| Course | NU 655 Foundations of Public Health Nursing |
|---|---|
| Unit | Unit 3 |
| Paper type | Upstream cause trace |
| Length | About 1,020 words, 6 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | MSN Public Health Nursing |
| Updated | October 2026 |
Free sample paper for NU 655 Unit 3
Why 42% of a Rural County's Two-Year-Olds Are Behind on Vaccines: An Upstream Cause Trace From Missed Doses to Labor and Payment Policy
Student Name
Department of Nursing, Herzing University
NU 655: Foundations of Public Health Nursing
Instructor Name
February 5, 2026
Why 42% of a Rural County's Two-Year-Olds Are Behind on Vaccines: An Upstream Cause Trace From Missed Doses to Labor and Payment Policy
The Outcome and the Group
In a composite rural county, 58% of children born in 2022 had completed the combined 7-vaccine series by 24 months according to the state immunization registry, so about 42% had not. The registry figure overstates the gap somewhat, because some children who moved away remain on the county list. Even allowing for that, coverage is well below what the state's larger counties report. This trace asks why, link by link, and argues each link from the county's own data and from published evidence. The information comes from the registry, the state Medicaid quality report, interviews I conducted with 18 families at the WIC office, and conversations with staff at the county's two family medicine clinics.
Link 1: What Children Miss
Registry data show where children fall behind. At 7 months, about 80% of the county's children are up to date on the infant doses. The drop comes in the second year: the fourth DTaP dose, due at 15 to 18 months, is the dose most often missing, followed by the second-year doses of pneumococcal and hepatitis A vaccines. Children are not refusing vaccination in large numbers; they are falling behind at a particular age.
Link 2: Why They Miss Those Doses
The doses due in the second year are given at the 12-, 15-, and 18-month well-child visits. The state Medicaid report shows that only 51% of the county's continuously enrolled children completed the recommended schedule of at least six checkups before 15 months. When that fourth DTaP dose is missing, the cause may be a missed opportunity, a visit at which the vaccine was due but not given, or a missed visit. Research on incomplete series has found missed visits to be an important part of the explanation (Robison, 2013). In this county, clinic staff confirmed that when children come in, vaccines are almost always given at one clinic; at the other, discussed below, they often are not.
The immediate explanation, then, is that children are not coming to second-year visits, and at one clinic, not being vaccinated when they do.
Link 3: The Conditions That Make Missing Visits Sensible
The 18 families I interviewed gave consistent reasons. Distance and transport: 11 described driving 30 to 45 minutes to a clinic, and 6 had no reliable car or shared one with a working partner. Work: 12 parents worked hourly jobs, mostly at the county's two poultry processing plants and on farms, with fixed shifts and no paid sick leave, so a weekday appointment meant losing a half day's pay. Clinic hours: both family clinics keep weekday daytime hours only, opening at 8 a.m. and closing at 5 p.m. Insurance: 5 families had a gap in Medicaid coverage during their child's first two years, often after a missed renewal notice, and some delayed visits during the gap. Children with breaks in insurance coverage have been found to have lower vaccination coverage than continuously insured children (Smith et al., 2006). Only 3 of the 18 families expressed hesitancy about vaccines, and all three had older children who were fully vaccinated; their concerns were about the number of shots at one visit, which a clinician can address by discussion or by spacing doses across visits.
At one of the two family clinics, a separate condition operates: it is not enrolled in the federal program that supplies free vaccines for eligible children, so it refers Medicaid-enrolled children to the health department's monthly clinic for their shots. For families already struggling to make one trip, a second trip for vaccines often does not happen.
Link 4: What Set Those Conditions
Each condition has a cause above the family. The county has no pediatrician because the regional pediatric group closed its satellite office in 2019 and consolidated in the city 45 minutes away. Clinic hours reflect a primary care workforce stretched across a large area, with two physicians and three nurse practitioners serving the whole county. The clinic not enrolled in the vaccine program cited storage requirements, paperwork, and low payment for vaccine administration as reasons, which its manager described as unaffordable for a small practice. There is no public transit in the county. And the state does not require employers to provide paid sick leave, so for hourly workers, time for a child's appointment is unpaid.
Link 5: The Policies Beneath the Conditions
At the deepest level, the chain reaches decisions made in the state capital and in health systems: Medicaid payment rates for vaccine administration and well-child care; the design of Medicaid renewal, which produces coverage gaps; state labor law on paid leave; rural transportation funding; and the economics that lead health systems to close small rural offices. Public health writers call these the causes of the causes: circumstances fixed far from the clinic that decide who can reach it (Braveman & Gottlieb, 2014). None of them can be changed by the health department alone, but each can be informed by the county data the department holds.
The Chain, and Where a Public Health Nurse Can Act
The chain runs from a missing fourth dose, to missed second-year visits, to distance, work, clinic hours, and coverage gaps, to a thin rural workforce and one clinic outside the vaccine program, to state payment, renewal, and labor policy. A public health nurse can act at several links. At link 2: work with the non-enrolled clinic to join the vaccine program, which would end the second trip. At link 3: offer immunization clinics on a Saturday and one evening a month, and at the WIC office, where 60% of infants' families already come. At link 4: bring the data on distance and work schedules to the board of health and the regional health system. At link 5: provide county data to the state's Medicaid renewal and paid leave discussions, through the health department's formal channels. A plan that acts only at link 1, with reminder letters, would miss most of the causes this trace found.
References
Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206
Robison, S. G. (2013). Incomplete early childhood immunization series and missing fourth DTaP immunizations; missed opportunities or missed visits? ISRN Preventive Medicine, 2013, Article 351540. https://doi.org/10.5402/2013/351540
Smith, P. J., Stevenson, J., & Chu, S. Y. (2006). Associations between childhood vaccination coverage, insurance type, and breaks in health insurance coverage. Pediatrics, 117(6), 1972-1978. https://doi.org/10.1542/peds.2005-2414
The Herzing NU 655 Unit 3 instructions
Unit 3 asks you to trace a population health outcome to its upstream causes. Expect to define the outcome and population, then move step by step from the immediate cause to conditions, then to the decisions and policies behind them, supporting each link with evidence. Many versions ask you to use a social determinants framework or a causal diagram. Check how far upstream your section expects you to go; most want at least three levels. Local data, interviews or published research can support each link. The trace should end by identifying where a public health nurse can intervene, which may be several levels up from where the problem appears. Avoid stopping at family choices, since that misses the conditions that make missing visits sensible.
How this NU 655 Unit 3 example is built
The trace opens with the outcome and population, using registry figures. Each link is a section with a question and the evidence that answers it, so the chain is easy to follow. The first link uses registry timing to locate the gap. The second uses Medicaid visit data. The third draws on family interviews and reports reasons in counts. The fourth traces those conditions to decisions above the family, such as a clinic closure. The fifth reaches state payment and labor policy. The final section lays the chain out in one paragraph and marks where a public health nurse can act, from clinic hours to advocacy on Medicaid transportation. Each link cites evidence, which keeps the trace from becoming speculation.
NU 655 Unit 3 rubric: what full points look like
Herzing's rubric for an upstream trace generally covers the definition of the outcome, the causal links, evidence for each link, depth of analysis, identification of intervention points and writing. Causal links draw the closest reading, since each step must follow from the one before with evidence attached. Depth criteria reward tracing past individual behavior to conditions and policies. Evidence points go to local data, interviews or research that support each link specifically. Intervention points earn credit when the nurse's possible actions are matched to levels in the chain. Graders often fold a named determinants framework into the depth score. The APA 7 list should also include Robison's study of incomplete immunization and Smith on vaccine coverage disparities.
NU 655 Unit 3 help: mistakes that cost points
Upstream traces in Unit 3 most often lose points by stopping at the family level, such as parents not valuing vaccines. Another frequent problem is links asserted without evidence. Students often jump from the outcome straight to poverty without the steps in between. The trace becomes a list of determinants rather than a chain. Intervention points are missing, or limited to education. Interview findings are summarized vaguely instead of counted. Finally, end with where a public health nurse can act, because graders look for a trace that leads to action, and a chain that ends at state policy with no role for the nurse misses the purpose of the assignment.
Get a NU 655 Unit 3 example written to your instructions
Send the Unit 3 instructions and the rubric from your NU 655 classroom, and name the outcome and the population it should follow. We write a custom example with the behavioral layer recorded honestly, each descent justified by the question above it, and an action with an actor at every level. First custom sample free, delivered in 24 to 48 hours.
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NU 655 Unit 3 questions, answered
How far down should the trace go?
Until the next answer would be the same for every health outcome in the country. Once a layer explains everything, it has stopped explaining this. Three or four levels below the behavior is usually where the useful ground is, and saying why you stopped where you did is worth a sentence, because a reader can otherwise assume you ran out of evidence.
Does the trace need a named framework?
Use whichever the instructions point at, and if none is named, any recognized model of causes operating at different levels will hold the document together. Cite it and then use it, since the credit sits in the application. What weakens a trace is borrowing terms from two frameworks with different level definitions, which leaves a reader unsure what the middle of the chain represents.
Can environmental hazards sit in the middle layers?
They frequently belong there. Housing age, air quality, water systems, industrial neighbors and heat exposure all shape conditions of daily life, and they connect naturally to the arrangements above them. Treat them as evidence rather than as illustration: name the hazard, say who is exposed and how that exposure is distributed, and keep any measurement you did not take yourself properly attributed.
Where can I find a free NU 655 Unit 3 sample paper?
This page shows the whole NU 655 Unit 3 vaccine delay trace for free, all five links with evidence and where the nurse can act. A custom trace can follow a different outcome in your own population.
What is upstream thinking in public health nursing?
It means tracing a health problem past the individual to the conditions and policies that produce it. This sample traces late vaccines from missed doses to missed visits, then to long drives and hourly jobs, then to clinic closures and state policy.