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thesis entitled

ADEQUACY OF IMMUNIZATION
FOR CHILDREN
BY AGE TWO YEARS

presented by

Patricia Mary Jurcich

has been accepted towards fulfillment
of the requirements for

Master of_&c:_i_e_n_c_e_degree in_un:c_sing_

Major professor

Date November 5, 1996

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ADEQUACY OF IMMUNIZATION FOR CHILDREN BY AGE TWO YEARS
by

Patricia Mary Jurcich

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1996

ABSTRACT
ADEQUACY OF IMMUNIZATION FOR CHILDREN BY AGE TWO YEARS
By

Patricia Mary Jurcich

This study explored the level of adequacy of immunization rates in a local county
health department immunization clinic for children under age two years. The Starfield
model guided this retrospective review of 101 immunization records randomly selected
from 551 eligible records. Analysis of the data included three categories for adequacy of
care: complete, adequate, and inadequate.

The major findings of this study were that immunization rates remain low with
only 60% of the sample starting their immunizations on time, 6.9% receiving complete
care, and only 28.7% of the children receiving adequate care. These findings will assist
the advanced practice nurse in improving immunization coverage rates for children under
age two through education, dissemination of research and periodic assessment of
coverage levels, and clinical application in practice. Two recommendations for future
research include development of a system for assessment of immunization rates and

investigation of perceived bam'ers to vaccination.

ACKNOWLEDGMENTS

This author would like to acknowledge and thank my thesis committee
chairperson, Rachel Schifi‘man, R.N., Ph.D., who provided the support, time,
encouragement, and understanding I needed to assist me in creating this finished product.
I would also like to thank my thesis committee members Patty Peek, R.N., MS. and
Linda Spence, RN, PhD. for their time and constructive help to ensure a quality
product.

Also, I would like to thank Pat Burke of the Muskegon County Health
Department for all the time he spent assisting me in collection of the data.

Last, but most definitely not least, I would like to thank my husband, John, for

without his support this project would not have been possible.

iii

Table of Contents

LIST OF TABLES ......................... vi
LIST OF FIGURES . ....................... vii
Introduction ........................... 1
Statement of the Problem ................... 4

Study Purpose and Research Questions .............. 6
Theoretical Framework ....................... 7
The Starfield Model ..................... 7
Application of Model to Study ................. 9
Structure ....................... 9

Process ........................ 11

Social and Physical Environment .............. 11

Outcome ....................... 12

Review of Literature ........................ 14
Critique of the Literature .................... 18
Methods ............................. 19
Research Design . ...................... 19
Sample .......................... 19
Setting .......................... 20
Operational Definition of Variables ................ 20
Adequacy of Care ................... 20

Proper Spacing of Doses ................. 21

Race ........................ 22

Data Collection Procedure . . . ................ 23
Statistical Analysis of Data ................... 23

Study Limitations ...................... 24

Study Assumptions ...................... 25
Protection of Human Rights ................... 25
Results ............................. 26
Description of Sample ..................... 26
Answers to Research Questions ................. 26

iv

Discussion ............................ 34

Discussion of Results with the Theoretical Framework ......... 39
Implications for Advanced Practice Nursing in Primary Care ......... 40

Recommendations for Further Research .............. 46
Summary ............................ 47
APPENDIX A: UCRIHS Approval . . ................ 49
APPENDIX B: Muskegon County Health Department Approval ....... 50
REFERENCES .......................... 51

LIST OF TABLES

Table 1 - Sociodemographic Characteristics of Sample ........... 27

Table 2 - Frequency and Percent of Adequacy of Care for Each Immunization
Series .......................... 28

Table 3 - Frequency and Percent of Adequacy Level for Individual Immunizations . 30

Table 4 - Frequency and Percent of Adequacy Level for the Subset of Subjects who
Received Complete Care for the First Set of Immunizations ..... 32

Table 5 - Cross Tabulation of Adequacy of Care for All Immunization Series by
Race .......................... 33

vi

LIST OF FIGURES

Figure 1 - Starfield Model: A Basis for Evaluating Primary Care ....... 8

Figure 2 - Adequacy of care through immunization for children age two years
utilizing the public health system ............... 10

Figure 3 - Recommended immunization schedule by the ACIP, AAP, and AAFP . 21

vii

Introduction

The meaning of health has changed dramatically over the past century. In the first
half of the twentieth century, health was defined as the "freedom from disease" (Pender,
1987, p. 17). This definition required providers to only treat the disease with which the
client presented. Health and illness were viewed as the extremes on a continuum; the
presence of one indicated the absence of the other. Changes have come about which place
the definition of health as an individual perception of his/her complete physical,
emotional, and social status. This transformation of the definition of health has been
reflected in the delivery of health care that has changed from a primarily disease
intervention focus to an illness prevention and health promotion focus. National health
policy has responded to public pressure and changed dramatically, with disease
prevention and health promotion emerging as major goals. In 1979, the Healthy People
report, published by the Surgeon General of the United States, introduced broad goals for
Americans for improving health by the year 2000 (U .S. Department of Health, Education,
and Welfare, 1979). This report came about as a reaction to the realization that the health
of the country for the rest of the century would have more to do with health promotion
than disease intervention. Americans have recognized the advantages of maintaining and
promoting health and utilizing strategies for disease prevention.

Since the discovery of vaccines which can prevent common childhood illnesses
and decrease morbidity and mortality rates, immunizations have been viewed as one of
the major illness preventive strategies in a child's life (Fielding, Cumberland, & Pettitt,
1994; Michigan League for Human Services (MLHS), 1995). "Immunization provides the

starkest example of the power of prevention to save or prolong lives, prevent significant

2

disability, and lower medical costs" (Office of Technology Assessment (OTA), 1988, p.
11). According to the KIDS COUNT in Michigan 1995 Data Book. every one dollar
spent on immunizations saves ten to fourteen dollars in direct medical costs and indirect
costs such as missed work by parents who care for the sick child (MLHS, 1995).

The purpose of this study was to investigate the adequacy of health care of
children by analyzing immunization coverage rates for two-year—old children. The family
is the primary social structure for health promotion within society. It is within the family
that health behaviors are learned and patterns of healthy living emerge (Pender, 1987).
Within the family parents have the responsibility for health education of their children,
family nutrition, and health care planning. Children learn early in life how to maintain and
promote their health from the examples set by their parents and the community. The first
opportunity a parent has in encouraging health promotion and illness prevention alter
their child is born is through well-child care. The overall goal of well-child care is to
improve the physical, cognitive, and psychological health of children (OTA, 1988). Well-
child care incorporates immunizations and health supervision as the two main aspects of
illness prevention and health promotion (OTA, 1988). The second aspect, health
supervision, is important for health education, parental guidance, and screening for
physical or developmental problems.

Children are currently immunized in the United States against nine diseases:
diphtheria, pertussis, tetanus, measles, mumps, rubella, poliomyelitis, Haemophilus
influenza type B (Hib), and hepatitis B (Centers for Disease Control and Prevention
(CDC), 1994a). Many states have in place laws which require immunizations to be up to
date before entry in elementary school. These laws result in reported vaccination levels of
greater than 90% for school-age children (Vetter & Johnson, 1995; Zell, Dietz,
Stevenson, Cochi, & Bruce, 1994). However, proper immunization is necessary much
earlier in life because many diseases are more serious before age two and often pose a

higher risk of mortality if contracted at an early age. To achieve the maximum

3

effectiveness of vaccinations to prevent illness, children must receive their immunizations
according to the schedule recommended by the Advisory Committee on Immunization
Practices (ACIP), the American Academy of Pediatrics (AAP), and the American
Academy of Family Physicians (AAFP) (CDC, 1994b). This immunization schedule
recommends children receive 80% of their vaccinations before age two. Timing of
vaccinations is also important especially in the prevention of Hib and pertussis, which
have their highest morbidity in the first year of life. The most recent statistics fi'om the
National Immunization Survey (NIS) indicate that for children age two, estimated
coverage levels range fi'om 63 to 86 percent across the 50 states (CDC, 1996). Michigan
has the lowest rate for the 50 states at 63% coverage. This is equivalent to about 200,000
children in Michigan who have spent their early childhood vulnerable to disability or death
fi'om preventable diseases (MLHS, 1995).

Due to the low immunization rates which have been estimated over the past few
years, the national government has established goals for the nation’s immunization rates
and several programs to meet these immunization objectives. The H_ealthy People 2000
report established broad goals regarding the health and well-being for Americans by the
year 2000 (U .S. Public Health Service, 1990). Specifically, this report established the goal
of increasing immunization levels to 90% for the basic immunization series among
children under age two.

One of the first programs established to help meet the 90% immunization goal
was President Clinton's “Childhood Immunization Initiative” (CII) which was a proactive
movement to set goals of eliminating indigenous cases of six vaccine-preventable
illnesses, increasing vaccination coverage levels, and establishing a vaccination-delivery
system which maintains and fiirther improves coverage levels (CDC, 1994a; Osguthorpe
& Morgan, 1995; Robinson, Evans, Mahanes, & Sepe, 1994). The CII called for major
steps to address the barriers to immunization and to improve the delivery of childhood

immunizations.

4

A second public policy to increase the rate of immunizations for children in
America is the “Vaccines for Children” (VFC) program which provides free vaccines to
eligible children at various public and private locations (Osguthorpe & Morgan, 1995).
An anticipated benefit from the VFC program is the reduction of the number of referrals
from private to public health care providers for children who do not have immunization
insurance coverage. This benefit may increase immunization rates and decrease
fragmentation of care.

There has also been progress toward collaboration of the public and private health
care sectors to increase vaccination levels. The "Standards for Pediatric Immunization
Practices" resulted fiom a meeting of public and private health care provider groups to
address barriers to vaccinating preschool-age children (CDC, 1993). This type of
collaboration can help to decrease fragmentation of services which results from families
receiving well-child care from their primary care provider and obtaining immunizations
from the public sector health care. Pruitt, Kline, and Kovaz (1995) found that the use of
multiple providers in the private and public sectors lefi incomplete records and inaccurate
pictures of a child's immunization status.

The issue of immunization coverage rates in children is of central concern in a
primary care setting. According to Starfield (1992), primary care practices have a large
percentage of prevention-related visits. Many children receive well-child visits and
immunizations in a primary care oflice. Advanced practice nurses (APNs), as primary
care providers, develop continuous relationships with their pediatric clients and the
clients' families. The APN can use this relationship to encourage vaccination practices and
identify which children have not received their immunizations.

Statement of the Problem

With this knowledge of the benefits, cost-effectiveness, and health promoting

effects of immunizations and the multitude of national programs to encourage high levels

of immunization rates, why are the nation's children still falling well below the goal of

90% at the age of two? Many barriers to obtaining and receiving vaccination are listed in
the literature. The three main categories of barriers include those from the parents' view,
the provider’s View, and missed opportunities. Some of the most commonly cited barriers
from a parents' view include vaccine cost, parental knowledge and attitudes regarding
cultural beliefs and side effects, misunderstandings of true contraindications for
administration of the vaccine, and inaccessibility of the health care systems (Dixon,
Keeling, & Kennel, 1994; Kefelas, 1993; Lyznicki & Rinaldi, 1994; Miller, Hoffman,
Baron, Marine, & Melinkovich, 1994). Barriers within the health care system, from the
provider’s view, include lack of knowledge of the true contraindications of administering
immunizations, continually changing recommendations for vaccine administration,
inefficient record and tracking systems, and inadequate access to health care.

The last barrier is missed opportunities (MO) which is a problem within the health
care system. An MO was defined by the CDC in a report as a "health care visit during
which a child eligible for vaccination on the day of the visit and with no contraindication
for vaccination failed to receive the needed dose(s)" (1994b, p. 710). According to this
CDC report, estimated coverage of immunizations in four major cities would have
increased 12 to 80 percentage points for children aged 24 months if the MOS had been
eliminated.

National immunization programs designed to help increase immunization rates
must have involvement of community agencies to be successfirl at the local level. One of
the agencies which becomes involved in many local health programs is the public health
department. Most county health departments are major sources of services for
immunization in communities. It is through the health department that children can
receive free or reduced cost vaccinations. Health departments can help to increase
immunization rates for communities; however, in order for the county health department
to address the immunization concerns, information is needed about the types of problems

requiring attention such as low immunization rates and the extent of these problems.

Study Purpose and Resemsh Questions

The purpose of this study was to analyze the adequacy of immunization of

children in one local county from health department immunization clinic records, by age

two years. This study was modeled after Ambrose (1995) and addressed the questions:

1.

What percentage of children from the Muskegon County Health Department
obtain complete care, adequate care, or inadequate care with respect to a_ll
immunizations by age two years as recommended by the Advisory Committee on
Immunization Practices (ACIP)?

For m series of immunizations, what percentage of children received complete
care, adequate care, and inadequate care?

What pattems of immunization are evident for those children receiving adequate
inadequate care with respect to initiation of immunizations and the spacing of
those immunizations by age two years?

For the subset of children who received complete care for the first set of
immunizations, what is the percentage of complete, adequate, and inadequate
care for subsequent immunizatiOns?

What are the differences by race in the percentage of complete, adequate, and
inadequate care for all immunizations?

This study did not address the reasons behind compliance or noncompliance of

receipt of immunizations but served to assess the number of children who are receiving

their immunizations in a timely fashion which will help to reduce the morbidity and

mortality associated with these preventable diseases. To enhance the health and well-

being of American children by reducing the morbidity and mortality attributed to

preventable diseases it is important to continually assess the current level of coverage of

vaccinations. With this knowledge, the APN in primary care can focus interventions to

increase the immunization coverage of children.

Theoretical Framework
The Starfield Model

The variables to be used in this study were derived from the Starfield model for
evaluating primary care (Starfield, 1992). This method of evaluation emphasizes the
measurement of adequacy of care by inspecting the structure and process components of
a health care system which affect the desired outcomes.

Determinants of health, according to Starfield, include genetic structure, social
and physical environment, individual behaviors, and health care services. The health of an
individual is predetermined by genetic structure which is modified by the individual's
physical and social environment, learned health behaviors, and interaction with health care
systems.

Each health service system has three components, structure, process, and
outcome, which are three of the major elements of the Starfield model (Figure 1). The
fourth component is the social and physical environment which influences the structure,
process, and outcome. The interaction of structure, process, and social and physical
environment determines whether the desired health status, or outcome, will be attained.

In Starfield's model there are nine main components of the structure variable (See
Figure 1). These components are utilized to assess the structure of a health care system
and include: 1) personnel; 2) facilities and equipment; 3) range of services;

4) organization of services; 5) management and amenities and governance of the health
care system; 6) mechanisms for providing continuity of care; 7) mechanisms for providing
access to care; 8) arrangements for financing; and 9) population eligibility.

The processes of a health care system are comprised of two elements (See Figure
I). First is the process which represent the provision of care by the providers. This
includes problem recognition, diagnosis, treatment, and reassessment. The second
element of process is that which represents receipt of care by the patient. This includes

utilization, acceptance and understanding of the services, and satisfaction and

The Health Care System

 

STRUCTURE

 

Personnel

Facilities and Equipment
Range of Services
Organization

Management and Amenities
Continuity

Accessibility

Financing

Population eligible

 

 

 

Provision
of care

 

Problem recognition
Diagnosis
Managementt
Reassessment

 

 

PROCESS—*

l
l
1-

Persons

 

 

\ Receipt

of care

 

Utilization

Acceptance and satisfaction
Understanding

Participation

 

 

 

 

l

 

 

 

Social
and
physical
environment

 

 

OUTCOME

 

Longevny

Activity

Comfort

Perceived well-being
Disease
Achievement
Resilience

 

 

 

Figgre l. Starfield Model: A Basis for Evaluating Primary Care (Starfield, 1992).

 

participation with the health care provided.

The outcome of primary care is conceptualized by Starfield (1974, 1992) as the
health status of an individual. This outcome is the cumulative effect of the client's health
behaviors, influence of the structure and process, and the efl‘ects of the social and physical
environment of the client and provider. Health status has seven parts: longevity, activity,
comfort, perceived well-being, disease, achievement, and resilience (See Figure 1). These
seven elements are all measured on a continuum.

The social and physical environment represent the elements of the client's and the
health care system's society, culture, and environment (See Figure 1). These elements,
according to Starfield, have impact on the structure, process, and outcome.

Application of Model to Study

The conceptual definitions utilized in this study were modeled after those of
Ambrose (1995). The primary component from Starfield‘s model used in this study was
outcome, as shown in Figure 2. Process, structure, and social and physical environment
are elements which interact with and influence the outcome. These last three components,
however, were not the focus of this study.

flr_t_rc_tur_e, Structure is defined by Starfield as the characteristics needed by a
health care system to provide services (Figure 2). The structural components utilized in
this study were the immunization records from the selected subjects who obtained their
vaccinations from the Muskegon County Health Department clinic. The population
eligible for services at the health department immunization clinic are Muskegon County
residents who choose to receive vaccinations at this site, regardless of insurance or
socioeconomic
status. The immunization records are entered and maintained in the computer database at
the health department. The printouts of the subjects' immunization records were used in

this study instead of the individual immunization cards filed at the health department. The

10

 

SWCIUI’B Immunization Records

/ for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Muskegon County/State of ‘—
Michigan Residents
Reception of , ,
/ Immunizations: Sociodemographics:
am <
Process. MMR 1' 1 Race
Reception of Care Hib 1:4 Urban/Suburban
\ Rural Setting
r' __ __ _ _ _ Public or
I Malelfemale children I... U"d°""s”'ed
whose parents use 1
l the MCHD for i
I obtaining immunizations I
___________ 44——
Outcome Adequacy of Immunization:
Complete Cane *___,

 

Adequate Care
Inadequate Care

 

 

 

Figure 2. Adequacy of care through immunization for children age two years utilizing the
public health system. Adapted from the Starfield Model (Ambrose, 1995; Starfield,
1992)

11

accuracy of this variable is dependent upon the computer program and the data input and
retrieval by the health department staff.

Process. Process refers to the acquisition of vaccinations by the children (Figure
2). Parents, in addition to the children, are included in the process since it is the parent
who decided when, and if, the child received the vaccines. Within this study, the process
was limited to whether or not the immunizations were obtained. Other elements of the
process to obtain immunizations which were not addressed in this study include barriers
and facilitators to obtaining vaccinations, missed opportunities by providers, and the steps
taken by parents and children to receive the immunizations.

Social and Physical Environment. Social and physical environment were defined in
this study as race, sex, age, insurance status, and type of neighborhood (urban, suburban,
rural) of the sample population (Figure 2). These components of the social and physical
environment influence the structure, process, and outcome aspects of the model. The
structure component is influenced through the delineation of the population which
receives the services of the clinic. The health department must be able to define the
community it serves and must know important demographic information of that
community to maximize its service potential. Receipt of vaccinations, in the process
component, can be influenced by the sociodemographic information of the community
serviced. For example, if the majority of the community who are eligible for services in
the clinic are underinsured for immunization coverage there will be a greater need for
these services and result in increased use of the health department clinic (Bates,
Fitzgerald, Dittus, & Wolinsky, 1994). Lastly, the outcome component of adequacy of
immunization for children can also be influenced by sociodemographic information. Bates
et al. (1994) reported poverty to be a predictor of decreased immunization coverage and
Mustin, Holt, and Connell (1994) reported a lower percentage of adequate immunization ‘
for black infants than white infants. The overall description of the population is the

defined service area of the health provider.

12

Race was conceptually defined, for the purpose of this study, as the combination
of biological and cultural influences (Betancourt & Lopez, 1993). Within this study race
was included as a social and physical environment variable which could impact the
outcome of immunization status. Biological factors of race include observable physical
characteristics such as skin color, hair type, and facial features. Cultural factors include
social norms, learned behaviors, and self definition.

Outcome. Outcome was defined within this study as the measurable adequacy of
immunization for the sample; complete care, adequate care, and inadequate care (Figure
2). Complete care was defined in this study as the reception and proper timing of all
immunizations by age two according to the ACIP recommended schedule. Adequate care
was defined as the reception of all immunizations by age two but not properly timed
according to the recommended schedule. Lastly, inadequate care was defined as the
reception of less than all the recommended immunizations by age two. The communicable
childhood diseases of diphtheria, measles, mumps, rubella, poliomyelitis, pertussis,
tetanus, and Haemophilus influenza were studied in this research.

Adequate health care for children has been identified as a major strategy in
improving the health status of the Nation (OTA, 1988). Illness prevention and health
promotion in early childhood can benefit a child for a lifetime. Health care interventions
which result in the positive health status of a child are included in the adequacy of health
for children. These interventions include health education and teaching about injury
prevention, obtaining treatment when sick, routine evaluation of physical health and
developmental status at well—child visits, establishing a health supervision relationship
between child, parents, and health provider, and prevention of childhood illnesses through
immunization.

Health is viewed as a state of well-being, although specific definitions are made
subjectively by each individual. Generally, however, health is viewed as a positive goal,

something which is of value to every individual. A state of health is maintained and

13

influenced by many factors including health care activities which are actively sought out
by individuals. Immunization of infants and children is considered a health seeking
behavior.

Children in the United States are vaccinated against the nine preventable
childhood diseases mentioned previously in this paper. Vaccines were developed in
response to the high numbers of morbidity and mortality associated with these childhood
diseases. A schedule of childhood immunizations has been established in the United States
based upon the efficacy of vaccines in preventing childhoodillnesses. A series of
immunizations is the sequence and number of vaccines recommended in the schedule for a
specific disease.

Immunizations are viewed as an important factor in health promotion of children
and their families. Also, vaccinations are a preventive intervention which has been
researched and found to have a high benefit-to-cost ratio (MLHS, 1995; OTA, 1988).
Childhood vaccination helps to reduce the incidence of disease, disability, and death and
can lower medical costs in a Nation whose health care expenditures are growing out of
control (Mitchell, 1986).

Since infant and child immunization is widely accepted as an indicator of the
adequacy of health care and is a cost-effective approach to prevention, APNs, as health
care providers, have a role in providing this preventive care. Multiple research has proven
the effectiveness of immunization in promoting health and preventing morbidity and
mortality of preventable diseases in children (CDC, 1995b). As shown by the many
programs mentioned previously to increase immunization numbers, providing adequate
care for the Nation's young through control and elimination of all preventable childhood
diseases has been a goal in public health care for decades, continues on today and into the

future (CDC, 1994a; U. S. Public Health Service, 1990).

Review of the Literature

Rates of preventable diseases in children are reported widely in the literature
(Bouffard, 1995; CDC 1994a; Vetter & Johnson, 1995). In a report on the prevalence of
Haemophilus influenza type b (Hib) in infants and children the CDC (1995a) states that
the incidence of Hib declined rapidly among children between 1988 and 1992. Since 1992
however, the decline has slowed and they report that one barrier to eradication of this
disease is the high percentage of under-vaccinated children. The incidence of measles was
also on the decline until the period from 1989 to 1991 when there was a resurgence of
measles which was attributed primarily to a failure to vaccinate pre-school children on
time (CDC, 1994a).

It is important to combine the surveillance data of both disease numbers and rates
of vaccination coverage to obtain a complete picture of the health status of children.
Surveillance data on disease numbers alone only demonstrate problems after they occur.
There must be monitoring of progress toward immunization coverage targets rather than
only progress toward disease reduction targets.

The US. Public Health Service, as part of the filthy People 2000 guidelines,
have set the goal of 90% coverage of vaccinations for two year olds by the year 2000
(US. Public Health Service, 1990). This has been established in the literature as the goal
for research on the topic of immunizations.

The National Immunization Survey (NIS) was established as one element of the
objectives set by the CH to monitor the progress toward the C11 goal of 90% coverage by
the year 1996 (CDC, 1994c). This survey is done quarterly by the CDC through a random
sample of telephone numbers and questionnaires which are sent to households with
appropriately aged children ages 19 through 35 months. Parental recall of immunization
dates and types received is verified with the health care provider named by the parent.
This helps to improve the accuracy of the vaccination coverage estimates for the entire

sample. Based on the NIS, among children who were born during May 1991 through

14

15

May 1993 and who were aged 19 to 35 months when surveyed, estimated coverage was
75% for the nation for receipt of the 4:3:1 series (four doses of diphtheria and tetanus
toxoids and pertussis vaccine (DTP), three doses of poliovirus vaccine (OPV), and one
dose of measles-mumps—rubella vaccine (MMR))(CDC, 1996). The coverage level fell to
72% when three doses of Hib were added (4:3: 1:3 series). Specific information was given
on each state with Michigan being the lowest with an estimated coverage of 63% for the
4:3:1 series and 59% for the 4:3:1:3 series. Detroit also had the lowest estimated
coverage levels for the cities surveyed, with 52% and 49% for the 4:3:1 and 4:3: 1 :3
series, respectively.

Many studies of immunization coverage levels rely on parental recall, either fi'om
memory or household records, for data. Fielding, Cumberland, & Pettitt (1994) surveyed
1500 randomly selected employees of the Johnson & Johnson Company with children
born between 1984 and 1991. Surveys were mailed to the employees home and telephone
follow-up was done if the survey was not returned. Everyone in the sample had insurance
coverage for immunizations with varying co—pays. Children were considered to be up to
date with their immunizations if, by age two, they had received all the recommended
shots, not necessarily on time. Results of the study included a 65.1% immunization
coverage level for age two. The authors also showed that receiving the first set of
immunizations as recommended at two months was a predictive factor for higher
coverage. Ifchildren received their first DTP late, the coverage at two years was 50.6%,
whereas the coverage level was 72.2% for children who had received their first DTP as
recommended. A limitation to this study was the specific population utilized; only
Johnson & Johnson employees with immunization insurance coverage were included in
this study. This study was not generalizable to the greater population.

A second study which utilized parental recall for the data was by Salsberry,
Nickel, and Mitch (1994). This study was conducted in a suburban community and

included 299 children with birth dates in 1988 and 1989 whom were randomly selected

16

from birth certificates. The parents who responded in this study were mostly white
(92%), married, and had household incomes greater than the county median. In this
study, only 31% of children had received all their recommended immunizations by the age
of two. Eighty percent of the children had received three doses of DTP, two OPV, and
the MMR vaccines, suggesting that the basic deficiencies in immunization of the families
surveyed were in Obtaining the 18-month doses of DTP and OPV.

Several studies verified parental recall of vaccination records with provider
records. This verification can help to increase the reliability of the data. In a study by
Bobo, Gale, Thapa, and Wassilak (1993) immunization coverage levels were estimated
for children six through 24 months of age. A sample of 1163 children were selected fiom
Oregon and Washington; 601 were more than 24 months old. Copies of provider
immunization records were obtained for 90% of the participants in the study. Results of
the study included a coverage level of 69% and 60% for the 33:1 and 4:3:1 series,
respectively, for both states combined. The authors of this study also addressed the
question of coverage rates if the first series is at the recommended time. Children who
were not up-to-date at 2 months of age were significantly less likely to be adequately
immunized at 24 months of age. Delayed immunizations were associated with more than
a twofold difference in rates at 24 months.

Two studies assessed vaccination levels based upon the timing of the
immunizations received and the recommended schedule of immunizations for children
under age two. Zell, Dietz, Stevenson, Cochi, and Bruce (1994) obtained retrospective
data from 25 kindergarten and first grade classes in 35 schools. Random selection of the
schools and children was done to increase the generalizability of the study. Data were
collected and arranged for analysis by two categories: up-to-date (all vaccinations
received by age two) and age-appropriate immunizations (all immunizations received
within 30 days of the recommended schedule). School records were reviewed and dates

of immunizations before age two were obtained retrospectively. The percentage of

17

children who were up-to—date for the recommended 4:3:1 series ranged fiom 11 to 58%
(median, 43%) by age two. The percentage of children who were age-appropriately
immunized for the 4:3 :1 series ranged from 5 to 20% (median, 12%). The authors of this
study also assessed coverage levels of each individual vaccine. The percentages for the
individual vaccines were always higher than for the vaccination series.

Ambrose (1995) used the same variables to assess adequacy of immunizations by
age two years as those mentioned in the previous study by Zell et al. (1994). In the
Ambrose (1995) study, retrospective data from patient records were obtained from a
health department immunization clinic. A sample of 96 children born between 1990 and
1992 who obtained vaccinations at the health department clinic were utilized to assess
coverage rates for up-to-date and age-appropriate immunizations. No children in the
study were age-appropriately immunized, 45% received all immunizations before age two
but not by the recommended schedule, and 55% had not received all their immunizations
before the age of two. This author also analyzed the percentages for each individual
vaccine received as recommended. The percentage of children who received the
individual vaccines as recommended decreased with each subsequent vaccine.

All of the studies mentioned in this section assessed immunization rates for two
year old children. The immunization coverage rates reported ranged from a low of31% in
the Salsbeny et a1. (1994) study to a high of 75% in the NIS study (CDC, 1994c). It is
notable, however, that none of these studies reached the 90% immunization coverage
goal. Also, only the NIS study reported coverage rates for the immunization series which
includes the Hib vaccine (CDC, 1994c). However, the majority of the studies reported
data from time periods before the Hib vaccination series was added to the recommended
schedule. Fielding et a1. (1994) and Bobo et al. (1993) both reported in their studies that
if immunizations were not started on time, according to the recommended immunization
schedule at two months old, the likelihood of receiving all the vaccinations recommended

by two years decreased.

18

The Zell et a1. (1994) and Ambrose (1995) studies compared percent coverage of
receiving all vaccinations before age two and receiving all vaccinations before age two
according to the schedule recommended by the AAP. Zell et al. (1994) reported a median
percent coverage of 43% for the first category whereas Ambrose (1995) reported a
coverage of 45%. Results for the second category of properly timed immunizations in the
Zell et al. (1994) study were a median of 12% and 0% in the Ambrose (1995) study.
Critique of the Literzgure

All of the reported studies fall well below the Healthy People 2000 goal of 90%
coverage by the year 2000. Limitations to these research studies include the use of
retrospective data with parental recall. Parents may have problems recalling the vaccine
information accurately when some of the information is three to four years old. This
problem is resolved in some studies with verifying immunization information with the
provider records (Bobo et al., 1993). Also, most coverage levels were reported as
percentage of children up-to-date on their immunizations, i.e. had received all of their
immunizations recommended for that age (Bobo et al., 1993; CDC, 1996; Fielding et al.,
1994; Salsberry et al., 1994). Within these studies no information was given on the
percentage of children who were age-appropriately immunized i.e., within 30 days of the
recommended schedule by the ACIP.

Future studies will be required to continually assess the progress toward the 90%
immunization coverage goal for the year 2000. Progress toward this goal will help to
reduce the morbidity and mortality of infants and children which is associated with totally
preventable diseases.

As mentioned previously, it is important to continuously monitor the progress of
the immunization coverage rates toward the 90% goal for two year old children. Without
this continual assessment programs and interventions to increase vaccination rates cannot
be evaluated. Investigation of adequacy of care for the young continues to be a need to

better focus the resources necessary to decrease sickness and death for children at risk

l9

(Ambrose, 1995). Specifically, this study was important to gain an understanding of the
current coverage rates in a local county and to use this information to design
interventions and implications for the APN in primary care.
_ Methods

Resejarch Desigg

This study was a retrospective review of immunization records and was modeled
after Ambrose (1995). This was a nonexperimental study utilizing descriptive research to
investigate immunization rates for a local health department immunization clinic.
Secondary analysis of vaccination records was done to obtain the data. Nominal and
ordinal levels of measurement were applied to the data to attain results for this study.
Semis

This investigation utilized a randomly selected sample which was requested from
the Muskegon County Health Department (MCI-ID) immunization records database. The
population ofMuskegon County is a mixture of urban, suburban, and rural residents
whose household median household income is below the median household income for
the state (MLHS, 1995). In Muskegon County, 24% of all children are minority children.

The sample size utilized in this study was 101 randomly sampled records of
children who received their vaccinations at the MCI-II) immunization clinic. These sample
cases were drawn from a population of 551 eligible immunization records which met the
inclusion criteria. The following were the criteria for record selection:
1) Birth dates from 1-1-93 through 5-1-94. These dates were selected based upon
the beginning date of the addition of the Hib vaccination series to the recommended

schedule by the ACIP (CDC, 1994b).
2) All records of children immunized at the MCI-ID were eligible regardless

of the child's status as a MCHD client.

20

The random sampling of the population was done by the MCHD computer. The
total number of eligible subjects (551) were identified and the 101 subjects were then
randomly selected from this population.

Mg

The setting used was the Muskegon County Health Department immunization
clinic located in Muskegon Township, Michigan. Outreach clinics managed by the health
department to access rural sites within the county were also included in the setting since
the data is maintained centrally at the health department in Muskegon Township. This site
was selected because it immunizes a significant portion of children in the county and is a
central site for immunizations in Muskegon County.

Operational Definition of Variables

The operational definitions utilized in this study were the definitions developed by
Ambrose (1995) with the addition of the Hib vaccine.

Adeqrnrcy of Care. Adequacy of care was defined as the number of immunizations
the child has received and the timing in which they received them in relation to the
recommended immunization schedule. The childhood immunization schedule approved by
the Advisory Committee on Immunization Practices (ACIP), the American Academy of
Pediatrics (AAP), and the American Academy of Family Practice (AAFP) (CDC, 1995b)
was used as the standard for care for this study because this schedule” was inclusive for
the many variations in the recommended schedule during 1993, 1994, 1995, and 1996
which was the time identified as the study period (Figure 3). The shaded bars on Figure 3
indicate that the specific vaccination is recommended within that time period. For
example, the fourth DTP (DTP4) is recommended between ages 12 and 18 months.
Hepatitis B was not studied because it was not considered to be a standard of care for
this time period and because of the many variations in the recommended schedule (CDC,

1995b)

21

 

AGE> 2 4 6 12 15 18
VACCINE V months months months months months months

 

 

 

 

Diphtheria, Tetanus, DTp1 [)sz DTP3 *sli‘iii'533vi:..ljjr{iv/i..5'1,31}.I£11)IP4f;izizfi7i-ff7‘:5:if.tif-jglix".;il.'
Pertussis l 'jf*’;fjf;';jj'tiajf‘*‘j‘fiiiffljj11*;[j‘iiffii'iij‘iffi2;,§;.,f_*¥p" L ‘

H. influenzatypeb Hibl Hib2 Hib3 Hrb4

l
Polio OPV] Opvz -i' OPV3 ' "

l

Measles, Mumps, Rubella .9 . - 1.1 m 5;...

L

Figure 3. Recommended immunization schedule by the ACIP, AAP, and AAFP. Adapted
from CDC (1995b).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The variable, adequacy of care, was operationalized with three levels:

1) Complete Care--4 DTP immunizations, 3 OPV immunizations, 1 MMR, and 4
Hib immunizations received before age two and correctly spaced within 30 days
of the ACIP recommended schedule;

2) Adequate Care-- All immunizations received by age two years, but not properly
spaced or outside 30 days of the recommended ACIP schedule; and

3) Inadequate Care-- Less than all of the recommended immunizations within 30
days of age two years or all immunizations not completed by two years of age.
Parameters for each immunization variable were defined using three levels: 1)

obtained on time, properly spaced; 2) obtained by age two years, but not properly spaced;

3) not obtained by age two years. This was done to allow analysis of each series of

immunization to determine if any differences exist between immunizations.
Proper Spacing of Doses, Criteria for properly spaced doses, according to the

ACIP and AAP, were defined as follows: the first DTP dose must be given on or after 42

days (six weeks) of age; the second and third doses given after a minimal interval of

28days. The fourth dose must be given at least 184 days after the third dose. A child who

22

received the fourth DTP at 12 to 18 months (plus or minus 30 days) will be categorized
as correct spacing. For OPV, the first dose must be given on or after 42 days (six weeks)
of age; the second and third doses each given after a minimum of 42 days from the last
dose. The third OPV was considered to be correctly spaced if it is 42 days after the
second and received at six to 18 months (plus or minus 30 days). Any MMR given on or
after the first birthday but before, or at 15 months (plus 30 days), was defined as being
properly spaced (Ambrose, 1995). The first Hib must be given on or after 42 days (six
weeks) of age; the second and third doses each given after a minimum interval of 42 days
from the last dose. The fourth Hib must be given 42 days after the third dose and between
12 and 15 months (plus or minus 30 days) to be properly spaced (CDC, 1995a). When
information on the month and year were available but not the date, the 15th was
designated as the date (Zell et al., 1994).

Immunization records at the MCHD are updated with immunization dates of
series given at other facilities if the information can be verified by the provider over the
phone or in writing. However, if immunization records contained information on the
fourth DTP, third OPV, first MMR, and fourth Hib, but did not have data on preceding
immunizations, it was classified as either adequate or inadequate care based on the date
the immunization was obtained relative to the date of birth. Any other immunization for
which there was no date was deemed not obtained and reflected as inadequate care. This
assumed the later immunizations would not have been given without evidence of prior
immunization; however, they may not have been obtained at the MCHD and MCHD
records had not been updated. No conclusions were able to be drawn in these cases
regarding the spacing of prior immunizations.

R_ag_e_. Race was operationally defined in this study by the Muskegon County
Health Department policy for entering information into the computer database. The
classification of race accepted by the computer database was broken into eight categories:

white, black, Asian/Pacific Islands, American Indian/Alaskan Native, Hispanic, no

23

response, unknown, and other. The selection of which category to place clients was done
by the desk clerk who entered the information into the computer. There was no paper
work for the client's parent to fill out in this clinic so there was no self-selection of
categories.
Data Collection Procedure

Immunization data sheets of the children who received immunizations through the
clinic at the MCHD with birth dates between 1/1/93 through 5/1/94 and whose
immunization records were entered into the MCHD database were requested. In addition
to the immunization data, date of birth, sex, race, and insurance information were
requested. The computer program which was used to obtain the data from the health
department records was not available to this researcher.

The immunization records themselves were used as the collection instrument.
Each record was assigned a case number in sequential order starting with one.
Statistical Analysis of Dali

Data analysis was done with the SPSS statistical software package. Frequency,
percentage, mean, and cross tabulation with chi square statistics were used, as
appropriate, to describe the study results. The sample was described using demographic
information including date of birth, gender, race, and type of insurance.

Analysis of the data included the following:
1. Percent of records sampled which indicated complete care, adequate care, and

inadequate care for children by age two for all immunizations.
2. Percent of records sampled which indicated complete care, adequate care, and

inadequate care for children by age two for each series of immunization.
3. Percent of records which indicated complete care, adequate care, and inadequate

care for the subsequent series of immunization if the first series was complete.

 

7 'J

24

4. Mean number of days from date of birth to date of starting immunizations and
between subsequent immunizations for those children receiving adequate and
inadequate care.

5. Percent of records sampled which indicated adequate care and inadequate care in
the proper spacing for all immunizations.

6. Percent of sample receiving complete, adequate, and inadequate care for all
immunizations by race.

Cross tabulation with chi-square analysis for question six was performed to
determine any statistically significant differences. The level of significance was established
at 0.05.

Missing immunization data were reported as inadequate care for all series

combined and each individual series at age two years. This was done because if a record

 

was missing immunization data, it resulted in the incomplete receipt of all recommended
immunizations before age two years. In assessing the adequacy level for individual
immunizations, percent missing data was included to avoid inflating values.
Study Limitajons

Three limitations can be found in this study. First, the sample used was fi'om a
public health care clinic in an urban/suburban/rural setting which may not be
representative of the population of the county and state. Also, data were limited to
records of children who received their immunizations at the public health clinic. The
immunization status of the sample of records of children who receive their immunizations
at the MCHD may be different from the immunization status of the state and county
population. Therefore, discussion of the results of this study must be limited to the
specific sample and may not be generalizable to the county and state populations as a
whole. Second, the parental and provider barriers to immunizing these children as
recommended were not available. Thus, conclusions about the reasons behind the

immunization coverage levels are beyond the scope of this study. Finally, data were

25

obtained from the Health Department computer records only; no attempt was made to fill
in the missing data or verify records of the immunizations received by other providers
which were entered by the health department staff. This was also beyond the scope of this
study.

Study Assumptions

The assumptions identified by Ambrose (1995) were also utilized for the purpose

of this study:
1. Immunizations against childhood disease are reasonably safe and effective.
2. The immunization schedule recommended by the Advisory Committee on

Immunization Practices, the American Academy of Pediatrics, and the American
Academy of Family practice is a valid standard for prevention of some childhood
illnesses.

3. High vaccination coverage levels in the general population benefit the children
immunized and the population in the United States as a whole by decreasing the
risk of morbidity and mortality associated with these preventable diseases.

4. The data that was recorded at the MCHD was accurate.

5. Those seeking immunizations at a public health clinic are primarily people with
public health insurance, those without insurance, or those who have insurance
that does not cover the cost of immunizations.

Protection of Human Right;

The rights of the individuals from whom immunization records were utilized in
this study were protected in accordance with the guidelines developed by the University
Committee on Research Involving Human Subjects (UCRIHS) at Michigan State
University. Approval was obtained from this committee before gathering the data (See
Appendix A).

Verbal permission was obtained from the Health Director and Deputy Health

Director at the Muskegon County Health Department to collect data. Written permission

tn

1‘.

 

Mi

26

was obtained before initiating data collection (See Appendix B). No data was used which
could identify individuals in the study. Once the immunizations records were obtained
they were assigned an arbitrary number beginning with one. No names, addresses, or
other identifying information were removed from the health department. All data were
entered into the SPSS database by this investigator. Confidentiality of the information
was maintained.

Results
Description of Sample

The sample consisted of 101 records of immunization from the Muskegon County
Health Department (MCHD) clinic. As illustrated in Table 1, the majority of the sample
consistent with gender distribution for Muskegon County and the State of Michigan but
not with racial distribution due to the high missing/unknown data in this category
(MLHS, 1995).

The years of birth included in the study were 1993 and 1994 with the majority of
the sample (73.2%) from 1993 due to the limitation of the inclusion criteria of birth dates
through 5-1-94. The sample was fairly evenly distributed between the months with April,
1993 containing the highest number of records (10%, p = 10). Insurance information was
listed on only three of the records and this information was missing in the remainder of
the sample (n = 98). Physician Health Plan and Blue Care Network were the only
insurance companies identified in the sample.

Answers to Research Questions

The five research questions presented in this study were based upon the concern
that children under two years of age are at highest risk for morbidity and mortality of
preventable diseases if they do not receive their vaccinations. The outcome in this study
was measured by level of care received with respect to the immunizations obtained by

two years of age: complete, adequate, or inadequate care.

27

Table 1

Sociodemographic Characteristics of Sanprle (p = 101)

 

 

Characteristic Frequency Percent
Gender:
Female 56 55.4
Male 44 43.6
Missing data 1 1.0
Race:
White 53 52.5
Unknown 22 21.8
Black 19 18.8
Hispanic 2 2.0
Other 2 2.0
American Indian 1 1.0
Missing data 2 2.0
Insurance:
Physician Health Plan 2 2.0
Blue Care Network 1 1.0
Missing data 98 97.0

 

Question 1. What percentage of children from the Muskegon County Health
Department obtained complete care, adequate care, or inadequate care with respect to Q1
immunizations by age two years as recommended by the ACIP, AAP, and AAFP?

The percentage of children receiving complete care was 6.9% (p = 7); adequate
care, 28.7% (p = 29); and inadequate care, 64.4% (p = 65) (Not listed in a table). This
sample obtained an adequate coverage level by age two of only 28.7% and when
combined with the complete care results, coverage of receiving all immunizations by age

two for the entire sample was only 35.6%.

28

A notable result for the percentage of subjects with complete care was that four of
the seven children (57%) who received all their immunizations as recommended had dates
of birth in 1994. As stated earlier, the percentage of birth dates in 1994 was only 26.7%
of the entire sample.

Qpestion 2. For _e_a_c_h_ series of immunizations, what percentage of children
received complete care, adequate care, and inadequate care?

For each series of immunizations, the percentage of children who received
complete, adequate, or inadequate care is listed in Table 2. The percentages of complete
care ranged from 8.9% (p = 9) for the DTP series to 34.7% (p = 35) for the MMR series.
The level of adequate care ranged from 27.7% (a = 28) for the MMR series to 38.6% (p
= 39) for the OPV series.

Table 2

Frequency and Percent of Adequacy of Care for Each Immunization Series (p = 101)

 

 

Immunization Series Adequacy of Care Frequency Percent
DTP Complete 9 8.9
Adequate 3 1 30.7
Inadequate 61 60.4
Hib Complete 1 1 10.9
Adequate 32 3 1.7
Inadequate 5 8 57.4
MMR Complete 3 34.7
Adequate 28 27. 7
Inadequate 3 8 3 7.6
OPV Conrplete 26 25.7
Adequate 3 9 38.6

Inadequate 36 35.6

 

29

Sixty-four percent of the sample received the OPV series as either complete care
(25.7%) or adequate care (38.6%). The majority of subjects received the recommended
number of OPV and MMR vaccines by age two (64.3% and 62.4%, respectively). The
DTP and Hib series percentages, however, were only 39.6% and 42.6%, respectively, for
children having received all immunizations within each series by age two.

my; What patterns of immunization are evident for those children
receiving adequate or inadequate care with respect to initiation of immunizations and the
spacing of those immunizations by age two years?

Table 3 reports the findings for each individual immunization. Several patterns
were noted for the DTP, Hib, and OPV vaccinations, where more than one immunization
is recommended. First, the coverage rates of subjects in this study ranged fiom 60% to
66% for the first DTP, Hib, and OPV vaccinations received according to the
recommended schedule. Secondly, with each subsequent immunization, coverage rates
dropped, especially between the third and fourth DTP and Hib immunizations. The
decreasing rates paralleled the other immunizations, particularly the first three DTP and
Hib, and the OPV series. The decline was the greatest between the third and fourth DTP
immunizations where the rate of immunizations received before age two dropped 37
percentage points between DTP3 and DTP4. Also, the number of missing data, indicating
a missed vaccination, increased with each subsequent immunization. The number of
rrrissing data ranged from 25 to 48 for OPV3, DTP4, and Hib4. The percent of missing
data was incorporated in the evaluation of percents to avoid misinterpretation of inflated
values due to the decrease in frequency of receipt of vaccinations.

A surprising result was the increase of 32.8 percentage points in the rate of
complete care between OPV2 and OPV3. However, the percentage of adequate care
dropped dramatically and overall, the rate of all immunizations received before age two
(complete and adequate care percentages combined) decreased between OPV2 and

OPV3 by 12 percentage points.

30

Table 3

Frequency fld Percent of Adequacy Level for Individual Immunizations (p = 101)

 

 

Immunization Adequacy Level Frequency Percent
DTPl By ACIP 66 65.3
By 2 years 32 31.7
> 2 years 2 2.0
Missing 1 1.0
DTP2 By ACIP 37 36.6
By 2 years 51 50.5
> 2 years 3 3.0
Missing 10 9.9
DT P3 By ACIP , 27 26.7
By 2 years 50 49.5
> 2 years 5 5.0
Missing 19 18.8
DTP4 By ACIP 25 24.8
By 2 years 15 14.9
> 2 years 17 16.8
Missing 44 43.6
Hibl By ACIP 61 60.4
By 2 years 34 33.7
> 2 years 3 3.0
Missing 3 3.0
[-1in By ACIP 35 34.7
By 2 years 51 50.5
> 2 years 1 1.0
Missing 14 13.9
Hib3 By ACIP 25 24.8
By 2 years 46 45.5
> 2 years 4 4 0

Missing 26 25.7

31
Table 3 (cont’d).

Hib4 By ACIP 25 24.8
By 2 years 19 18.8
> 2 years 9 8.9
Missing 48 47.5
MIVIR By ACIP 35 34.7
By 2 years 28 27.7
> 2 years 15 14.8
Missing 23 22.8
OPVl By ACIP 67 66.3
By 2 years 31 30.7
> 2 years 2 2.0
Missing 1 1.0
OPV2 By ACIP 38 37.6
By 2 years 51 50.5
> 2 years 2 2.0
Missing 10 9.9
OPV3 By ACIP 60 59.4
By 2 years 5 5.0
> 2 years 11 10.9
Missing 25 24.8

 

These results support that the continued morbidity and mortality of preventable
diseases is due, in part, to a failure to adequately irnmunize children at an early age. Also,
a low percentage of children begin their immunizations on schedule with a decreasing
number accomplishing even adequate coverage for any of the subsequent individual
immunizations.

Question 4. For the Subset of children who received complete care for the first set
of immunizations, what is the percentage of complete, adequate, and inadequate care for
subsequent immunizations?

Sixty children (59.4%) in the sample received complete care for the first DTP, Hib

and OPV given at two months of age. Table 4 reports the findings for the percentages of

32

level of adequacy for the each series and all immunizations by age two for the subsets of
subjects having received the first set of immunizations at two months of age according to
the recommended schedule and those who received the first set after two months of age.
The 59.4% of infants who received their first immunizations on-time were two to
three times as likely to have received each series before age two and two-and-a-half times
as likely to be up to date (48.4% versus 17.1%) at 24 months than the 40.6% of infants

who were delayed in receiving their first set of immunizations at two months of age. The

Table 4

Frequency and Percent of Adequgzy Level for the Subset of Subjects who Received

Complete Care for the First Set of Immunizations

 

 

 

Immunization Adequacy First Set at 2 months First Set > 2 months
Series Level (p = 60) (p = 41)
n % n %
All Series Complete 7 1 1.7 0 0
Adequate 22 36. 7 7 17. 1
Inadequate 3 l 5 1.7 34 82.9
DTP Complete 9 15.0 0 0
Adequate 22 36.7 9 22.0
Inadequate 29 48.3 32 78.0
Hib Complete 1 1 18.3 0
Adequate 25 41.7 7 17 . 1
Inadequate 24 40.0 34 82.9
MMR Complete 25 41.7 10 24.4
Adequate 14 23.3 14 34.1
Inadequate 21 35.0 17 41.5
OPV Complete 23 38.3 3 7.3
Adequate 21 3 5 .0 18 43 .9

Inadequate 16 26. 7 20 48. 8

 

33

one exception was the MMR series which had a difference of 17.3 percentage points for
complete care between the two subsets and a higher adequate level for children who did
not begin their immunizations on time. The overall coverage for immunizations before
age two was about equal with inadequate care levels of 35% and 41.5% for the MMR
series. Overall, starting immunizations on time yielded an increased percentage of children
having received complete and adequate care at two years of age.

Question 5. What are the differences by race in the percentage of complete,
adequate, and inadequate care for all immunizations?

The cross tabulation and chi-square analysis of the adequacy of care for all series
of immunizations by race is illustrated in Table 5. As reflected in the overall sample, only
a small percent of subjects received complete care. When separated by race, five of the 53
white subjects (9.5%) received all immunizations according to the recommended

schedule, as compared with one of the 24 non-white subjects (4.2%). The percentage of

Table 5
Cross Tabulation of Adequacy of Care for All Immunization Series by Race (p = 77)

 

 

 

Race
Care Level White Non-white

Complete

Frequency 5 1

Percent 9.5 4.2
Adequate

Frequency 1 8 8

Percent 33.8 33 .3
Inadequate

Frequency 3 1 5

Percent 56.7 62. 5

 

xz (df2, p = '77) = 0.688, p > 0.05

34

adequate care was essentially even for the white and non-white subjects (33.8% and

33.3%, respectively). The level of inadequate care, however, was unequal with 62.5% of

the non-white sample and 56.7% of the white sample not having received all their

immunizations by age two. The differences in the levels of care were not statistically

significant. This could be due to the small numbers for the non-white subjects.
Discussion

The major findings of this study were that immunization levels in this population
of MCHD clinic patients were low overall with only about one-third (35.6%) of the
children up-to-date by their second birthday, far below the national goal of 90%
immunized by age two. Even worse, only 7% of the children received all of the
immunizations at the age appropriate periods. The results of this study are consistent with
other documented studies in that the immunization coverage rates of the studies in the
literature review did not meet the 90% goal.

The percentage of adequate care in this study was lower than what was reported
by the CDC (1996) in the National Immunization Survey (NIS) for the 4:3:1 :3 series
within the state of Michigan (59%). The NIS did not report county data but did report the
coverage rate of 49% for the city of Detroit (CDC, 1996); this percentage for the city of
Detroit falls closest to the level of coverage found in the current study. Further, the rates
for complete and adequate care in this study fall within the ranges found by Zell et al.
(1994) of 1 l to 58% coverage for adequate care and 5 to 20% coverage for complete
care. Salsberry et al. (1994) also found a low rate of adequate care (31%). It is dificult to
compare results of the current study with those found in the literature because of the
many differences in the population sampled. The only study found with similar
sociodemographic information was the NIS which was done for the state of Michigan
(CDC, 1996).

The Ambrose (1995) study was similar to the current research since it was done

with health department records. The Ambrose study found no cases with complete care

35

but had an overall higher rate of adequate care (45%) than this study (28.7%). This
difference in rates of complete and adequate care may have been due to a computation
error found in the Ambrose study when the current study data analysis was completed.
The limitation of assessment of the sociodemographic information due to missing data
and small race numbers was consistent in both studies.

There are many reasons for the results obtained in this study. One main limitation
to this study which could be reflected in the results is the lack of ability to track the
children. A number of the cases which received inadequate care had missing data which
could have been due to parents taking their children to another provider for the
completion of the immunization series. Thus, these children would have received all their
immunizations but within this study there was no means of tracking them to validate this
possibility without direct contact of the child’s parent. There was no system in which this
researcher could have determined which records were incomplete for this reason and so
all eligible records were included in the study.

Data records provide no insight into the barriers for childhood immunizations.
Problems with inadequate and inaccurate data entry creates an inherent weakness in a
records audit such as in this study. Also, according to Murphy et a1. (1995), “clinic audits
are most reliable when the population is stable and attends a single clinic (p.565).” The
MCHD has recognized the inadequacies in their computer data system and are currently
setting up a county-wide database to track the immunization records of children even if
they receive vaccinations at an alternate provider. This new database should improve the
accuracy of the records and improve the ability to assess this level of care for the children
in Muskegon County.

The barriers for children not receiving immunizations have been well documented
in the literature and include cost, lack of insurance coverage for preventive care such as
immunizations, missed opportunities, and limited access to health care such as

transportation or restricted clinic hours (CDC, 1994b; Salsberry, Nickel, & Mitch, 1993,

36

1995).Barriers specific to parental attitudes, cultural beliefs, knowledge, and
misunderstandings regarding immunizations can affect receipt of vaccinations for
children. Parental attitudes and misunderstandings of the prevalence and severity of the
communicable diseases for which children can be immunized can play a large role in the
receipt of immunizations. For instance, if parents believe that their children will not catch
these diseases, or that they will not be very ill if they do contract the disease, parents are
more likely not to obtain their children’s recommended immunizations. Also, cultural
beliefs regarding religious and health promotion practices of health care can positively or
negatively affect immunization rates. Barriers to adequate care can also be due to the
provider and include missed opportunities, lack of knowledge regarding true
contraindications of administering the vaccination, and not keeping up with current
changes in the recommended schedule (Kefelas, 1993; Lyznicki & Rinaldi, 1994).

Within Muskegon County, the community from which the data for this study was
obtained, some barriers can be addressed which are specific to this urban/suburban/rural
population. Muskegon County has large inner-city and rural populations which are, in
general, economically depressed. This low socioeconomic status creates unique problems
in accessing health care including immunizations. Parental barriers which can be identified
as the most relevant to this community include lack of insurance which leads to out-of-
pocket costs for health care and limited access to health care, especially transportation to
primary care clinics.

All the previously listed barriers could apply to clients seeking immunizations at
the MCI-ID. Additional barriers specific to a public health clinic could affect the level of
adequate care found at the MCHD immunization clinic. The first of these is the necessity
of two visits for the parents and children; one to obtain well-child care at the primary care
provider’s office and the second to receive immunizations at the health department. In
addition to limited access problems, forcing families to make two health care

appointments four or five times in the first two years of life could decrease the rate of

37

immunization coverage (Bobo et al., 1993; Salsberry et al., 1994). Secondly, the facility is
located in Muskegon township, making it less accessible to the city and rural residents of
the county. As mentioned previously, outreach clinics are organized to minimize this
limitation. Lastly, there are often long waiting periods to receive immunizations at the
clinic and a stigma attributed to families who obtain services at the health department and,
therefore, parents are often hesitant to seek out services at a health department.

Media coverage and the increase in government programs and money toward
increasing immunization rates for two year olds in the past three years could be a reason
for the result of a greater percentage of children having received complete care with birth
dates in 1994 over 1993 (CDC, 1994a; Osguthorpe & Morgan, 1995; Robinson et al.,
1994). Perhaps parents are becoming more aware of the recommendations and benefits
regarding immunizations. The recent findings of low coverage rates by the NIS (CDC,
1996) have instigated a flurry of campaigns and media coverage to increase public
awareness of this problem. It will be interesting to observe if the immunization coverage
rates for two-year-old children in 1998 increase due to this national attention.

The rates for complete and adequate care vary widely for the individual series of
immunizations. The DTP and Hib series reflect the same coverage rates for complete,
adequate, and inadequate care. This may be due to similar recommended schedules for
each series. The OPV series has the highest level of adequate care (38.6%) and
immunizations received before age two (62.3%). This series has the greatest amount of
flexibility in the recommended schedule, especially for OPV3 which has a recommended
range of six to 18 months. This wide range for complete care is a reason the OPV series
had the highest level of adequate care. Also notable is that each. series has a higher rate of
adequate care than complete care except the MMR series. The MMR is a single
vaccination before age two, has a range of three months (12 to 15 months of age) to be

considered on-time, and is usually given at 12 months of age which is also a common age

38

to have a well-child visit. These three factors could result in the high level of complete
care for this series.

The low rates of complete care found in this study are of particular concern since
the greatest benefit from the DTP and Hib vaccines is achieved when each series is
completed in the first six months of life as recommended (Mustln et al., 1994). These low
numbers are reflected in the rapidly decreasing rates of adequate care shown for each
individual vaccination. The drop in immunization coverage starts early in infancy with
40% not starting their vaccinations on time and less than 30% having received complete
care by their third DTP and Hib. This decrease in the proportion of infants who receive
immunizations on time may reflect a combination of parental and provider barriers
discussed earlier and restrictions of the recommended schedule such as that the first three
immunizations are scheduled close together and may be difficult to catch up a child who
has started their immunizations late (Guyer et al., 1994).

The largest decrease in the rate of adequate care is between the third and fourth
doses of DTP and Hib vaccines. This is consistent with other studies which found that
when the fourth dose of DTP was excluded from the analyses, coverage levels improved
(Bobo et al., 1993; Zell et al., 1994). This decrease in coverage levels can be attributed to
difliculties in administering the fourth DTP and Hib, misconceptions regarding approved
simultaneous administration of MMR, DTP, and Hib vaccinations at 12 months of age
(CDC, 1995b), and large amount of time in the recommended schedule between the third
doses at six months and the fourth at 12 months which could cause the parents to forget
that the children are due at this time.

As noted earlier, timely receipt of the initial doses of DTP, Hib, and OPV were
associated with a higher appropriate vaccination rate at 2 years. This finding is consistent
with other studies although the percentage of impact varied with each study. Fielding et
a1. (1994) found that of 50.6% of children who received their first DTP late were firlly

immunized at 2 years compared with 72.2% of those who received the first DTP dose as

39

recommended at 2 months. Bobo et a1. (1993) found that a delay in the receipt of the first
set of immunizations was associated with more than a twofold difference in rates (3 0%
versus 70%) for receiving all immunizations by age two. This association could be due to
many factors. Perhaps parents who obtain their children’s first set of vaccinations on time
are less likely to have barriers to immunizations or limited access to the health care
system which would also affect subsequent receipt of immunizations. Also, parental
knowledge of the importance of vaccinations and immunization schedules could affect
timely initiation and proper scheduling of vaccinations (Fielding et al., 1994). Thus, initial
immunization delay provides an important predictor of lower immunization status at two
years of age.

Race has been shown in the literature to be a predictor of immunization status
with non-white children having lower rates of immunization coverage at two years of age
(Fielding et al., 1994; Lieu et al., 1994; Mustin et al., 1994). This research study found
no statistically significant difference in the rates of complete, adequate, and inadequate
care for the white versus non-white subjects. These findings do not follow the results of
the majority of the literature but this may be due to the small numbers of non-white
subjects (p = 24) and the number of missing or ‘race unknown’ data m = 24). Race is not
a totally definable demographic statistic such as gender or age and thus increases the
difficulty in interpretation of the results. This is a limitation within this study due to the
responsibility of the health department employees in classifying the clients into a race
category. These employees must be inserviced on the importance of filling in this
information on each record and inquiring of the parents the appropriate category for their
child.

Discussion of Results with the Theoretical Framework

The results from this study support the adapted theoretical framework from

Starfield (1974, 1992) of evaluation of primary care through measurement of adequacy of

care. The immunization status of two year old children is the outcome in the Starfield

40

model when applied to this study. This desired outcome of adequacy of care related to
immunization status was shown to be an accurate predictor in a primary care setting of
the health status of a child. The findings of low immunization status within this study
reflects that the health status of two year old children is compromised due to risk of
contracting preventable communicable diseases. The interaction of the structural
components of immunization records from the MCHD, the process or receipt of
immunizations, and the social and physical environment of race, gender, age, and
insurance status of the subjects helped to determine the outcome of low immunization
status at two years of age.

The reasons behind these findings, as discussed in the previous section, can be
applied to the Starfield Model through classification within the components of structure,
process, and social and physical environment which influence the outcome of
immunization status. Examples of this include limited access to the public health clinic
due to restricted hours and location which, in the Starfield Model, are characteristics of
the structure component. Also, missed opportunities by parents and providers can
negatively impact a child’s immunization status and is classified in Starfield as a
characteristic of the process component.

Implications for Advanced Practice Nursing in Primary Care

This study was designed to discover the level of adequacy of care through analysis
of immunization rates for two year old children who received their immunizations at a
public health clinic. The major findings of this study include: 1) low immunization rates
for this sample which fell well below the national expected goal of 90% and 2) higher
rates of complete and adequate care associated with starting immunizations on time per
the recommended schedule.

Many implications for the advanced practice nurse (APN) arise from these major
study findings. Specifically these include educational, research, and clinical measures to

increase immunization status for two year old children. Preschool children remain at high

41

risk for preventable diseases when they are underimmurrized as shown in this study. The
APN in primary care has the opportunity to impact this inadequate state of care through
education, research, and practice.

Lack of education has been cited many times in the literature as reasons for the
low rates of immunization coverage found throughout the country (Bobo et al., 1994;
Salsberry et al., 1994). This lack of education encompasses parents, providers,
communities, and the national government. The APN in primary care can impact this
aspect of underimmunization because if education can be identified as a problem, then
education can also be a solution.

Education of parents can begin prenatally with the introduction of immunization
practices and benefits at meetings between expectant parents who are interviewing
potential APN providers for care of their newborn. Collaboration between prenatal care
providers and the APN in primary care can enhance the learning experience of the parents
through the dissemination of consistent and reliable information to every family. The
importance of immunizations for children age two and under can also be addressed after
birth with a postpartum visit from the APN in the hospital during maternal discharge or
infant assessments for discharge, to discuss early care of the infant including the timing of
immunizations and well-child care visits. At this time, two week and two month well-
child visits can be scheduled with the APN to increase the rate of children receiving their
first immunizations on time at two months which, as shown in the findings of this study,
can increase the chance of receiving all immunizations by age two.

After birth the APN must involve parents in health promotion and illness
prevention interventions for their child(ren). Immunization of children under the age of
two is one of these interventions. Involvement in the child’s care includes educating the
parents on the risks, benefits, and side effects of each immunization. Discussions would
also include dissemination of current research, the importance of beginning immunizations

on time to increase the rate of receiving all immunizations by age two and decrease the

42

morbidity associated with these diseases, and a copy of the current recommended
schedule. All together, this information allows the parents to make knowledgeable
decisions regarding illness prevention health practices for their child. The APN can use
the opportunity of each contact with the families to continuously reinforce and educate
parents regarding proper timing of immunizations and their importance in preventing
disease in young children.

In addition to education of parents regarding the cost-effectiveness of on-time
vaccinations and the risks of morbidity and mortality associated with undervaccination,
the APN must assess parental beliefs and attitudes toward immunization to specifically
address individual parents’ concerns. The unique relationship established between the
APN in primary care and the child and his/her family can support communication of these
parental concerns and help to dispel incorrect attitudes or beliefs regarding
immunizations. Also, concrete approaches to education could be used by the APN to
impress upon parents the severity of the problem of undervaccination. One example of a
concrete application of education is a monetary incentive program when a child obtains
all recommended immunizations before age two. The APN could locate local sources for
these incentives from area businesses or non—profit organizations such as March of Dimes
or United Way.

In addition to education of parents to increase immunization rates, education of
primary care practice staff and providers can also help to increase vaccination coverage
rates for the health care system. Dissemination of current immunization research by the
APN to other providers and the office or clinic staff will keep everyone involved in the
child’s care aware of the most recent information. This education would include
inservices on the current changes in the recommended immunization schedule, true
contraindications for administration of immunizations to decrease missed opportunities,
and current standards of immunization practices. Also, since installation of a reminder

system for upcoming immunization appointments and recall messages to families after

43

missed appointments has been shown to have positive results on immunization coverage
rates (Grabowsky & Marcuse, 1996), this information could be utilized by the primary
care practice to increase the rate of children who receive their vaccinations by age two.

Discussion and education regarding the implications of this study on managed
care environments must be addressed by the APN since immunization status of clients is
included as a component of provider evaluation in the ‘report card’ distributed by
managed care companies. As clients are assigned primary care providers within the
managed care environment, it will be the responsibility of this provider to ensure that
clients are properly immunized. Managed care environments can decrease fragmentation
of care, increase use of case management, and promote use of a tracking system with
reminder cards. These three aspects of managed care can help to increase immunization
status through identification of ‘at risk’ client such as those who do not begin their
immunizations on time.

Communities can be educated by the APN on the benefits to society of high
immunization rates. These benefits include lower health care costs and a decrease in the
morbidity and mortality associated with totally preventable diseases. The APN can access
community educational programs of church groups, school health education programs,
parenting classes, and prenatal classes to disseminate this information. Also, it has been
well documented that high risk groups for inadequate immunization coverage include low
income, underinsured, and single parent families (Bates etal., 1994; Bobo et al., 1993).
These findings would encourage the APN to access community programs which are
designed for low income families and teenage mothers such as Women, Infant, and
Children (WIC) supplemental food program centers and teenage prenatal classes.

Local publicity programs can be instituted with firnding fi'om area businesses to
increase the awareness in the APN’s community. Recently in Muskegon, the MCHD
cooperated with area McDonalds restaurants to disseminate information regarding the

dangers of lead poisoning by creating placemats on the food trays which had pictures and

44

facts about lead hazards. This same idea of teaching through local businesses could be
applied to immunization education which would increase the community’s awareness of
the need for vaccinations and the dangers of underimmunizing their children. A concern
regarding this approach is the need for continuity of care. The education should focus on
the importance of receiving all immunizations by age two to increase immunization rates
and decrease the morbidity and mortality for this at—risk age group.

A last area for education by the APN is the national government. It is important
for the APN in primary care to inform local, state, and national governments of research
findings regarding factors which have been found to positively or negatively impact
immunization coverage rates such as beginning immunizations on time to increase
coverage rates at two years of age. This information will help to increase government
awareness of the risks of the current low immunization status of two year old children
and to also increase funding and programs which can improve these numbers.

One program which has been proven to increase immunization rates in other
countries is a national tracking system for health care (Preventive Health Care, 1992).
These systems enter the child’s information from the birth certificate into a database and
are designed to assure continuing participation of the infant in one or more systems of
health care throughout childhood. Nearly all infants in the United States are registered
with official agencies after birth when birth certificates are filed (Preventive Health Care,
1992). However, there is no system of tracking these children for appropriate health care
till they enter the educational system unless they are associated with a primary care
provider who assumes this case managing responsibility. The APN can educate
government ofiicials on the benefits of this system and assist in development of legislation
which supports policies and programs such as this which increase immunization coverage
rates.

A second measure which the APN can utilize to increase the level of adequate

care for children under age two is that of research. As mentioned previously, through

45

dissemination of research findings of current immunization coverage rates and reasons
behind these numbers the APN will help to increase personal and public awareness of the
importance of maintaining adequate care for children under age two. Also, the APN can
use research findings to guide his/her practices in the primary care setting regarding
immunizations. Many research findings, such as the drastic decrease in level of adequate
care of individual vaccines over the first 18 months of life or recent changes in the
recommended immunization schedule, can alert the APN to the importance of following
children through tracking and reminder systems to increase coverage rates.

The importance of following the coverage rates for two year old children at state
or local levels has been shown throughout the literature (Bobo et al., 1993; Zell et al.,
1994). However, assessment at city and individual practice levels is also important
because coverage levels found for large geographic areas can hide local areas and
populations which are underimmunized and at high risk for outbreaks of vaccine-
preventable diseases (Zell et al., 1994). APNs in primary practice can calculate their own
clinic’s childhood immunization rate to obtain an awareness of immunization barriers
which are specific to the clinic and to potentially increase the level of care. One example
of potential barriers to increasing immunization rates is a study which evaluated missed
opportunities and found that high rates of well-child visits in a practice are not always
associated with high rates of immunization coverage (Grabowsky & Marcuse, 1996).
This finding in a clinic setting could impact the APNs policy toward assessment of
immunization status at each visit and administration of vaccinations to increase coverage
rates. Chapman and Hacker (1995) report on a family practice office which evaluated the
coverage levels of two year old children who attend the clinic. These authors report the
immunization rates found and state that calculation of a clinic’s immunization rate can be
easy and have modest costs.

Clinical measures is the final area through which the APN can impact the level of

care for two year old children. As providers of pediatric primary care, APNs assess the

46

need for immunization; plan the schedule for the child’s vaccinations and, if needed,
utilize the minimum spacing of immunizations to ‘catch up’ a child who is not on time;
directly or indirectly administer the vaccine; and document administration. APNs can raise
immunization coverage levels among their patients through utilization of all appropriate
opportunities for vaccination, giving patients all vaccines for which they are eligible, and
awareness and use of only valid contraindication for administration. Assessment of a
child’s immunization status at each visit, regardless of the reason the parent is seeking
care, can increase level of care. Also, the APN can increase the rates of immunization
coverage for his/her patients through institution of a tracking system to identify children
at higher risk for underimmunization such as children who begin their immunizations late.
Lastly, use of appropriate standards for immunization practices can assure that the APN
will continue to provide adequate levels of care for two year old children.
Recommendations for Further Resea_r_ch

This investigation revealed several possibilities for firture research. First is the
need to find an adequate system of assessment to measure two year old immunization
rates. As identified in the literature review, parental recall is a frequently used assessment
technique which is often inaccurate or incomplete and clinic audits, such as the current
study, assess only a small segment of the community. This limitation of assessment
techniques encourages a need to develop an accurate system to monitor trends in
immunization coverage. In addition, continued analysis of immunization status of two
year old children is needed to track movement toward the year 2000 goal of 90%
immunization coverage.

A second recommendation for fiJture research is the assessment of not only the
coverage rates but also concurrent assessment of perceived parental and provider
barriers. This research could help the APN understand how and why children receive their

immunizations late and off schedule. For example, for the children who received their first

47

immunization on time, what was the reason for delayed receipt of the subsequent
immunizations?

The addition of several steps to the current research could have revealed more
information for the MCHD immunization clinic data. First, follow-up of records with
missing information would increase the reliability of the results of this study.
Determination of whether the missing data was due to receipt of the vaccine at another
site could be done by contacting the parents to verify this data and also access any other
immunization records. Verification of missing data could also be done through other
providers to confirm immunization status. The implementation of a county wide
immunization database as discussed previously will also help to increase the reliability of
the data since, eventually, all pediatric providers in the county will have access to this
computer system to update immunization records. Secondly, additional information, such
as coverage rates divided by race and percent coverage for 2, 4, 6, 12, 15, and 18 months
of age could reveal new implications and interventions for the APN.

Lastly, use of a larger, more diverse sample could improve the reliability and
generalizability of this study. A larger sample would help to more accurately determine
any statistical differences in immunization rates for race, insurance status, and economic
status as found in other studies.

Summary

This study assessed the adequacy of care for children under two years of age
through immunization coverage rates. The levels of complete, adequate, and inadequate
care were evaluated for a sample of records of children fiom the Muskegon County
Health Department immunization clinic. The level of complete care within this study was
only 6.9%; adequate care, 287%; and inadequate care, 64.4%. The findings of this study
support other studies that current immunization rates fall well below the Healthy PeOple
20%), goal of 90% coverage. Specifically, this study identified that the subset of children

who received their first immunizations at two months were twice as likely to receive all

48

immunizations by age two. There was no significant difference in level of adequate care
for white and non-white groups.

The findings of this study will assist the APN in improving the immunization
coverage rates for children under age two through education of parents, communities,
and government; dissemination of research and periodic assessment of coverage levels;
and clinical application of the research findings in practice. Increasing the coverage rates
of immunization for two year old children is important to decrease the morbidity and
mortality associated with totally preventable diseases. Prevention of health care problems
in early childhood can benefit a child for a lifetime, and failure to prevent such problems

can be costly to the child, the child’s family, and the Nation.

APPENDICES

APPENDIX A

UCRIHS Approval

 

OWEEW‘
RESEARCH
AND
GRADUATE
STUDIES

University Committee es
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5173554180
FAX1517l432-1171

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49

APPENDIX A

UCRIHS Approval

MICHIGAN STATE

 

UNIV

ERSITY

May 17, 1996

To: Patricia Jurcich
10$ Harmony Lane
Muskegon, I 49445
RE: IRE“: 96-354
TITLE: ADEQUACY OF IMMUNIZATION FOR CHILDREN BY AGE TWO
YEARS
REVISION REQUESTED: N/A
CATEGORY: l-E
APPROVAL DATE: 05/17/96

The university Committee on Research Involving Human Subjects'IUCRIH51
review of this project is complete. I am pleased to advise that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain infcrmed :onsenc are appropriate.

Therefore,
above.

RXNBWAL:

REVISIONS:

Pnosnms/
cannons :

If we can be of any future hel

che UCRIHS approved this project and any revrsrons listed

UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be end one year must use the green renewal
form (enclosed with c.e original approval letter or when a.
project is renewed) to seek u date certification. Therevrs a
maxrmum of four such expedrce renewals possible. Investigators

wishing to continue a project beyond that time need to submit it
agaln or complete :evzew.

UCRIHS must review any changes in rocedures involving human
subjects, :10: to insulation of c e change. If chrs is done at
the time o renewal. please use the green renewal form. To
revise an approved protocol a: any other trme durtng the year,
send your written request to the. CRIBS Chart, requesting revrsed
approval and referencrng the prOJeCC's IRS 8 and title. Include
in your request a descrrptron of the change and any revised
instruments. consent forms or adverczsements that are applicable.

Should either of the following arise during the course of the
work, investigators must notr y UCRIHS promptly: (l) roblems
(unexpected side effects comp aincs, etc.) involving uman
subjects or (2)_changes in the research environment or new
information lndtcacrng greater risk to the human sub eccs than
existed when the protocol was previously reviewed an approved.

lease do not hesitate to contact us

at (517)355-2180 or FAX (517legi- 171.

ncerel

CRIBS Chai
DEW:bed

vid 8. Wright,

 
    
 

Ph.D.
r

cc: Rachel F. Schiffman

APPENDIX B

Muskegon County Health Department Approval

50

APPENDIX B

Muskegon County Health Department Approval

MUSKEGON COUNTY

_ 1611 e. OAK AVENUE. MUSKEGON.MCHIGAN49M2 . 616-724-6311

MICHIGAN

ecm 0‘ OWNER!

emm4.m.cm

MG. InevwceCnoe

Om; soococe

”00'”.me

Matthieu-Id

new O-MW June 10. 1996

Laue Mom
CWO Stan

Patricia Jurcich. RN
105 Harmony Lane
Muskegon. MI 49445

Dear Patricia:

This letter confirms approval of your request to use Muskegon County Health

FAX 616-724-6674
HEALTH DEPARTMENT

Department immunization record data in your graduate research project Please submit

your request for data to Pat Burke. Microcomputer Analyst.

If you have any questions. please contact me at 724-1212.

Sincer 1y.

enneth A. Kraus. M.P.A.
Deputy Health Officer

pf
c: Pat Burke

REFERENCES

REFERENCES

Ambrose, K. (1995). Adequacy of immunization for children We two years.
Unpublished master's thesis, Michigan State University, Lansing.

Bates, A. S., Fitzgerald, J. F ., Dittus, R. S., & Wolinsky, F. D. (1994). Risk
factors for underimmunization in poor urban infants. Journal of the American Medical
Association. 272(14), 1105-1110.

Betancourt, H., & Lopez, 8. R. (1993). The study of culture, ethnicity, and race
in American psychology. American Psychologi_st,_4§(6), 629-637.

Bobo, J. K., Gale, J. L., Thapa, P. B., & Wassilak, S. G. (1993). Risk factors for
delayed immunization in a random sample of 1163 children from Oregon and
Washington. Pediatrics. 91(2), 308-314.

Boufi‘ard, K. (1995). Immunizing Michigan's children: What went wrong and what
can be done to improve Michigan's pitiful record? Michigan Medicine. 9402), 26-33.

Centers for Disease Control and Prevention. (1993). Standards for pediatric
immunization practices. Morbidityand Mortality Weekly Report. 42. Report RR—S.

Centers for Disease Control and Prevention. (1994a). Reported vaccine-
preventable diseases-- United States, 1993, and the Childhood Immunization Initiative.
Morbidity and Mortality Weekly Report,113(4), 57-60.

Centers for Disease Control and Prevention. (1994b). Impact of missed
opportunities to vaccinate preschool-aged children on vaccination coverage levels--
Selected U. S. sites, 1991-1992. Morbidity and Mortality Weekly Report. 43(39), 709-
711, 717.

51

52

Centers for Disease Control and Prevention. (19940). State and national
vaccination coverage levels among children aged 19-35 months-- United States, April-
December 1994. Morbidity and Mortality Weekly Report. 44(33), 613, 619-623.

Centers for Disease Control and Prevention. (1995a). Progress toward elimination
of Haemophilus influenza type B disease among infants and children-- United States,
1993-1994. Morbidity and Mortality Weekly Report. 44(29), 545-550.

Centers for Disease Control and Prevention. (1995b). Recommended childhood
immunization schedule-- United States, 1995. Morbidityzaid Mortality Weekly Report,
fl, RR-S.

Centers for Disease Control and Prevention. (1996). National, state, and urban .
area vaccination coverage levels among children aged 19-35 months-- United States,
April 1994-March 1995. Morbidity _a_1_1_d Moflality Weekly Report, 45(7), 145-150.

Chapman, R. W., & Hacker, T. W. (1995). Calculation of a clinic’s childhood
immunization rate. Archives of F afimily Medicine. 4. 625-627.

Dixon, M., Keeling, A. W., & Kennel, S. (1994). What nurses know about
immunization. Maternal and Child Nursing, 19(2), 75-78.

Fielding, J. E., Cumberland, W. G., & Pettitt, L. (1994). Immunization status of
children of employees in a large corporation. Joanal of the American Medical
Association, 271(7), 525-530.

Grabowsky, M., & Marcuse, E. K. (1996). The critical role of provider practices
in undervaccination. Pediatrics. 96(5), 73 5-73 7.

Guyer, B., Hughart, N, Holt, E., Ross, A., Stanton, 3., Keane, V., Bonner, N.,

Dwyer, D., & Cwi, J. (1994). Immunization coverage and its relationship to preventive

 

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