Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics

Background: Controlling vaccine-preventable diseases by achieving high chil dhood vaccination coverage levels is a national priority. However, there ar e few, if any. comprehensive evaluations of state immunization programs in the United Slates, and little attention has been given to the importance of vaccination clinic management style and staff motivation. Objective: To evaluate the factors associated with the increase in childhoo d vaccination coverage levels from 53% in 1988 to 89% in 1994 in Georgia's public health clinics. Design: A 1993 mail survey obtaining information on clinic vaccination poli cies and practices and management practices. Setting: All 227 public health clinics in Georgia. Participants: Clinic nurses responsible for vaccination services. Outcome Measure: The 1994 clinic-specific coverage level for 21- to 23-mont h-old children for 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of polio vaccine, and 1 dose of a measles-containing vacci ne as determined by an independent stale assessment of clinic coverage leve ls. Results: Univariate analysis showed that higher coverage levels were signif icantly (P<.05) associated with smaller clinic size, higher proportions of clientele enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), being a nonurban clinic, and numerous vaccina tion practices and policies. Multivariable analysis showed that only 8 of g reater than 150 factors remained associated with higher coverage levels, in cluding having no waiting time to be seen, having telephone reminder system s, conducting home visits for defaulters, and restricting WIC vouchers when a child was undervaccinated. Motivational factors related to higher covera ge included clinic lead nurses receiving an incentive to raise coverage and lead nurses participating in assessments of clinic coverage levels by stat e immunization staff. Conclusions: No single factor is responsible for raising vaccination covera ge levels. Efforts to improve coverage should include local assessment to p rovide feedback on performance and identify appropriate local solutions. Co ordinating with WIC, conducting recall and reminder activities, motivating clinic staff, and having staff participate in decisions are important in ra ising vaccination levels.