis
Does Suburban versus Urban make a difference?
Suburban Cities combined Minneapolis Communities combined
Hennepin County Analysis Suburbs vs. Minneapolis (ImmuLink and Census Data)
0
50
100
150
200
250
Suburban Minneapolis
Ind
ex t
o H
enn
epin
Co
un
ty A
vg (
=10
0)
4-3-1 UTD
White
Black
Am. Indian
Asian
County Average =100
Hennepin County Analysis Suburbs vs. Minneapolis (ImmuLink and Census Data)
0
50
100
150
200
250
Suburban Minneapolis
Ind
ex t
o H
enn
epin
Co
un
ty A
vg (
=100
)
4-3-1 UTD
Population Density
Poverty 200%
Single Parent HH
Foreign Born
Poor English Skills
County Average=100
Hennepin County Analysis
Minneapolis Communities Combined•Greater population density•Greater poverty, etc.•And, higher UTD rate
Look at each geographic area•Minneapolis Communities•Suburban Cities
Hennepin County Analysis Minneapolis Communities (ImmuLink and Census Data)
0
50
100
150
200
250
300
350
Ind
ex
to
He
nn
ep
in C
ou
nty
Av
g (
=1
00
)
4-3-1 UTD
Poverty 200%
County Average
Hennepin County Analysis Minneapolis Communities (ImmuLink and Census Data)
0
50
100
150
200
250
300
350
400
450
500
Ind
ex
to
He
nn
ep
in C
ou
nty
Av
g (
10
0)
4-3-1 UTDPoor English skills
County Average
Hennepin County Analysis
Minneapolis Communities: Inverse relationship with UTD rates
•Poverty (As poverty increases, UTD rate decreases)
•Poor English-speaking skills•Continue analysis for other factors
Look at Suburban Cities
Hennepin County Analysis Suburban Cities (ImmuLink and Census Data)
0
20
40
60
80
100
120
Gold
en V
alley
Plymou
th
Hopkin
s
Edina
Minn
eton
ka
Map
le G
rove
St. Lo
uis P
ark
Richfie
ld
Eden
Prairi
e
New H
ope
Robbin
sdale
Bloom
ingt
on
Brook
lyn P
ark
Crysta
l
Brook
lyn C
ente
rInd
ex t
o H
enn
epin
Co
un
ty A
vg (
=10
0)
4-3-1 UTD
Poverty 200%
County Average
Hennepin County Analysis Suburban Cities (ImmuLink and Census Data)
0
20
40
60
80
100
120
Ind
ex
to
He
nn
ep
in C
ou
nty
Av
g (
=1
00
)
4-3-1 UTDPoor English skills
County Average
Hennepin County Analysis
Suburban CitiesUTD rates and other factors don’t show expected relationships
Do further analysis with GIS
Hennepin County AnalysisGIS
Use GISUTD Rates by geographic area
24-35 month olds in ImmuLink as a percent of population
Different assumptions
Maple Grove
MinnetonkaBeach
GreenwoodTonka Bay
Osseo
Robbins-dale
Fort SnellingChanhassen
Medicine Lake
Rockford
Loretto
SpringPark
Woodland
ExcelsiorSt. Bonifacius
Long Lake
Maple Plain
St.Anthony
Deephaven
Hanover
Wayzata
New Hope
Hopkins
Brooklyn Center
Rogers
Mound
Golden Valley
St. Louis Park
Richfield
Crystal
Champlin
Shorewood
Brooklyn Park
Greenfield
Minnetonka
Independence
Edina
Eden Prairie
Minnetrista
Bloomington
HassanDayton
MedinaPlymouth
Corcoran
Orono
Minneapolis
NokomisSouthwest
Northeast
Camden
University
Longfellow
Central
Near-North
Calhoun-Isles
Powderhorn
Phillips
Immunizations Percent Up-To-DateAmong 24-35 Month Old Children,
as of September 1, 2002
Hennepin County
2 0 2 4 Miles
N
EW
S
Source: Hennepin County Community Health Department, ImmuLinkPrepared by: Hennepin County Community Health Department, 10/23/2002il_registry-conference.apr
Data Aggregated and Displayed byHennepin County City and Minneapolis Community
City boundariesMpls Community boundaries
Percentage of Children in ImmuLinkAge 24-35 Months WhoseImmunizations Are Up To Date
19% - 32%33% - 45%46% - 57%58% - 66%Insufficient data to calculate rate
NokomisSouthwest
Northeast
Camden
University
Longfellow
Central
Near-North
Calhoun-Isles
Powderhorn
Phillips
Maple Grove
MinnetonkaBeach
GreenwoodTonka Bay
Osseo
Robbins-dale
Fort SnellingChanhassen
Medicine Lake
Rockford
Loretto
SpringPark
Woodland
ExcelsiorSt. Bonifacius
Long Lake
Maple Plain
St.Anthony
Deephaven
Hanover
Wayzata
New Hope
Hopkins
Brooklyn Center
Rogers
Mound
Golden Valley
St. Louis Park
Richfield
Crystal
Champlin
Shorewood
Brooklyn Park
Greenfield
Minnetonka
Independence
Edina
Eden Prairie
Minnetrista
Bloomington
HassanDayton
MedinaPlymouth
Corcoran
Orono
Minneapolis
Data Aggregated and Displayed byHennepin County City and Minneapolis Community
il_registry-conference.apr
Source: U.S. Census, 2000: Hennepin County Community Health Department, ImmuLinkPrepared by: Hennepin County Community Health Department, 10/23/2002
N
EW
S
2 0 2 4 Miles
Hennepin County
ImmuLink Children Age 24-35 Months(September 1, 2002) as a Percentageof All Children 24-35 Months of Age
(U.S. Census, April 2000)
ImmuLink 2 Year Oldsas a Percentage of All 2 Year Olds
3% - 25%26% - 50%51% - 75%76% - 90%> 90%Insufficient data to calculate rate
City boundariesMpls Community boundaries
Hennepin County Analysis
Minneapolis Communities• Highest UTD Rates• Highest percent of population represented in
ImmuLink
Look at “High end” and “Low end” Assumptions
Hennepin County Analysis
Look at “High end” and “Low end” Assumptions
• High end: Assumes that all children not in ImmuLink ARE Up-To-Date
• Low end: Assumes that all children not in ImmuLink are NOT Up-To-Date
NokomisSouthwest
Northeast
Camden
University
Longfellow
Central
Near-North
Calhoun-Isles
Powderhorn
Phillips
Maple Grove
MinnetonkaBeach
GreenwoodTonka Bay
Osseo
Robbins-dale
Fort SnellingChanhassen
Medicine Lake
Rockford
Loretto
SpringPark
Woodland
ExcelsiorSt. Bonifacius
Long Lake
Maple Plain
St.Anthony
Deephaven
Hanover
Wayzata
New Hope
Hopkins
Brooklyn Center
Rogers
Mound
Golden Valley
St. Louis Park
Richfield
Crystal
Champlin
Shorewood
Brooklyn Park
Greenfield
Minnetonka
Independence
Edina
Eden Prairie
Minnetrista
Bloomington
HassanDayton
MedinaPlymouth
Corcoran
Orono
Minneapolis
NokomisSouthwest
Northeast
Camden
University
Longfellow
Central
Near-North
Calhoun-Isles
Powderhorn
Phillips
Maple Grove
MinnetonkaBeach
GreenwoodTonka Bay
Osseo
Robbins-dale
Fort SnellingChanhassen
Medicine Lake
Rockford
Loretto
SpringPark
Woodland
ExcelsiorSt. Bonifacius
Long Lake
Maple Plain
St.Anthony
Deephaven
Hanover
Wayzata
New Hope
Hopkins
Brooklyn Center
Rogers
Mound
Golden Valley
St. Louis Park
Richfield
Crystal
Champlin
Shorewood
Brooklyn Park
Greenfield
Minnetonka
Independence
Edina
Eden Prairie
Minnetrista
Bloomington
HassanDayton
MedinaPlymouth
Corcoran
Orono
Minneapolis
High End (Assumes that All ChildrenWho Are Not In ImmuLink ARE
Up To Date With Immunizations)
Low End (Assumes that All ChildrenWho Are Not In ImmuLink Are NOTUp To Date With Immunizations)
(Potential) Range of Immunization Up To Date Percentages in the Population of ChildrenAge 24-35 Months, Based on ImmuLink Up To Date Records (as of September 1, 2002)
Hennepin County
2 0 2 4 Miles
N
EW
S
Source: U.S. Census, 2000; Hennepin County Community Health Department, ImmuLinkPrepared by: Hennepin County Community Health Department, 10/23/2002il_registry-conference.apr
(Potential) Percentageof Children Age 24-35Months WhoseImmunizations areUp To Date
0% - 25%26% - 50%51% - 75%76% - 90%91% - 97%Insufficient datato calculate rate
City boundaries
Mpls Communityboundaries
Data Aggregated and Displayed by Hennepin County City and Minneapolis Community
Hennepin County Analysis
Dramatic differences in the picture depending on assumptions
Retrospective Survey Results show “High End” closer to reality
Hennepin County Analysis
When registry penetration is high, as in Minneapolis, analysis of patterns is more reliable
When registry penetration is low, analysis is less reliable
Hennepin County Analysis
Strong ImmuLink expansion in metro area continues
Additional Factors at Work
•Successful Outreach Program-Baby Tracks
Hennepin County Analysis
Baby Tracks - Outreach Program
•Focuses on high risk 0-2 year olds in 23 zip codes in Minneapolis and inner ring suburbs
•Personal reminders and incentives to parents to immunize their children
ConclusionsHow to identify pockets of under-immunization
Integrate your sources/tools • ImmuLink Registry
• 2000 Census Data
• CASA
• GIS
Analyze data for patterns Consider level of registry penetration Look further, e.g. targeted programs