Evaluating a Health Care Policy: Reversing the Decline in Childhood Immunization Rates

Evaluating a Health Care Policy: Reversing Childhood Immunization Decline

Introduction

Regular childhood immunizations are one of the most powerful public health interventions available to prevent communicable disease, disability, hospitalization, and early death.

The implementation of vaccination programmes in the United States has led to a significant reduction in the incidence of measles, mumps, rubella, pertussis, polio and varicella, and Talbird et al. (2022) estimated that the routine childhood vaccine prevented millions of disease cases and that the net health benefit could extend lifelong.

Despite this, vaccination rates among children have declined over the last several years, and there are disparities across race/ethnicity, household income, insurance status, and geography.

The situation as it is now is that the problem is not yet solved. Coverage rates differed by Vaccines for Children eligibility, race/ethnicity, poverty status, urbanicity, and jurisdiction among children born in 2021 and 2022, with several vaccines having lower coverage for Black and Hispanic children, children eligible for the federal free and reduced-price lunch program, and children in rural areas (Hill et al., 2026).

In 2025-2026, national kindergarten coverage for most of the required vaccines was nearly 92%, and national exemptions from one or more vaccines rose to 4.2% (Centers for Disease Control and Prevention [CDC], 2026a).

It examines Indiana's childhood immunization policy from legal, ethical, multicultural, and evidence-based perspectives. It evaluates three complementary options: improving access and financial support for immunization providers, strengthening school immunization requirements, improving reminders and tracking, and creating culturally and linguistically responsive community partnerships.

Each of the following items is measured by the 2024 CDC Program Evaluation Framework: implementation, outcomes, health equity, and room for improvement.

Policy Problem and Indiana Context

The policy issue is low or incomplete childhood immunization rates and inequitable access to immunization. There are factors involved in vaccine hesitancy, but it is just one of them. Families equally experience transportation barriers, lack of insurance, restricted clinic hours, lack of time for work to stop, language barriers, low health literacy, and fragmented medical records and access to primary care.

A policy focusing solely on parental attitudes is unlikely to identify these structural barriers. Indiana has certain immunizations required for school attendance. Those requirements are established by the Indiana Department of Health and monitored through the Indiana Department of Health's Children and Hoosiers Immunization Registry Program (CHIRP).

The state law acknowledges medical exemptions and written religious exemptions, but not a philosophical or personal-preference exemption. Schools use CHIRP to verify immunization information and to determine the percentage of students enrolled in the school who are immunized (Indiana Department of Education [IDOE] 2026; Indiana Department of Health [IDOH] 2026a).

Indiana's regulations strike a compromise between the protection of public health and parental rights and religious freedom. The moral argument for the mandate is primarily for beneficence, nonmaleficence, justice, and protection from preventable harm: vaccination helps to protect not only the child, but also those who are unable to receive certain vaccines or who may not have developed full immunity to them.

The concept of respect for autonomy still means that the voice of parents as participants in their child's health decisions must be considered. Fundamentally, good policy must be able to balance the prevention of disease against parental concerns, cultural beliefs, and even real medical contraindications.

Health Equity and Affected Populations

An assessment of childhood immunization policy should always focus on health equity. Families that are not fully vaccinated do not necessarily refuse to vaccinate. Social determinants of health are a factor in determining whether families have a practical opportunity to achieve vaccination recommendations and school requirements at all.

 One factor behind the difference is income and insurance. This pattern has also been seen among children on Medicaid or another nonprivate insurance coverage, children who are uninsured, and children who live below the federal poverty line (Hill et al., 2024); more recent data confirm that children in poverty and eligible for the Vaccines for Children program (VFC) are less likely to be vaccinated than their peers (Hill et al., 2026). In countries where programs eliminate direct vaccine costs, these gaps remain, indicating that barriers to access are not cost-related.

A second disparity is in terms of race and ethnicity. Black, Hispanic/Latino, and American Indian/Alaska Native children have lower levels of national surveillance coverage than White children for several vaccines. Hispanic children's coverage was 10.1 percentage points lower for rotavirus vaccination and 7.1 percentage points lower for the seven-vaccine series combined compared to children who were White for children born in 2021 and 2022 (Hill et al., 2026).

These disparities are not due to any characteristic of the groups but rather to access to care, insurance, language, trust, discrimination, socioeconomic factors, and unequal opportunities for preventive care.

A third difference is that of geography. Many rural children have fewer pediatricians, longer travel times, limited public transportation, and fewer available appointment slots, and CDC data indicate that they are less likely to receive many vaccines compared to those in metropolitan areas (Hill et al., 2024, 2026). Geographic access is most important where it is necessary for a person to be vaccinated, but there is no convenient service available.

A fourth level of language and culture. When vaccine information, exemption process, school notices, and catch-up schedules are only in English, families who speak languages other than English may find it difficult to follow. Real cultural competence is not just translation; it is getting the community to participate, identifying trusted health information sources, listening to concerns with respect, and delivering health education that is understandable and culturally relevant.

Evaluation Framework and Evaluation Types

The CDC Program Evaluation Framework 2024 is an evaluation tool that is suitable for a childhood immunization programme in Indiana that is based on scientific rigor and equity. It identifies six steps: Assess context, Describe the program, Focus evaluation questions and design, Gather credible evidence, Draw and support conclusions, Take action on findings, and outlines three cross-cutting actions: Engage collaboratively, Advance equity, Learn from and use insights. The pieces that matter for immunization work are the need for cooperation between families, providers, schools, public health departments, insurers and community groups to get the policy implemented well (Kidder et al., 2024).

It would be important to consider multiple types of evaluation rather than just relying on vaccination coverage as the only measure of evaluation. Prior to or early in implementation, formative evaluation would identify community needs, attitudes, spoken languages, access barriers and trusted methods for communication (surveys, listening sessions, etc.) so that families in a specific Indiana county can be shown where they are lagging before resources are allocated.

Process evaluation would determine if the policy is operating as designed, including the number of vaccination clinics conducted, the percentage of providers who join Vacunet, the percentage of families who receive reminders in their language, and the percentage of schools that submit information to CHIRP.

Outcome measures would determine the achievement of short and medium-term objectives - increased number of completed appointments, fewer missed vaccine opportunities, increased completion of age-appropriate vaccine series, and closing the racial, income, insurance, and geographic vaccine gap.

Vaccine-preventable disease rates, frequency of outbreaks, hospitalizations, school closures related to outbreaks, and closing of gaps between groups in vaccine coverage over time would be examined in the impact evaluation. Finally, summative assessment would consider the overall benefit of the policy after it has been in operation, taking into account its effectiveness, equity, costs, feasibility, unintended effects, stakeholder experience, and sustainability to determine what is to be retained, modified, extended, and abandoned.

Policy Alternative One: Expand Access and Reduce Financial and Administrative Barriers

The first option is enhanced federal and state funding for enhanced access to vaccination, provider participation, provider workforce capacity, and reimbursements. Indiana should build on relationships with vaccine providers, including pediatric practices, community health centers, school-based health programs, pharmacies (if appropriate based on age and vaccine rules), mobile clinics, and Vaccines for Children providers, and expand hours at clinics to evenings and weekends for parents who are unable to make traditional appointment times.

There is supporting evidence for this. The Community Preventive Services Task Force (CPSTF) suggests that multifaceted programs that create demand while improving access and provider systems, such as decreasing out-of-pocket costs, reminder/recall systems, home visiting for hard-to-reach populations, standing orders, and expanded vaccination access, are effective (CPSTF, 2015).

The advantage is that this approach tackles the structural inequities directly, rather than a blanket assumption that underimmunization is driven by parental refusal, which could be particularly beneficial for low-income families, Medicaid beneficiaries, people in rural areas, those who lack a reliable means of transportation, and parents who have inflexible work schedules.

There is a downside, though: It costs money to add reimbursement, mobile clinics, staffing, technology, transportation support, and longer clinic hours, and as staff members are added, they need to be trained, documented, stored, and monitored to maintain vaccine safety. Although existing immunization programs and enrollment in an immunization registry in Indiana already exist, CHIRP can help identify children who are due or overdue, making this an actual possibility.

Policy Alternative Two: Strengthen School Requirements and Reminder/Recall Systems

The second option maintains strong school immunization mandates and strengthens reminder and recall processes before entering school. Schools and health departments could identify and reach out to families months before the first day of school to remind them about missing vaccinations.

There is proof on each side of these two alternatives. A study of state immunization laws over 35 years revealed that policies focused on recommended immunization practices had higher MMR and DTaP coverage rates. In contrast, more comprehensive nonmedical exemptions had lower coverage rates (Shaw et al., 2018). The CPSTF concluded that client reminder and recall interventions increased vaccination coverage by a median of approximately 11 percentage points among the studies it reviewed (CPSTF, 2015).

This will increase completion numbers, identify children who are behind earlier and reduce the risk of preventable outbreaks in schools. It is limited by the fact that it can have the most adverse impact on those who face barriers to accessing care: If a child has not been immunized, but is ineligible to attend school because the child or their family has not been able to secure transportation, insurance, disability, language, or scheduling, this would create a barrier to school attendance that the policy is seeking to address.

Enforcement should always be coupled with guidance: families that are flagged as not compliant with the requirement should be provided with clear guidance, language support, information on no cost or reduced cost providers, catch up provisions, and referrals to accessible vaccination locations before any action is taken, and of course, any legitimate medical or religious exemption under Indiana law should continue to be addressed by the statute.

Policy Alternative Three: Culturally Responsive Community Partnerships

The third choice has a community-engagement approach that will be carried out statewide through a partnership of trusted health care providers, schools, faith-based organizations, community centers, culturally specific organizations, and parent representatives, but with each community receiving a local message rather than a single statewide campaign.

This is based on the premise that misinformation and mistrust do not necessarily translate to more facts. Community engagement should allow parents to have questions answered without being stereotyped or brushed aside. It should take into account their families' appreciation of health information, experience of health institutions, religious and cultural beliefs, trusted relationships and feeling respected by health professionals.

Materials should be available in languages commonly used and at health-literacy appropriate levels. This provides an alternative infrastructure to develop for Indiana's school immunization requirements rather than starting from scratch, as some resources are already available in Spanish, Haitian Creole, Hakha Chin, and Karen (IDOH, 2026b).

The primary advantage is an increased cultural responsiveness and possibly also enhanced trust between families and public health institutions, and a means of distinguishing between informational mistrust and logistical barriers. The downside to culturally tailored engagement is that it requires time, trained staff, community partnerships, and continual evaluation, and should not be considered a stand-alone access intervention; evidence supports a combination of community-based demand creation, access creation and provider system development (CPSTF, 2015).

Stakeholder Engagement

Parents and caregivers, pediatricians, nurses, pharmacists, school nurses, school administrators, local health departments, IDOH, Medicaid managed-care organizations (MCOs), community health centers, disability advocates, immigrant and refugee groups, rural communities, and representatives from racial and ethnic minority groups should be engaged throughout all three alternatives.

It is not enough for parents to be given information. They should be members of advisory councils, participate in focus groups, participate in formative research, and provide input to evaluation results. This type of interaction provides a better understanding to policymakers of why families are not being immunized in a timely manner, and ensures that policies do not inadvertently make things harder for those already struggling to access care.

Monitoring and Evaluation Plan

The overall goal is to increase childhood vaccination rates in Indiana at the age-appropriate rate to reduce disparities. A second outcome is to enhance the timely completion of vaccination without creating inequitable school exclusion and/or new barriers to education. Various items should be monitored.

Examples of coverage indicators would be a percent of children who have completed age-appropriate vaccinations, such as the kindergarten MMR, DTaP, polio, hepatitis and varicella requirements. Equity indicators would be disaggregated by race and ethnicity, insurance type, Medicaid coverage, community socioeconomic measures available, rural vs. urban, preferred language, and county. Access indicators would include provider availability, travel distance (where applicable), appointment wait time, participation in vaccines for children, clinic hours, and missed vaccination opportunities.

Process indicators would show the percentage of overdue children receiving reminders, the percentage of children attending mobile and/or community vaccination clinics, the percentage of community organizations participating, and the percentage of educational encounters provided in languages other than English. Qualitative would capture parents' experiences, parents' perceptions of trust, satisfaction with communication, providers' experiences, reasons for delay, and family barriers reported.

The data would come from CHIRP, school immunization data, Medicaid claims, Vaccines for Children program data, CDC surveillance data, local health department records, provider electronic health records, surveys, focus groups and community listening sessions. Quantitative analysis should include rate comparisons before and after implementation, and for demographic groups and counties.

It should include rate differences and rate ratios to determine whether the differences were narrowing or widening over time, and if they are narrowing, whether the changes are statistically significant. Thematic analysis should be used to identify themes and patterns in the qualitative data that highlight common barriers, concerns, and implementation "snags."

Findings from formative and process evaluations should be reviewed during implementation to enable prompt adjustments to programs. It could be done annually for outcome measures, and over several years for impact measures, as the incidence and outbreak of diseases vary. After approximately 3-5 years, a summative review could provide a snapshot of coverage, equity, disease outcomes, cost, stakeholder feedback, and implementation.

Related Paper: Ethical Health Promotion: Medical Misinformation, Patient Autonomy, and the Role of Nurses

Conclusion

The failure of children to be immunized against preventable diseases is a public health issue and a problem in health equity. Immunization policies in Indiana can help keep children and communities safe from vaccine-preventable diseases. However, they cannot address disparities that are caused by poverty, insurance coverage, rural challenges, language barriers, inadequate health care systems, and mistrust.

More than one lever is needed to respond to an evidence-based response. Increasing access to affordable, convenient vaccines eliminates structural barriers, pairing effective school vaccine requirements with reminder systems increases timely completion, and culturally responsive partnerships increase communication and community buy-in. To be successful, all three require the full engagement of the populations that they are meant to serve. The CDC Program Evaluation Framework is a useful tool for assessing these approaches as it incorporates principles of stakeholder engagement, equity, strong evidence, transparency of approach, and ongoing application of evaluation results.

A higher overall vaccination rate for Indiana is not the only measure of success for a policy, but it is successful when disparities in rates of vaccination by race, socioeconomic status, geography, language, and insurance status diminish. Evidence-Based Public Health (EBPH), combined with cultural competence and equitable access, provides Indiana with a chance at reducing vaccine-preventable disease while honoring the spectrum of needs within the community and families of Indiana.