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Immunization Coverage of Children in Care of the Child Welfare System in High-Income Countries: A Systematic Review

Open AccessPublished:December 04, 2018DOI:https://doi.org/10.1016/j.amepre.2018.07.026

      Context

      Children in care of the child welfare system tend to underutilize preventive health services compared with other children. The purpose of this systematic review was to assess current knowledge regarding immunization coverage levels for children in the child welfare system and to determine barriers and supports to them utilizing immunization services.

      Evidence acquisition

      Articles published in Medline, Embase, Cochrane Library, CINAHL, SocINDEX, and ERIC from January 1, 2000 to October 13, 2017 were searched. Thesis and conference databases and relevant websites were also examined. Studies were included if written in English, from high-income countries, and addressed immunizations for children in the child welfare system. Independent dual screening, extraction, and quality appraisal were conducted between October 2016 and December 2017, followed by narrative synthesis.

      Evidence synthesis

      Of 2,906 records identified, 33 met inclusion criteria: 21 studied coverage, two studied barriers/supports, and ten studied both. Nineteen studies were moderate or high quality and thus included in the narrative synthesis; 15 studied coverage, one studied barriers/supports, and three studied both. Most studies found lower coverage among children in child welfare. The few studies that explicitly studied barriers/supports to immunization identified that a collaborative and coordinated approach between health and social services was key to service delivery to this population.

      Conclusions

      This review highlights that children in care of the child welfare system are at risk of poor immunization coverage. There is a need for high-quality studies on this issue, with a focus on assessing supports/barriers to immunization in this population.

      CONTEXT

      The child welfare system offers supports and interventions to children and families when there is concern for the child's safety and well-being.

      Canadian Child Welfare Research Portal. Frequently Asked Questions (FAQs). http://cwrp.ca/faqs. Accessed October 17, 2017.

      Children in care of the child welfare system (“children in care”) may reside in various settings, including the family home and out-of-home care (e.g., foster care and kinship care). This population often has greater developmental, physical, and psychosocial needs than children not in care.
      • Bruskas D.
      Children in foster care: a vulnerable population at risk.
      • Zwi K
      • Joshua P
      • Moran P
      • White L
      Prioritizing vulnerable children: strategies to address inequity.
      Council on Foster Care, Adoption, and Kinship Care, Committee on Adolescence and Council on Early Childhood
      Health care issues for children and adolescents in foster care and kinship care.
      • Laurel LK
      • Gordon JN
      • Meneken L
      • Premji K
      • Michelmore KL
      • Ganger W
      The physical, developmental, and mental health needs of young children in child welfare by initial placement type.
      • McDavid LM
      Foster care and child health.
      Preventive health services are a key component of ensuring the well-being of all children, but children in care may face particular challenges in accessing preventive health care because of unstable living circumstances and inconsistent care providers.
      Council on Foster Care, Adoption, and Kinship Care, Committee on Adolescence and Council on Early Childhood
      Health care issues for children and adolescents in foster care and kinship care.
      This may be especially true for access to immunization services, as obtaining all the requisite vaccine doses to achieve adequate protection requires attendance at multiple appointments over a period of time.
      Given the critical role of immunizations in the protection of individual and public health,
      • Andre F
      • Booy R
      • Clemens J
      • et al.
      Vaccination greatly reduces disease, disability, death and inequity worldwide.
      it is important to understand whether disparities in immunization coverage are present in this vulnerable population. A recent review that focused on immunizations among children in care in the United Kingdom found that these children are less likely to be immunized than their counterparts.
      • Walton S
      • Bedford H
      Immunization of looked-after children and young people: a review of the literature.
      To understand the extent of the problem for children in care across all high-income countries, a systematic review was conducted to (1) assess the state of knowledge regarding vaccine coverage and barriers/supports to immunization for routine childhood vaccines in high-income countries (as defined by the World Bank

      World Bank. World Bank country and lending groups historical classification by country. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519. Accessed July 21, 2016.

      ), and (2) synthesize the literature to identify trends in coverage, barriers, and supports, in order to guide future policy and practice recommendations.

      EVIDENCE ACQUISITION

      This systematic review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines
      • Moher D
      • Liberati A
      • Tetzlaff J
      • et al.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      and was guided by a published protocol
      • Hermann JS
      • Featherstone RM
      • Russell ML
      • MacDonald SE
      Immunisation coverage of children in the child welfare system: a systematic review protocol.
      that was registered with PROSPERO (CRD42016047319). A brief summary of the methods and analysis plan are provided below. The detailed protocol, including search terms, can be found in the published protocol.
      • Hermann JS
      • Featherstone RM
      • Russell ML
      • MacDonald SE
      Immunisation coverage of children in the child welfare system: a systematic review protocol.
      No ethics approval was necessary for this study.
      This search sought out published and unpublished, English language, original research of any study design produced between January 1, 2000 and October 13, 2017. Published peer-reviewed articles indexed in MEDLINE, Embase, Wiley Cochrane Library, CINAHL, SocINDEX, or ERIC were searched, as well as unpublished works through searches of Conference Proceedings Citation Indices, and websites of key international, national, and provincial organizations in high-income countries. The reference lists of included studies were also searched for additional eligible articles. Articles were screened for inclusion in two stages, titles and abstracts followed by full-text review. Both stages were conducted in duplicate by two reviewers. Discrepancies in screening decisions were resolved through discussion, or adjudication by a third reviewer if necessary. To be included articles needed to meet the following criteria: (1) assess coverage, barriers, and/or supports for routine immunizations for children receiving child welfare services of any kind; (2) focus on children aged ≤17 years; and (3) be based in a high-income country, as defined by the World Bank.

      World Bank. World Bank country and lending groups historical classification by country. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519. Accessed July 21, 2016.

      For the purpose of this review, immunization coverage is the proportion of eligible children in the study population who received the vaccines being studied. Routine immunizations were based on the recommended immunization schedule from the study setting, as defined by the author. Duplicate data extraction of relevant content was conducted by two team members. Variables that were extracted are listed in the published protocol.
      • Hermann JS
      • Featherstone RM
      • Russell ML
      • MacDonald SE
      Immunisation coverage of children in the child welfare system: a systematic review protocol.
      Study authors were contacted by e-mail to seek any relevant information missing from the publication.
      Quality/risk of bias was assessed for each included study using tools specific to the study design (Newcastle-Ottawa Scale
      • Wells GA
      • Shea B
      • O'Connell D
      • et al.
      Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.
      for case-control and cohort studies, adapted Newcastle-Ottawa Scale for cross-sectional studies,

      Newcastle-Ottawa Scale adapted for cross-sectional studies. http://journals.plos.org/plosone/article/file?type=supplementary&id=info:doi/10.1371/journal.pone.0199413.s003. Accessed August 3, 2018.

      and Mixed Methods Appraisal Tool
      • Pluye P
      • Robert E
      • Cargo M
      • et al.
      for qualitative and mixed-method studies). To produce a standardized measure of quality appraisal, regardless of the tool used, the numerator was divided by the denominator. Quality assessments were conducted in duplicate, with discrepancies resolved through discussion or adjudication by a third reviewer, if necessary. When missing data were obtained from study authors, the quality assessment score was revised to reflect the quality of the study (versus the quality of reporting). Publication bias was assessed by including a grey literature search for unpublished works in the field.
      The search and screening results were presented per PRISMA guidelines. The characteristics and findings of all included studies were reported in tabular format. Only the findings from moderate- and high-quality studies were analyzed through narrative synthesis. The outcomes (coverage and barriers/supports) were assessed relative to data source, publication type, and presence/absence of comparison group. For the purpose of synthesis, studies that did not have a comparison group were divided into two groups based on calculated coverage levels for children in care: ≥80% vs <80%. This cut off was chosen based on WHO statements that 80% is considered “high immunization coverage”
      WHO
      Immunization in Practice: A Practical Guide for Health Staff—2015 Updated.
      and is the target minimum coverage for children aged <5 years in each district in a nation.
      WHO, UNICEF, World Bank
      State of the World's Vaccines and Immunization.
      Identified barriers and supports, including the effectiveness of interventions, were described.

      EVIDENCE SYNTHESIS

      There were 33 studies that met inclusion criteria (Figure 1). Of these, 21 measured immunization coverage,
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Anderson L
      • Vostanis P
      • Spencer N
      The health needs of children aged 6–12 years in foster care.
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      • Kling S
      • Vinnerljung B
      • Hjern A
      Somatic assessments of 120 Swedish children taken into care reveal large unmet health and dental care needs.
      • Nathanson D
      • Tzioumi D
      Health needs of Australian children living in out-of-home care.
      National Statistics
      Statistical First Release: Outcomes for children looked after by Local Authorities in England, as at 31 March 2014.
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      ten studied both coverage and barriers/supports to immunization,
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      • Ensign J
      The health of shelter-based foster youth.
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      • Rodrigues VC
      Health of children looked after by the local authorities.
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      and two studied only barriers/supports.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      • Goff ELS.
      Addressing Immunization Rates in Foster Care Youth 0–18 Years Old [dissertation].
      The heterogeneity in the study design, data sources, inclusion of comparison group, type of care settings, and period of time children were in care precluded meta-analysis of results. Instead, a narrative synthesis of the findings is presented.
      Figure 1.
      Figure 1PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
      QA, quality appraisal.

      Characteristics of Studies

      The characteristics of included studies are presented in Appendix Table 1, (available online). The studies primarily came from the United Kingdom (n=15),
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      ,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      ,
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Anderson L
      • Vostanis P
      • Spencer N
      The health needs of children aged 6–12 years in foster care.
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      ,
      National Statistics
      Statistical First Release: Outcomes for children looked after by Local Authorities in England, as at 31 March 2014.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ,
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      ,
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      • Rodrigues VC
      Health of children looked after by the local authorities.
      the U.S. (n=9),
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      ,
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ,
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      ,
      • Ensign J
      The health of shelter-based foster youth.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      ,
      • Goff ELS.
      Addressing Immunization Rates in Foster Care Youth 0–18 Years Old [dissertation].
      and Australia (n=6),
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      ,
      • Nathanson D
      • Tzioumi D
      Health needs of Australian children living in out-of-home care.
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      ,
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      with a smaller number from Italy (n=1),
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      and Sweden (n=2).
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Kling S
      • Vinnerljung B
      • Hjern A
      Somatic assessments of 120 Swedish children taken into care reveal large unmet health and dental care needs.
      They included 29 peer-reviewed journal publications, three government reports, and one thesis. Study designs included cross-sectional (n=22),
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      ,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      ,
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Anderson L
      • Vostanis P
      • Spencer N
      The health needs of children aged 6–12 years in foster care.
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      • Kling S
      • Vinnerljung B
      • Hjern A
      Somatic assessments of 120 Swedish children taken into care reveal large unmet health and dental care needs.
      • Nathanson D
      • Tzioumi D
      Health needs of Australian children living in out-of-home care.
      National Statistics
      Statistical First Release: Outcomes for children looked after by Local Authorities in England, as at 31 March 2014.
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      ,
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      ,
      • Goff ELS.
      Addressing Immunization Rates in Foster Care Youth 0–18 Years Old [dissertation].
      case-control (n=1),
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      prospective and retrospective cohort (n=2),
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      retrospective cohort with pre-/post-intervention assessments (n=3),
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      ,
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      mixed methods (n=3),
      • Ensign J
      The health of shelter-based foster youth.
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      ,
      • Rodrigues VC
      Health of children looked after by the local authorities.
      mixed methods with pre-/post-intervention (n=1),
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      and qualitative (n=1).
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      A variety of data sources were used to determine immunization status of children, including caregiver or self-report (n=5),
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ,
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Anderson L
      • Vostanis P
      • Spencer N
      The health needs of children aged 6–12 years in foster care.
      ,
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      caregiver or self-held record (n=1),
      • Ensign J
      The health of shelter-based foster youth.
      child welfare data (n=6),
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      ,
      National Statistics
      Statistical First Release: Outcomes for children looked after by Local Authorities in England, as at 31 March 2014.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      ,
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      community health records (n=2),
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      electronic health database (n=5),
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      ,
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      ,
      • Rodrigues VC
      Health of children looked after by the local authorities.
      medical records (n=4),
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      ,
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Kling S
      • Vinnerljung B
      • Hjern A
      Somatic assessments of 120 Swedish children taken into care reveal large unmet health and dental care needs.
      electronic immunization databases (n=1),
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      and mixed data sources (n=7).
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      ,
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      • Nathanson D
      • Tzioumi D
      Health needs of Australian children living in out-of-home care.
      ,
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      ,
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      Very few studies (n=7)
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      ,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ,
      • Rodrigues VC
      Health of children looked after by the local authorities.
      reported on coverage for specific vaccines, whereas the remainder did not specify or reported more broadly on “age appropriate” or “recommended vaccines.”
      Terminology, setting, and time in care varied by study. Included studies used various terms to describe immunization coverage, such as “up-to-date immunizations,” “fully immunized,” or “incomplete immunizations.” In some cases, authors did not define these terms, making it unclear whether they meant that the child had received all age-appropriate immunizations and whether these terms encompassed timeliness of immunization. Authors from different countries used different terminology for children in care (e.g., “looked-after children” is typically used in the United Kingdom, “out-of-home care” is more common in Australia, and “foster care” is common in the U.S. and the United Kingdom). It was not always clear from the article whether these terms captured comparable types of care status, especially as many studies also used specific terms (e.g., foster care and kinship care) to identify subsets of children in care. Some studies specified that they studied children in more than one type of care setting (e.g., foster care, residential care), whereas others did not describe the type of care setting beyond the broad terms of looked-after or out-of-home care. Four studies compared coverage between groups of children in different care settings within the child welfare system.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      ,
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      The majority of studies (n=15)
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      ,
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      ,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ,
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      ,
      • Ensign J
      The health of shelter-based foster youth.
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      ,
      • Rodrigues VC
      Health of children looked after by the local authorities.
      did not describe how long the children had been in care before the study period, whereas others included children who had been in care varying lengths of time (n=4).
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Anderson L
      • Vostanis P
      • Spencer N
      The health needs of children aged 6–12 years in foster care.
      ,
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      • Nathanson D
      • Tzioumi D
      Health needs of Australian children living in out-of-home care.
      Others studies looked at more defined periods of time in care, including in care ≥3 months (n=1),
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      ≥6 months (n=2),
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      or ≥12 months (n=2).
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      National Statistics
      Statistical First Release: Outcomes for children looked after by Local Authorities in England, as at 31 March 2014.
      Yet, others looked at children who had recently entered care (n=7),
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      ,
      • Kling S
      • Vinnerljung B
      • Hjern A
      Somatic assessments of 120 Swedish children taken into care reveal large unmet health and dental care needs.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      ,
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      ,
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      with two of these studies comparing coverage upon entry into care to coverage after children were established in care.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      Two of the studies assessing barriers/supports to immunization did not study any children in care, instead focusing on nurses
      • Goff ELS.
      Addressing Immunization Rates in Foster Care Youth 0–18 Years Old [dissertation].
      or foster caregivers.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      Fourteen of the included studies were of low quality (score <0.50),
      • Anderson L
      • Vostanis P
      • Spencer N
      The health needs of children aged 6–12 years in foster care.
      • Bundle A.
      Health of teenagers in residential care: comparison of data held by care staff with data in community child health records.
      • Kling S
      • Vinnerljung B
      • Hjern A
      Somatic assessments of 120 Swedish children taken into care reveal large unmet health and dental care needs.
      • Nathanson D
      • Tzioumi D
      Health needs of Australian children living in out-of-home care.
      National Statistics
      Statistical First Release: Outcomes for children looked after by Local Authorities in England, as at 31 March 2014.
      • Stein REK
      • Hurlburt MS
      • Heneghan AM
      • et al.
      Health status and type of out-of-home placement: informal kinship care in an investigated sample.
      ,
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      • Ensign J
      The health of shelter-based foster youth.
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      • Rodrigues VC
      Health of children looked after by the local authorities.
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      ,
      • Goff ELS.
      Addressing Immunization Rates in Foster Care Youth 0–18 Years Old [dissertation].
      12 were moderate quality (score ≥0.50 to <0.75),
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      ,
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      ,
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      and seven were high quality (≥0.75).
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      ,
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      ,
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      The most common reasons for a study being assessed as low quality were lack of a comparison group or the study not being focused specifically on immunization (i.e., it focused more broadly on child health and thus lacked the necessary information specific to immunization, even after follow-up with authors). In order to ensure that recommendations for policy and practice are guided by the best evidence available, the findings of only moderate- and high-quality studies were synthesized and presented.

      Immunization Coverage

      Appendix Table 2 (available online) presents the study findings from all articles, with moderate- and high-quality studies presented first. Of the 31 studies that measured immunization coverage, 18 were moderate or high quality.
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      ,
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      Of these, ten had a comparison group
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      ,
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ,
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      of the general population or children not in care. Nine of these found children in the child welfare system to have lower coverage than other children
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      ,
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      and one found higher coverage.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      Of the other eight studies (including all the government reports
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      ) that did not have a comparison group of children in the general population or not in care, the majority (n=5) found ≥80% immunization coverage among children in the child welfare system
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      ,
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      ,
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ; the remaining three found <80% coverage.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      ,
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      Of these eight studies without a comparison group, three compared immunization coverage between groups of children in care by type of care setting.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      ,
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      One of these found no statistical difference in immunization coverage between those in foster care and parental care
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      and another found no significant difference in immunization coverage between foster care and kinship care.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      The third study found that children living in the parental home were significantly less likely to be immunized than those in kinship care, foster homes, and residential care, though the difference in coverage was minimal.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      Studies that reported immunization coverage by age found that older children in care were less likely to have received the recommended immunizations for their age than younger children.
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      ,
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      Of the five high-quality studies that reported coverage for specific vaccines, the vaccines assessed included: diphtheria, tetanus, pertussis, and polio
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      ,
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ; Haemophilus influenzae type b
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ; pneumococcal
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      ; meningococcal
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      ; tuberculosis
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ; varicella
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      ; and measles, mumps, and rubella.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      ,
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      All five studies had a comparison group or comparable data from the general population, and all were published in the United Kingdom between 2003 and 2005, except for one
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      that was published in Italy in 2016. The vaccines most consistently assessed in these five studies were diphtheria, tetanus, pertussis, and polio (coverage of 80%–91% among children in care compared with 95%–100% for children in the comparison group/general population) and measles, mumps, and rubella (coverage of 75%–87% compared with 80%–100% for children in the comparison group/general population). Vaccine coverage for children in care was consistently lower than the comparison group/general population, with only one exception (in which measles, mumps, and rubella coverage was the same in both groups).
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.

      Immunization Barriers and Supports

      Of the 12 studies that assessed barriers/supports to immunization,
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      • Ensign J
      The health of shelter-based foster youth.
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      • Kaltner M
      • Rissel K
      Health of Australian children in out-of-home care: needs and carer recognition.
      • Raman S
      • Reynolds S
      • Khan R
      Addressing the well-being of Aboriginal children in out-of-home care: are we there yet.
      • Rodrigues VC
      Health of children looked after by the local authorities.
      • Tremellen S
      • Van Doorn H
      General practice: role and experience as providers of comprehensive health assessment for children and young people in out-of-home care.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      • Goff ELS.
      Addressing Immunization Rates in Foster Care Youth 0–18 Years Old [dissertation].
      only four were of moderate or high quality.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      ,
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      Of these, three studies identified barriers/supports that arose during specific program evaluations
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      or interventions
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      aimed at improving immunization services to children in care. Only one was a qualitative study, which conducted interviews of foster caregivers to identify barriers and supports to accessing immunization services.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      Of the few moderate-/high-quality studies that explicitly studied barriers/supports to immunization, a common barrier identified was discontinuity of care (n=3).
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      Placement moves and changes in social workers were factors identified as contributing to this issue (n=1).
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      Other identified barriers were the needs of children being seen as someone else's responsibility (n=1)
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      and lack of coordinated care (n=1).
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      One study found, contrary to the authors’ expectation, that identifying missing vaccines to social services did not bring children up-to-date in their immunizations.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      Incomplete or lack of immunization history was also identified as a barrier (n=1).
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      Interviews with foster caregivers found that forgetting appointments and hectic home lives were barriers to attending medical appointments.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      Identified supports included services designed to improve continuity of care, such as a specialized nursing service
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      and an Expanded Medical Home Model.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      These programs were found to be successful in improving immunization status for children in care, as they addressed inter-agency partnership and a lack of coordinated care. Foster caregivers stated that they were more likely to bring children to medical appointments when they had a positive healthcare experience, had a system in place for remembering appointments, and viewed the appointment as necessary.
      • Schneiderman JU
      • Kennedy AK
      • Sayegh CS
      Qualitative study of foster caregivers’ views on adherence to pediatric appointments.
      There were additional studies that did not explicitly study barriers/supports, but noted them based on the study context and experiences.
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      ,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      These suggest barriers to immunization included: a lack of coordination and communication,
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      discontinuity of care,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      poor record keeping,
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      ,
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      greater number of placement moves,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      and social workers not prioritizing medical needs of children.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.

      DISCUSSION

      This systematic review identified 19 moderate- or high-quality studies that focused on immunization coverage and barriers and supports to immunization for children in care. There was much variability in the study design, data sources, inclusion of comparison group, type of care settings, and period of time children were in care. The majority (n=12) of moderate-/high-quality studies found that immunization coverage among children in care was less than 80% (when no comparison group) or less than children not in care.
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      ,
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      ,
      • Snow L
      • Lorek A
      Is this looked after child fully immunised? A comparison of records and the development of an immunisation look-up tool.
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      ,
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      Few studies explicitly studied barriers and supports to immunization. Of those that did, discontinuity of care
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      was the most common barrier identified, and programs that support collaboration and coordination were found to promote immunization coverage.

      Immunization Coverage for Children in Care

      Influence of placement type on immunization status. Most studies did not clearly describe the type of care settings. In addition, the variability of terms used for children in care across countries made it difficult to assume that study populations were comparable. For those studies that did explicitly identify care placement, there was no apparent association between type of care and children's immunization coverage. A small subset of studies
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      ,
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      compared immunization coverage among different types of care settings. One of these found that children living at home with their parents were less likely to be immunized than those in formal/informal kinship care or foster care/group homes.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      However, immunization status in that study was self-reported, and though a statistically significant result was found, the small difference likely lacked clinical significance. Two smaller studies found no statistically significant differences in coverage for different types of care setting,
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      although the small sample sizes may have limited the power to find existing differences. Further research with larger sample sizes and reliable sources of immunization data is needed to identify whether specific placement types influence immunization coverage.
      Influence of time in care on immunization status. One might anticipate that immunization coverage increases with amount of time children spend in care, as the welfare system could intervene to improve care to this vulnerable population. However, there is no evidence to support this hypothesis. In fact, most (n=11) of the moderate-/high-quality studies did not even report time in care for their study population.
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      ,
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      ,
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Morritt J.
      The health needs of children in public care: the results of an audit of immunizations of children in care.
      ,
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ,
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      Of note, two low-quality studies looked at statutory assessments that occur once a child is in care and their impact on immunization coverage among a small sample of children, and neither found a significant increase in coverage.
      • Croft G
      Implementation of health recommendations after initial statutory health assessment.
      • Hill CM
      • Watkins J
      Statutory health assessments for looked-after children: what do they achieve.
      It would be important in future research to look at immunization at the time children are taken into care and compare this to immunization coverage once the child is established in care. This would discern whether the contributors to low coverage are a result of circumstances prior to entry in care or due to a failure of the welfare system to improve immunization service delivery.
      Influence of study design and data sources on validity of study findings. Although characteristics of children in care (e.g., placement type and time in care) may influence actual immunization coverage, other attributes of the study itself (e.g., data sources and study design) may influence the validity of immunization coverage measurement. For instance, the level/adequacy of immunization coverage appeared to be related to the immunization data sources used, suggesting that data source may introduce some bias in measurement and thus influence validity of study findings. For instance, of studies that used health records, medical records, immunization databases, or health databases (n=10),
      • Barnes P
      • Price L
      • Maddocks A
      • et al.
      Immunisation status in the public care system: a comparative study.
      ,
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Ferrara P
      • Fabrizio GC
      • Romani L
      • et al.
      Immunization status of children in foster homes: the first Italian data.
      • Hansen RL
      • Lakhan Mawjee F
      • Barton K
      • Metcal MB
      • Joye NR
      Comparing the health status of low-income children in and out of foster care.
      • Henderson JW
      • Arbor SA
      • Broich SL
      • Peterson JM
      • Hutchinson JE
      Immunization initiation among infants in the Oregon Health Plan.
      • Hill CM
      • Mather M
      • Goddard J
      Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home.
      • Köhler M
      • Emmelin M
      • Hjern A
      • Rosvall M
      Children in family foster care have greater health risks and less involvement in Child Health Services.
      ,
      • Raman S
      • Sahu S
      Health, developmental and support needs of vulnerable children—comparing children in foster care and children in need.
      • Ashton-Key M
      • Jorge E
      Does providing social services with information and advice on immunisation status of “looked after children” improve uptake?.
      ,
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      all but two
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      found coverage was lower among children in care (n=7) or less than 80% (when there was no comparison group; n=1). The two exceptions looked at groups of children who may experience higher coverage than other children in care: those considered for adoption
      • Colver AF
      • Gale C
      • Appleby L
      Health of children considered for adoption.
      and those participating in an Expanded Medical Home Model.
      • Jaudes PK
      • Champagne V
      • Harden A
      • Masterson J
      • Bilaver LA
      Expanded Medical Home Model works for children in foster care.
      By contrast, two of the three studies
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ,
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      that obtained immunization data from caregiver- or self-report
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.
      ,
      • Williams J
      • Jackson S
      • Maddocks A
      • Cheung W
      • Love A
      • Hutchings H
      Case–control study of the health of those looked after by local authorities.
      and two of the three studies
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      ,
      • Hunter D
      • McCartney G
      • Fleming S
      • Guy F
      Improving the health of looked after children in Scotland: 1. Using a specialist nursing service to improve the health care of children in residential accommodation.
      that used data from child welfare found immunization coverage of 80% or more.
      • Arora N
      • Kaltner M
      • Williams J
      Health needs of regional Australian children in out-of-home care.
      • Casanueva C
      • Stambaugh L
      • Tueller S
      • et al.
      NSCAW II Wave 2 report: Children's Services. OPRE Report #2012-59, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, HHS; 2012.
      ,
      • Rodgers H
      • Waugh I
      for Department of Health
      Children in Care in Northern Ireland 2014–15: Statistical Bulletin.
      • Sakai C
      • Lin H
      • Flores G
      Health outcomes and family services in kinship care.