Barriers to immunization and missed opportunities

Exploring childhood immunization uptake with First Nations mothers in north-western Ontario, Canada

BACKGROUND

Childhood immunization is an important component of preventive health care for young children. Successful control of vaccine-preventable diseases depends on high levels of immunization coverage. Immunization statistics show that on-reserve First Nations (Native Indian) children have lower vaccination coverage than children in the general Canadian population. There has been little research, however, conducted with First Nations populations on this topic.

AIM OF THE STUDY

This study explored First Nations parents' beliefs about childhood immunizations and examined factors influencing immunization uptake.

METHODS

This study used a qualitative descriptive design to explore the issue of childhood immunization uptake. Twenty-eight mothers from two First Nations communities in north-western Ontario, Canada, were interviewed about their perceptions of childhood immunizations and vaccine-preventable diseases. The interviews were transcribed and content analysis was used to examine the data.

FINDINGS

Data analysis revealed the following six themes: (1) the fear of disease; (2) the efficacy of immunizations; (3) the immunization experience; (4) the consequences of immunization; (5) interactions with health professionals; and (6) barriers to immunizations. Participants were motivated to seek immunizations for their children by a fear of vaccine preventable diseases. A small proportion of mothers, however, questioned the effectiveness of vaccines in preventing disease. Traumatic immunization experiences, vaccine side-effects and sequelae, negative interactions with health professionals, and barriers such as time constraints and childhood illnesses all served as deterrents to immunization.

CONCLUSIONS

The research outcomes highlight the varied beliefs of First Nations parents about childhood immunizations and the numerous factors that both positively and negatively influence immunization uptake. Further research is needed to explore the issue of childhood immunizations in First Nations communities and to determine strategies to improve uptake.

Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices

CONTEXT

An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations. Disparities in US childhood immunization rates persist, with inner-city, black, and Hispanic children having lower rates. Although practice or clinic-based interventions, such as patient reminder/recall systems, have been found to improve immunization rates in specific settings, there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level.

OBJECTIVE

To assess the effect of a community-wide reminder, recall, and outreach (RRO) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban populations and among white, black, and Hispanic children within an entire county.

SETTING

Monroe County, New York (birth cohort: 10 000, total population: 750 000), which includes the city of Rochester. Three geographic regions within the county were compared: the inner city of Rochester, which contains the greatest concentration of poverty (among 2-year-old children, 64% have Medicaid); the rest of the city of Rochester (38% have Medicaid); and the suburbs of the county (8% have Medicaid).

INTERVENTIONS

An RRO system was implemented in 8 city practices in 1995 (covering 64% of inner-city children) and was expanded to 10 city practices by 1999 (covering 74% of inner-city children, 61% of rest-of-city children, and 9% of suburban children). The RRO intervention involved lay community-based outreach workers who were assigned to city practices to track immunization rates of all 0- to 2-year-olds, and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations (tracking for all children, mail, or telephone reminders for most children, assistance with transportation or scheduling for some children, and home visits for 5% of children who were most behind in immunizations and who faced complex barriers).

STUDY PARTICIPANTS

Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993, 1996, and 1999.

STUDY DESIGN

Immunization rates were measured for each geographic region in Monroe County at 3 time periods: before the implementation of a systematic RRO system (1993), during early phases of implementation of the RRO system (1996), and after implementation of the RRO system in 10 city practices (1999). Immunization rates were compared for children living in the 3 geographic regions, and for white, black, and Hispanic children. Immunization rates were measured by the same methodology in each of the 3 time periods. A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practices in the county (covering 85% to 89% of county children). A random sample of children (>500 from the suburbs and >1200 from the city for each sampling period) was then selected for medical chart review at practices to determine demographic characteristics (including race and ethnicity) and immunization rates. City children were oversampled to allow detection of effects by geographic region and race. Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling.

MAIN OUTCOME MEASURES

Immunization rates at 12 and 24 months for recommended vaccines (4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella: > or =1 Haemophilus influenzae type b on or after 12 months of age).

RESULTS

DISPARITIES BY GEOGRAPHIC REGION: Baseline immunization rates (1993) for 24-month-olds were as follows: inner city (55%), rest of city (64%), and suburbs (73%), with an 18% difference in rates between the inner city and suburbs. By 1996, immunization rates rose faster in the inner city (+21% points) than in the suburbs (+14% points) so that the difference in rates between the inner city and suburbs had narrowed to 11%. In 1999, rates were similar across geographic regions: inner city (84%), rest of city (81%), and suburbs (88%), with a 4% difference between the inner city and suburbs. DISPARITIES BY RACE AND ETHNICITY: Immunization rates were available in 1996 and 1999 by race and ethnicity. Twenty-four-month immunization rates in 1996 showed disparities: white (89%), black (76%), and Hispanic (74%), with a 13% difference between rates for white and black children and a 15% difference between white and Hispanic children. In 1999, rates were similar across the groups: white (88%), black (81%), and Hispanic (87%), with a 7% difference between rates for white and black children, and a 1% difference between white and Hispanic children.

CONCLUSIONS

A community-wide intervention of patient RRO raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority populations. By targeting a relatively manageable number of primary care practices that serve city children and using an effective strategy to increase immunization rates in each practice, it is possible to eliminate disparities in immunizations for vulnerable children.

Provider-staff discrepancies in reported immunization knowledge and practices

BACKGROUND

The purpose of the study was to compare immunization-relevant knowledge, certainty about knowledge, self-efficacy, vested interest, and reported practices of providers and clinical staff in the same clinics.

METHODS

A valid and reliable instrument measuring the aforementioned issues was developed and administered to a sample of 50 providers and 60 members of the clinical staff.

RESULTS

Providers were significantly more knowledgeable than staff (P < 0.001); however, they were not more certain about their knowledge (P = 0.52) nor were they more confident in their capability to properly immunize all children in their practice (P = 0.10). Providers reported lower vested interest in immunizations than clinical staff (P < 0.05). Both groups were equally likely to immunize a child with a cold. Providers were less likely to defer needed immunizations for a 15-month-old child, and they were more likely to administer multiple injections to an 18-month-old (both P < 0.05). Providers were more likely than staff to immunize during acute and chronic illness visits (both P < 0.001), and both groups were equally likely to immunize during preventive visits.

CONCLUSIONS

Discrepancies in reported immunization practices between providers and staff may be a barrier to full immunization.

Visiting multiple sites for immunization and vaccine coverage levels of preschool children in 3 urban clinics: potential indicator of record scatter?

Record scatter is a clinic-level impediment to accurately reporting immunization coverage levels but may be attributed to certain patient characteristics. We determine the association between visiting multiple sites for immunization and underimmunization among urban clinic patients. After collecting immunization histories for patients aged 3-35 months, caregivers were surveyed by telephone. 159/483 caregivers (32.9%) were interviewed. Visiting > 2 sites for immunizations was associated with underimmunization, adjusted Odds Ratio (95% Confidence Interval)=2.7 (1.2-6.5). An interruption in health insurance showed a trend toward association with visiting > or = 2 sites. Our results support the need for working registries, clinic outreach, and continued evaluation of both.

Interventions aimed at improving immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached national goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g., all children who should receive the measles vaccine), and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g., patient reminders), provider interventions, and system interventions. One intervention strategy involves patient reminder/recall systems.

OBJECTIVES

Assess the effectiveness of patient reminder/recall systems in improving immunization rates, and compare the effects of various types of reminders in different settings or patient populations.

SEARCH STRATEGY

A systematic search was performed using MEDLINE (1966-1998) and 4 other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of EPOC in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts, and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings, and files of study collaborators were also searched for references.

STUDY DESIGN

Randomized controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series (ITS) studies written in English.

TYPES OF PARTICIPANTS

Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting. Types of interventions: Any intervention that falls within the Effective Practice and Organization of Care Group (EPOC) scope and that includes patient reminder and/or recall in at least one arm of the study. Types of outcome measures: Immunization rates, or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g., influenza vaccination) or standard combinations of recommended vaccinations (e.g., all recommended vaccinations by a specific date or age).

DATA COLLECTION

Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus.

ANALYSIS

Results are presented for individual studies as relative rates for randomized controlled trials, and as absolute changes in percentage points for controlled before and after studies. Pooled results were presented using the random effects model.

MAIN RESULTS

Patient reminder/recall systems were effective in improving immunization rates in 33 of 41 included studies, irrespective of baseline immunization rates, patient ages, type of setting, or type of vaccination. Increases in immunization rates due to reminders were in the range of 5 to 20 percentage points. Reminders were effective for childhood vaccinations (OR=2.02, 95% CI =1.49,2.72), childhood influenza vaccinations (OR=4.19, 95% CI =2.07,8.49), adult pneumococcus or tetanus (OR=5.14, 95%CI = 1.21, 21.8), and adult influenza vaccinations (OR=2.29, 95%CI = 1.69, 3.10). While reminders were most effective in academic settings (OR = 3.33, 95% CI = 1.98, 5.58), they were also highly effective in private practice settings (OR=1.79, 95% CI = 1.45, 2.22) and public health clinics (OR = 2.09, 95% CI = 1.42, 3.07). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but most costly.

REVIEWER'S CONCLUSIONS

Patient reminder/recall systems in primary care settings are effective in improving immunization rates.

The costs of registry-based immunization interventions

BACKGROUND

Part of the payoff of immunization registries may be to lower costs of immunization intervention. However, registry-based intervention costs have not been evaluated in a community setting.

METHODS

The purpose of this study was to prospectively measure the cost of three equally effective registry-based interventions, evaluate how the size of the targeted population affects cost estimates, and compare these results with previously reported studies. A total of 3050 children aged <12 months were randomized to one of four study arms: (1) computer-generated telephone messages (autodialer), (2) outreach worker, (3) autodialer with outreach worker backup, or (4) usual care. The cost data collected included capital equipment, supplies, travel, and personnel.

RESULTS

Monthly costs of the three registry-based intervention types were (1) autodialer, $1.34 per child; (2) outreach worker, $1.87 per child, and (3) combination, $2.76 per child. Personnel costs represented the majority of incremental costs for all three interventions. Increasing the number of children targeted sharply decreased the cost per child for the autodialer but had only a modest effect on outreach costs. The monthly costs for outreach were substantially lower than previously reported for nonregistry-based interventions in part because of differences in the number of children who were followed up. Monthly costs for the autodialer intervention were slightly higher than previously reported, but several published studies excluded important costs.

CONCLUSIONS

By facilitating the management of a larger cohort of children, some registry-based immunization interventions appear to be less costly than nonregistry interventions. Further work is needed to establish whether registry maintenance costs may be recouped in part by these savings.

Immunization recall: effectiveness and barriers to success in an urban teaching clinic

OBJECTIVE

To examine effectiveness of immunization recall in an urban pediatric teaching clinic and to identify barriers to recall effectiveness.

DESIGN

Randomized, controlled trial. Children aged 5 to 17 months who were not up to date (UTD) with recommended immunizations were identified and assigned to intervention (n = 294) or control groups (n = 309). The intervention consisted of a mailed postcard and up to 4 telephone calls. Two months after intervention, UTD status, visit, and probable missed opportunity rates were assessed.

RESULTS

Of the intervention group, 30% could not be reached. In 12-month-old children in the intervention group compared with those in the control group, there was a trend toward higher UTD rates (51% vs 39%, P =.07) and a higher proportion of UTD children receiving immunizations as opposed to getting more complete documentation (25% vs 10%, P =.005). Similar differences between intervention and control children were not seen in the 7-month and 19-month age categories. More children in the intervention group had a health maintenance visit (17% vs 11%, P =.03). Of children in the intervention group who were seen when not UTD, 17 of 24 (71%) of those seen for an illness visit and 5 of 24 (21%) of those seen for health maintenance probably had missed opportunities to be immunized.

CONCLUSIONS

Recall efforts were partially successful but were undermined by inability to reach the clinic population, poor documentation of immunizations, and missed opportunities.

Health department clinics as pediatric immunization providers: a national survey

OBJECTIVE

To describe a national sample of health department immunization clinics in terms of populations served, patient volume trends, services offered, and immunization practices.

METHODS

Telephone survey conducted with health departments sampled from a national database, using probability proportional to population size.

RESULTS

All (100%) 166 sampled and eligible clinics completed the survey. The majority of pediatric patients were uninsured (42%) or enrolled in Medicaid (34%). Most children (69%) and adolescents (70%) were referred to the health department, with only 12% using these clinics as a medical home. A number of clinics (72%) reported recent increases in adolescents served. Less than 25% of clinics offered comprehensive care, 47% conducted semiannual coverage assessments, and 76% and 38% operated recall systems for children and adolescents. Storage of records in an electronic database was common (83%).

CONCLUSIONS

Although the majority of these clinics do not provide comprehensive care, they continue to serve vulnerable children, including adolescents, Medicaid enrollees, and the uninsured, and may represent the main contact with the healthcare system for such patients. Because assuring the immunization of these children is essential to their health and the health of our nation as a whole, this immunization safety net must be preserved. Experience implementing key recommendations such as coverage assessment and feedback as well as reminder or recall may enable health department staff to assist private provider colleagues. Further research is needed to investigate how patient populations, services offered, and immunization practices vary by different clinic characteristics.

Undervaccinated African-American preschoolers: a case of missed opportunities

OBJECTIVE

To identify factors associated with undervaccination of African-American preschoolers, to describe the number of vaccination visits made by undervaccinated children and the number of visits needed to be series complete, and to describe the children who did not receive the single dose of measles-containing vaccine recommended for preschoolers.

METHODS

We used the 1999 National Immunization Survey (NIS) to describe vaccination coverage for the 4:3:1:3 vaccine series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of any measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine) among non-Hispanic, African-American preschoolers due to concerns that they may be at risk of undervaccination. Children who did not complete this basic vaccine series were classified for further analysis according to the number of doses they lacked (i.e., one dose missed, two or three doses missed, or four or more doses missed). Significant associations between demographic characteristics and vaccination status or degree of undervaccination were determined.

RESULTS

Of the 26.2% of African-American preschoolers who did not complete the 4:3:1:3 vaccine series, 40.3% lacked one, 35.3% lacked two or three, and 25.0% lacked four or more doses of vaccine. Children who did not complete the 4:3:1:3 vaccine series were less likely to have married mothers, were less likely to have mothers aged > or = 35 years, or were less likely to be up to date at age 3 months than the children who completed the 4:3:1:3 vaccine series. Among the undervaccinated, 63.7% had a sufficient number of vaccination visits to have completed the basic series. However, most (78.7%) of the severely undervaccinated (children who lacked more than three doses of vaccine) had three or fewer vaccination visits. For 72.6% of the undervaccinated preschoolers, only one additional vaccination visit was needed to complete the 4:3:1:3 vaccine series; among these, 78.3% had an adequate number of vaccination visits to have completed the series. Overall, 9.9% of the African-American children aged 19 to 35 months (i.e., approximately 85,000 African-American children aged 19 to 35 months) were at risk for measles. Among the children who lacked more than three doses of vaccine, 68.1% were at risk.

CONCLUSIONS

Our study suggests that the estimated coverage of 73.8% for the 4:3:1:3 vaccine series among African-American children aged 19 to 35 months was not a result of limited access to care. On the contrary, 90.5% of African-American children had enough vaccination visits to complete the series. To raise coverage and prevent potential outbreaks, providers should assess each child's vaccination status at every visit, and administer all needed vaccinations at that time. For the most severely undervaccinated children, this strategy may not be adequate, because they did not have the minimum number of vaccination visits required for series completion. For these children, other strategies are needed for increasing vaccination coverage.

Undervaccination with hepatitis B vaccine: missed opportunities or choice?

BACKGROUND

An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences.

METHODS

To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]).

RESULTS

Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%-82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%-82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%-89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%-75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%-56.4%).

CONCLUSIONS

Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series (n=326); children who made three or more vaccination visits and received one or two doses of HepB (n=1835); and children who made fewer than three vaccination visits (n=487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.

U.S. children living in and near poverty: risk of vaccine-preventable diseases

BACKGROUND

Poverty and factors associated with poverty are strong and persistent barriers to childhood immunization. Substantive differences in coverage with basic vaccinations have been consistently observed over time between children living in poverty and those who are not.

METHODS

The National Immunization Survey (NIS) uses a random-digit-dialing sample of telephone numbers in each state and in 28 urban areas. The NIS provides vaccination coverage information representative of all U.S. children aged 19 to 35 months. We categorized children in the NIS using Bureau of Census categories of poverty as follows: "above poverty" for household income > or = 125% of the federal poverty threshold for the household's size and composition; "near poverty," 100% to <125% of the poverty threshold; "intermediate poverty," 50% to <100% of the poverty threshold; and "severe poverty," <50% of the poverty threshold. We described coverage with basic vaccinations from 1996 through 1999 by poverty category and compare coverage between children in poverty and above poverty.

RESULTS

From 1996 to 1999, estimated vaccination coverage with the basic vaccine series was consistently higher among children living above the poverty level than all other children. The difference in estimated vaccination coverage between children living in severe poverty and those living above poverty was 13.6 percentage points in 1996, and 10.0 percentage points in 1999. Vaccination coverage with the series 4:3:1:3 among children living in near poverty was similar to that of children living in poverty (74.7% vs 73.3%, p=0.52). Estimated vaccination coverage increased significantly (p<0.05) between 1996 and 1999 for most antigens among children living above poverty and among those living in intermediate and severe poverty. Vaccination coverage among children living in poverty increased significantly (p<0.05) between 1996 and 1999 in 1 of the 28 urban areas in the NIS.

CONCLUSIONS

Low vaccination coverage among children living in and near poverty is a persistent problem in the United States. Additional efforts are needed to improve coverage.

Pharmacists and immunizations: a national survey

OBJECTIVES

To obtain information about pharmacists' current involvement in and willingness to provide immunization services, and to assess perceived barriers to providing immunization services.

DESIGN

Cross-sectional mail survey.

SETTING

National.

PATIENTS OR OTHER PARTICIPANTS

Random sample of 5,342 pharmacists from chain, independent, mass merchandiser/grocery, primary care clinic, and health maintenance organization settings.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Responses to survey on pharmacy-based immunization services--current involvement, willingness to get involved, perceived obstacles, and patients' interest.

RESULTS

Three mailings yielded a response rate of 25.3% (1,348 responses). Only 53.1% of respondents knew correctly whether their state allowed pharmacists to administer immunizations. Although a significant number of pharmacists were involved in immunization activities, such as counseling and promotion, only 2.2% and 0.9% of respondents were involved in actual administration of adult and childhood immunizations, respectively. In general, men, independents, owners/partners, and pharmacists who had attended immunization-related educational programs were more willing to provide immunization services than were women, chain and staff pharmacists, and educational program nonattendees. Pharmacists who had attended immunization-related educational programs also perceived pharmacist- and patient-related factors as less problematic for pharmacy-based immunization services than did nonattendees.

CONCLUSION

This survey provides a baseline measure of the nature and extent of pharmacist involvement in immunizations that can be used now and in future years. The profession can use the findings on pharmacists' willingness to provide immunization services and their perception of obstacles to such services as a basis for targeted educational and promotional programs and materials.

Risk and prevalence of treatable sexually transmitted diseases at a Birmingham substance abuse treatment facility

OBJECTIVES

We evaluated the prevalence of gonorrhea, chlamydia, trichomoniasis, and syphilis in patients entering residential drug treatment.

METHODS

Data on sexual and substance abuse histories were collected. Participants provided specimens for chlamydia and gonorrhea ligase chain reaction testing. Trichomonas vaginalis culture, and syphilis serologic testing.

RESULTS

Of 311 patients, crack cocaine use was reported by 67% and multisubstance use was reported by 71%. Sexually transmitted disease (STD) risk behaviors were common. The prevalence of infection was as follows: Chlamydia trachomatis, 2.3%; Neisseria gonorrhoeae, 1.6%; trichomoniasis, 43%; and syphilis, 6%.

CONCLUSIONS

STD counseling and screening may be a useful adjunct to inpatient drug treatment.

Immunization pockets of need: science and practice

Despite high overall immunization coverage levels among U.S. preschool children, areas of underimmunization, called pockets of need, remain. These areas, which pose both a personal health and a public health risk, are typically poor, crowded, urban areas in which barriers to immunization are difficult to overcome and health care resources are limited. The purpose of this report is to review barriers to immunization of preschool children living in pockets of need and to discuss current issues in the identification of and implementation of interventions within these areas. The Centers for Disease Control and Prevention administers a federal grants program that funds state and metropolitan immunization programs. This program promotes a three-pronged approach for addressing pockets of need: (1) identification of target areas, (2) selection and implementation of programmatic strategies to improve immunization coverage, and (3) evaluation of progress or impact. At each step, scientific evidence can guide programmatic efforts. While there is evidence that state and metropolitan immunization programs are currently making efforts to address pockets of need, much work remains to be done to improve immunization coverage levels in pockets of need. Public health agencies must take on a broadened role of accountability, new partnerships must be forged, and it may be necessary to strengthen the oversight authority of public health. These tasks will require a concentration and redirection of resources to support the development of an immunization delivery infrastructure capable of ensuring the timely delivery of immunizations to the most vulnerable of America's children.

Determining immunization rates for inner-city infants: statewide registry data vs medical record review

OBJECTIVE

This study evaluated the benefit of consulting a statewide immunization registry for inner-city infants whose immunizations appeared, after single-site chart review, to have been delayed.

METHODS

We prospectively enrolled 315 newborns in 3 inner-city pediatric clinics. When the infants turned 7 months old, we obtained immunization data from clinic charts and the state registry.

RESULTS

On the basis of chart review, 147 infants (47%) were assessed to be delayed in their immunizations; of these, registry data revealed that 28 (19%) had received additional immunizations and 15 (10%) were actually up to date.

CONCLUSIONS

A statewide registry can capture immunizations from multiple sources, improving accurate determination of immunization rates in a mobile, inner-city population.

Impact of vaccine financing on vaccinations delivered by health department clinics

OBJECTIVES

This study measured the number of childhood vaccinations delivered at health department clinics (HDCs) before and after changes in vaccine financing in 1994, and it assessed the impact of changes in financing on HDC operations.

METHODS

We measured the number of vaccination doses administered annually at all 57 HDCs in New York State between 1991 and 1996, before and after the financing changes. Interviews of HDC personnel assessed the impact of financing changes. A secondary study measured trends in Pennsylvania and California.

RESULTS

HDC vaccinations for preschool children in New York State declined slightly prior to the financing changes (6%-8% between 1991 and 1993) but declined markedly thereafter (53%-56% between 1993 and 1996). According to nearly two thirds of New York State's HDCs, the primary cause for this decline was the vaccine-financing changes. HDC vaccinations for preschool children in Pennsylvania declined by 12% between 1991 and 1993 and by 56% between 1993 and 1997. HDC vaccinations for polio-containing vaccines in California declined by 31% between 1993 and 1997.

CONCLUSIONS

Substantially fewer vaccinations have been administered at HDCs since changes in vaccine financing, thereby keeping preschool children in their primary care medical homes.

Factors influencing the immunization status of children in a rural setting

INTRODUCTION

The purposes of this study were to (a) assess parental perceptions of their decision making regarding children's vaccinations and (b) describe parents' evaluation of immunization services provided by rural clinics/offices.

METHODS

A qualitative design was used in this study, which was conducted in rural Missouri. Twelve mothers of children younger than age 3 years with fewer than the recommended number of immunizations were interviewed using a semi-structured format. The interview results were analyzed using the constant comparative method.

RESULTS

The following parental perceptions were identified as factors related to immunizations in this rural setting: knowledge of communicable diseases and vaccines, misperceptions about communicable diseases and vaccines, past experiences, competing tasks, transportation, health care personnel, need for reminders, health system, and cost.

DISCUSSION

Two findings unique to this study were the importance of relationships with health care providers and the challenge of competing tasks. These findings, combined with the other factors identified, reinforced the importance of rural health care providers' maintaining a strong relationship with clients, providing accurate and timely information, and ensuring a readily accessible health care system.

Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing

BACKGROUND

Physicians frequently refer children to health department clinics (HDCs) for immunizations because of high out-of-pocket costs to parents and poor reimbursement for providers. Referrals for immunizations can lead to scattered care. In 1994, two vaccine financing reforms began in New York State that reduced patient costs and improved provider reimbursement: the Vaccines for Children Program (VFC, mostly for those on Medicaid and uninsured) and a law requiring indemnity insurers to cover childhood immunizations and preventive services.

OBJECTIVE

To measure reported changes in physician referrals to HDCs for immunizations before and after the vaccine financing reforms.

DESIGN

In 1993, a self-administered survey measured immunization referral practices of primary care physicians. In 1997, we resurveyed respondents of the 1993 survey to evaluate changes in referrals.

SETTING/ PARTICIPANTS

Three hundred twenty-eight eligible New York State primary care physicians (65% pediatricians and 35% family physicians) who responded to the 1997 follow-up immunization survey (response rate of 82%).

RESULTS

The proportion of physicians reporting that they referred some or all children out for immunizations decreased from 51% in 1993 to 18% in 1997 (p<0.001). In 1997, physicians were more likely to refer if they were family physicians (28% vs. 13%,p<0.01), or did not obtain VFC vaccines (29% vs. 13%,p<0.001). According to physicians who referred in 1993, decreased referrals in 1997 were due to the new insurance laws (noted by 61%), VFC (60%), Child Health Plus (a statewide insurance program for poor children, 28%), growth in commercial managed care (23%), Medicaid managed care (19%), and higher Medicaid reimbursement for immunizations that is due to VFC (18%). For physicians noting a decline in referrals, the magnitude of the decline was substantial-60% fewer referrals for VFC-eligible patients and 50% fewer for patients eligible under the new insurance law.

CONCLUSIONS

Vaccine financing reforms decreased the proportion of physicians who referred children to HDCs for immunizations, and may have reduced scattering of pediatric care.

Meeting the preteen vaccine law: a pilot program in urban middle schools

California, the most populous state in the nation, is one of many states that implemented vaccination requirements for preteens. While kindergarten requirements are well-established and accepted by parents, implementation of preteen vaccination requirements requires inter- and intra-institutional adjustments, educational and public relations efforts, and an augmentation of vaccination delivery systems. This article describes a pilot program in two middle schools in an urban school district and offers planning strategies and practical tools to assist school nurses and health providers to implement preteen requirements.