Resources for Investigators Institutional Review Board Centers & Investigators Clinical Trials Unit Child Health Data Center Services Skills Current Projects Reports & Data Staff Resources for Families Support CCMC Research Contacts Site Search

EXECUTIVE SUMMARY Childhood Immunization and Primary Care An Investigation of Knowledge, Attitudes and Beliefs About Well Child Care and Immunizations Among Parents of Children 5 to 24 Months of Age. Part A — Residents of the City of Hartford Part B — Residents of the Torrington Health District Heidi Zavatone-Veth, M.A. Sandra Hale Georgine Burke, Ph.D. Ætna Foundation Child Health Data Center Hartford, Connecticut November 10, 1998 Conducted for the Hartford Childhood Immunization Project/Connecticut Immunization Registry and Tracking System, with support from the Ætna Foundation, Inc. In 1993, the Hartford Childhood Immunization Project (HCIP) initiated an immunization tracking system for all children born in Hartford as well as education and outreach programs to improve on-time immunization coverage. While the overall immunization rate for Hartford resident children enrolled in the Registry has increased to over 75%, Immunization Registry data show that a significant percentage of children who are on time for their early immunizations experience delays at later points during the first two years of life. This study was conducted from July, 1996 through September, 1997, to increase understanding of the reasons for delayed childhood immunization among infants under 24 months of age in the City of Hartford, Connecticut. In order to broaden the HCIP prospective beyond urban Hartford, as the program prepared for statewide implementation, a pilot study was carried out in the Torrington Health District (THD). Methods Qualitative interviews with Hartford parents of infants under age 2 were conducted for purposes of developing a quantitative survey instrument and to enrich understanding of the quantitative findings. Parents and other caregivers of infants under age two attending the pediatric primary care centers (PCC) of Connecticut Children's Medical Center or St. Francis Hospital and Medical Center (Hartford) and the Brooker Memorial Health Center (THD) were eligible for study. Additional THD participants were obtained from the Immunization Registry. The survey was administered as an in-person interview in English or Spanish and the infant's medical chart was abstracted for the immunization record and other data. Results are presented as cross-sectional analyses at each of 5 age categories - 5, 7, 12, 19 and 24 months. Infants were considered on-time if they had received all immunizations specified by the American Academy of Pediatrics within 30 days of the recommended age. Demographic, knowledge and attitudinal characteristics of respondents were compared to immunization status (on-time vs late) at each age using bivariate statistics and multivariate modeling. Results - Hartford Demographics The Hartford sample consisted of 228 infants, of whom 71% were selected at CCMC and 29% from SFH. 42% of interviews were conducted in Spanish and in 95%, the study infant's mother was the respondent. 60% of study infants were ages 6-12 months; 29% were 18-24 months. Respondent ages ranged from 15 to 54 years, with an average age of 24.5 years. Two-thirds were Latina and 26% African American or non-Spanish Caribbean. 41% were first-time mothers. 92% were covered by Medicaid for their infant's health care. Immunization Status: 59% on-time at 5 months, 53% at 7 months, 83% at 12 months, 56% at 19 months, 79% at 24 months. Factors associated with: Late immunization On-time immunization Difficulties scheduling appointments Change in primary care provider Would not recommend primary care provider to others Difficulties with transportation to primary care center No problem with payment or cost of care Parent forgot appointment Well-child appointment re-scheduled Infant out of state for ³ 2 consecutive weeks Parent reported personal problems with an important relationship Parent missed appointment to care for another family member Infant late for previously scheduled immunization Infant only child in the household Household includes other adults Education level of respondent/parent Interview conducted in Spanish Infant birthweight < 2500 grams Provider continuity Receiving a booklet/chart to record dates that vaccines were given Provider explanations about how to respond to side effects Provider explanations about the need for immunization Parent reported reading educational materials from PCC Parent agreed that "clinic should do more to help parents remember appointments" Factors associated with immunization status in other studies that did not emerge in the Hartford sample: age of parent, lack of prenatal care, marital status, source of payment for health care, parent knowledge of diseases prevented by immunization, parent knowledge of immunization schedule, parental employment. Results of the multivariate logistic regression models suggest the following profiles of infants likely to be late at each time period: 5 months - Infant lives in a household with at least one other child, does not see the same provider at each well-child visit, and is less likely to have documented evidence in their medical chart of screening for lead, hemoglobin status, or tuberculosis. His/her provider has not explained (according to parent's perception) why immunizations are important, his/her parent has not read materials distributed by the provider about immunizations and well-child care, does not agree that "the clinic should do more to help parents remember appointments", and needed to change date or time of at least one appointment. 7 months - Most characteristics important at 5 months, plus three additional factors - parent has not moved or sought a new residence, parent has not had personal health problems, infant was late at 5 months. 12 months - Lives in houshold with at least one other child, parent does not agree that "the clinic should do more to help parents remember appointments", infant has been out of state for more than 2 consecutive weeks and parent forgot appointment for well child visit. 19 months - Infant missed scheduled immunization at well-child visit due to illness, parent does not agree that "the clinic should do more to help parents remember appointments", and parent has been "feeling depressed". Results - Torrington Health District (THD) Demographics The THD sample consisted of 61 infants, of whom 31 were interviewed in person. The infant's mother was the respondent in 90% of interviews. 48% of study infants were ages 6-12 months; 45% were 18-24 months. Respondent ages ranged from 17 to 41 years, with an average age of 30.9 years. 84% were white, and 13% Asian; 77% were married and 61% employed. 61% had private medical insurance and 13% were uninsured. Immunization Status: 82% on-time at 5 months, 77% at 7 months, 96% at 12 months, 61% at 19 months, 96% at 24 months. For the most part, the analysis of the THD data did not identify correlates of immunization status, due to the small sample. Among demographic variables, parents of infants on-time at 7 months were more likely to be married. Parents most frequently cited concern over side effects of vaccines as a potential barrier to obtaining immunizations. This was followed by problems with the cost of care (40% reported financial difficulties generally), problems with transportation and childcare, infant illness and bad weather. Parents reported few problems with scheduling or obtaining appointments and generally high satisfaction with well-child care. Hartford vs Torrington Hartford respondents were younger, more often non-white, had fewer years of education, were less likely to be married and more likely to have changed residence in the past year. THD parents were more likely to be employed and to lack health insurance. THD parents were more likely to report seeing the same provider at each visit and convenient scheduling times. They less often reported problems scheduling and obtaining appointments than did Hartford parents. Hartford parents were more likely to have received a chart of immunization schedules. THD parents more often agreed that an infant with a cold could be immunized and that "getting shots can make a baby very sick". THD parents more often sought information about children's health from sources other than their provider and agreed more strongly that the "staff at the doctor's office really care about my baby". Hartford parents were almost twice as likely to agree that they "prefer to take my baby for medical care every time he gets sick", and more often agreed that providers should do more to help parents remember appointments. THD infants who were late immunized at 5 and 7 months were no more likely to be late at 12 and 19 months. Summary In Hartford, as in other urban settings, children from families with additional children were less likely to be on time for immunizations as were children born at low birthweight. Young mothers, Spanish speaking parents and unmarried parents were no less likely to have infants on time for immunizations. Although conducted during the transition to Medicaid managed care, parents did not report problems or barriers associated with their payer. Problems with scheduling, obtaining or re-scheduling appointments posed the most common health system barriers to on-time immunization. Provider communication and education about the importance of immunization, both direct and through written materials, were strongly associated with on-time immunization at younger ages. Although frequently cited, problems with transportation and childcare did not emerge as significant issues, particularly when parent attitudes, provider continuity and single child status were included in multivariate models. Many parents do not understand the purpose of immunizations, the vaccine preventable diseases and the importance of the immunization schedule. Parents of on-time infants agreed that their providers could increase efforts to help parents remember appointments. This may indicate high expectations for providers, high value placed on well-child care and immunizations or conversely, an expression among late parents that they do not want to be further reminded. Personal problems among parents such as health issues, relationship difficulties and depression showed modest associations with immunization status. Recommendations Rather than focusing support, education and outreach services primarily to young, first-time parents, families with more than one child should be considered at risk and targeted appropriately. Low birthweight infants should also be targeted. Other parent demographic characteristics assumed to place children at risk for inadequate primary care may not be important in and of themselves. Primary care scheduling systems should be examined to identify improvements that would promote scheduling a future appointment on-site at a current visit, increasing the availability of convenient appointment times, minimizing difficulties with telephone scheduling, and reducing the waiting time for another appointment when one is missed or re-scheduled. Primary care providers should not underestimate the importance of educating parents about immunizations, both directly and with written and other materials. This education should emphasize the reasons why immunizations are important, the nature and seriousness of vaccine-preventable diseases, the reasons for the immunization schedule, ways to handle side effects and any illnesses that preclude immunization. Provider education should continue into the infants second year of life and be repeated for subsequent children. Parent educational materials should include a record system for easily tracking the infant's immunization and screening schedule. Providers need to find ways to encourage parents who demonstrate high levels of motivation and activism for their children's health and resist any tendency to view their activism as too demanding or time-consuming. New approaches and incentives are needed to motivate parents during the periods during the infant's first 24 months when immunization rates are known to fall. These might include innovative educational approaches, improvements in communication and the use of WIC vouchers or other benefits as incentives.