134
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2000

' LBQRARY

Michigan State
University

 

 

 

This is to certify that the

thesis entitled

ADEQUACY 0F IMMUNIZATION FOR RURAL CHILDREN
THROUGH AGE TWO YEARS

presented by

Barbara A. McNamara

has been accepted towards fulfillment
of the requirements for

Master of Sciencefiegreein Nursing

 

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E 333 professor

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11m chlRC/DmDmpSS-p.“

 

ADEQUACY OF IMMUNIZATION FOR RURAL CHILDREN
THROUGH AGE TWO YEARS

BY

Barbara A. McNamara

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

1999

ABSTRACT

ADEQUACY OF IMMUNIZATION FOR RURAL CHILDREN
THROUGH AGE TWO YEARS

BY

Barbara A. McNamara

This study investigated the level of adequacy of
immunizations in a rural county health department. The
Starfield model provided the framework for this
retrospective review. Analysis of the data included three
levels for adequacy of care: complete, adequate, and
inadequate.

The major finding of this study was a vaccination
coverage rate of 89.4% nearly meeting the national goal of
at least ninety percent of children fully immunized through
age two. Additional findings were 64.4% of children started
immunization on time, 32.9% received complete care, 56.5%
adequate care and 10.6% inadequate care. The advanced
practice nurse can use these findings to improve the
childhood immunization rate through clinical application,
education and dissemination of current research to health
care providers, and periodic assessment of clinic
immunization rates.

Further research needs to study the health of rural
children and the association between poverty and under

vaccination to target interventions and improve coverage.

ACKNOWLEDGMENTS

I would like to extend a special thank you to my
chairperson, Linda Spence, for her understanding,
encouragement, and wisdom. I would also like to thank my
other committee members, Patty Peek and Rachel Schiffman for
their support and feedback, and for the time they dedicated
to reviewing this thesis. '

I would like to acknowledge District Health Department

Number 10 for the use of the immunization data.

iii

TABLE OF CONTENTS

LI ST OF TABLES O O O O O O O O O O O O O O O O O 0
LI ST OF FIGURES O O O O O O O O O O O O O O O O O O

I NTRODUCT I ON 0 O O O O O O O O O O O O O O O O 0
Statement of the Problem . . . . . . . . . .
Study Purpose and Research Questions . . . . .

Theoretical Framework . . . . . . . . . . . . . .
The Starfield Model . . . . . .
Application of the Starfield Model to Study
Review of Literature . . . . . . . . . . . .
Critique of Literature . . . . . . . . . . .

Methods . . . . . . . . . . . . . . . .
Research Design . . . . . . . . . .
Sample . . ‘ . . . . . .
Operational Definition of Variables
Data Collection Procedures . . . .
Statistical Analysis of Data
Study Limitations . . . . .
Study Assumptions . . . . .
Protection of Human Rights .

Results 0 O O O O O O O O O O O O O O O O 0
Description of Sample . . . . . . . . . . . .
Answers to Research Questions . . . . . . . .

Discussion . . . . . . . . .
Discussion of Results Within the Theoretical
Framework . . . . . . . . . . . . . .

Implications for APNs in Primary Care .
Recommendations for Future Research . .
Recommendations for Formal Education . .

smary O C O O O O O O O O O O O O O O O O O O O 0
LI ST OF REFWCES O O O O O O O O O O O O O O O 0

APPENDIX A: UCRIHS Approval . . . . . . .
APPENDIX B: District Health Department #10 Approval

iv

Page

0
\IUIH

11
14
17

18
18
18
19
22
23
24
25
26

41
42
46
47

LIST OF TABLES

Page
Table 1: Demographics of Sample . . . . . . . . . . . . . 27

Table 2: Adequacy of Care for Each Immunization
series 0 O O I I O O O O O O I O O O O O O O O 3 0

Table 3: Adequacy Level for Individual Immunization . . . 30

Table 4: Adequacy Level for all Immunizations with
Respect to Initiation of Initial Set of
Immunizations . . . . . . . . . . . . . . . . . 34

Table 5: Adequacy Level for the Subset of Children
who Received Complete Care for the First
Set of Immunizations . . . . . . . . . . . . . 35

LIST OF FIGURES

Page

Figure 1: Starfield Model: A Basis for Evaluating
Pr imary Care O O O O O O O O O O O O O O O O O 1 0

Figure 2: Adequacy of care through immunization for
children age two years utilizing the
public health system . . . . . . . . . . . . . 12

Figure 3: Recommended childhood immunization schedule
From the ACIP, AAP 8 AAFP . . . . . . . . . . 20

Figure 4: Minimum age for initial vaccination and

minimum interval between vaccine doses, by
type (CDC, 1995) O O O O O O O O O O O O O O O 23

vi

INTRODUCTION

Immunization, one of the most fundamental of preventive
services, is efficacious, cost effective and an essential
component of comprehensive well child care. Direct and
indirect savings to society range from $29.10 for every
dollar spent on DTP vaccination to $2.00 saved for each
Hepatitis B immunization (Orenstein, 1997).

Children in the United States receive vaccinations
against ten diseases from birth until school entry. The
current schedule of immunizations recommended by the
Advisory Committee on Immunization Practices (ACIP), the
American Academy of Pediatrics (AAP), and the American
Academy of Family Physicians (AAFP) includes diphtheria,
tetanus, pertussis (DTP), Haemophilus B influenza (Hib),
polio, mumps, measles, rubella (MMR), hepatitis B (HBV), and
varicella. Approximately five visits are required during
the first two years of life to adequately immunize children.
During this period, children are most susceptible to the
morbidity and mortality associated with vaccine-preventable
diseases.

An important relationship exists between immunization
and the use of other medical services. State laws enacted

in 1979 require complete immunization for school entry, but

1

immunization rates among younger children signal the overall
adequacy of well child care. Well-child care is an integral
part of family-focused preventive and primary care.

Although limited, data consistently indicate a preventive
health care deficit exists in rural America (Harris &
Leininger, 1993). Several characteristics associated with
lower levels of preventive care are more predominant among
rural clients when compared with urban clients. Rural
clients tend to be poorer, less educated, less well insured,
and have access problems related to lack of transportation
and greater distances to care (Harris & Leininger, 1993;
Slifkin, Clark, Strandhoy, & Konrad, 1997). In addition,
their communities are often designated as health care
personnel shortage areas. Not surprisingly, recent evidence
identifies rural residents as a population at greater risk
for many types of injuries, disease, and disability than
urban residents (Goeppinger, 1993; Knollmueller, 1994).

Also of concern is the trend for primary care
physicians, according to Hueston, Meade, and Mainous (1992),
to increasingly curtail the practice of offering childhood
immunizations in their office due to liability issues, cost
of vaccines and inconvenience. Discontinuation of childhood
immunizations is more common among rural practitioners.
Discontinuity of care and referral to county health
departments may cause children, especially those living in

rural areas, to miss or delay recommended vaccinations.

As part of a national health strategy focusing on
disease prevention and health promotion, Health¥_2egple;_1he
WWW
Prexention (U.S. Department of Health, Education and Welfare
(DREW), 1979) established broad goals for improving the
health of Americans by the year 2000. Immunization of
children was identified as an objective. Healthy_£ggplg
Winn
ijegtiyes (U.S. Department of Health and Human Services,
1992) established as an objective the completion of the
basic immunization series of at least 90% of American
children by age two years. The Hea1thy_2egplg_zggg_3ggign2
1225:1222 (National Center for Health Statistics, 1996)
revised the wording of the objective to reflect completion
of the basic immunization series through age 2 (35 months)
rather than by age 2 (24 months). This revision reflects
changes in data sources on immunization coverage that have
occurred resulting in the measurement of immunization levels
among preschool children 19-35 months old.

The development and widespread use of vaccines has been
vital in reducing the incidence of infectious diseases,
especially childhood diseases during the past half century.
Reported cases of measles in the United States decreased by
95% within 5 years of vaccine licensure (Markowitz, Preblud,
5 Orenstein, 1989) and pertussis decreased to one hundredth
of the prevaccination levels just 10 years after beginning

routine immunization (Cherry, Baraff, & Hewlett, 1989).

3

The marked decrease in the incidence of vaccine-
preventable diseases is associated with immunization rates
of 95 per cent or more in school-age children (Hinman,
1988). These immunization rates are the direct result of
enactment and enforcement of school immunization laws in
each state.

Unfortunately, there is no mechanism such as a
nationwide registry that tracks immunizations to achieve
similar rates among preschoolers and thus extend the
decreases in disease burden and mortality to this younger
age group. The measles resurgence that occurred in 1989 was
attributed primarily to a failure to vaccinate preschool-
aged children early in their second year of life (National
Vaccine Advisory Committee, 1991). In 1993, 5,793 cases of
pertussis were reported among preschool-aged children; 68
per cent of these children were less than one-year of age
(CDC, 1994a). Only 55% of 2 year olds (19 to 35 months)
have received the basic immunization series (four DTP, three
polio, and one MMR; 4:3:1) according to data from the 1992
National Health Interview Survey (CDC, 1994c). In 1994,
Michigan had the lowest immunization rate of all 50 states.
Only 61% of Michigan two-year-olds were fully immunized,
while nationally 75% of children ages nineteen through
thirty-five months had up-to-date immunizations (Bouffard,
1995). Despite this significant increase overall
nationwide, the 1995 National Immunization Survey documented

coverage rates for the 4 DTP, 3 polio, 1 measles containing

4

vaccine series (4:3:1) varied as much as 23 percentage
points between the highest state and the lowest state. A
variance of 25 percentage points in vaccination coverage
rates occurred between the highest city and the lowest city
(Orenstein, 1997). Based on data collected by the National
Immunization Survey from July 1996 to June 1997, Michigan's
vaccination coverage rate has improved and is no longer the
lowest in the United States. For the 4:3:1 series, the
vaccination coverage rate in Michigan is 76% and for the

:3:1:3 series (4 DTP, 3 or more doses of Hib, 1 MMR, and 3
polio) it is 73% among two year olds (CDC, 1998).

Despite the increase in vaccine coverage rates, the
United States is far from achieving the goal of at least 90
percent of American children completing the basic
immunization series through the age two. Fortunately, the
measles epidemics of 1989-1991 have resulted in renewed
national focus on achieving the elusive immunization goal
established in 1979.

Statement_nfi_the_229blem

Despite the proven efficacy and cost-effectiveness of
vaccines and the existence of many national immunization
programs, nearly one million two-year-olds are not fully
immunized. More than 20% of American children two years of
age are not fully protected against all preventable
childhood diseases (CDC, 1997a). Vaccination coverage
levels consistently remain below the goal of at least 90

percent of American children completing the basic

5

immunization series through age two established by Healthy

2gQp1g_zggn_neyien2_122§;122fi (National Center for Health

Statistics, 1996). Although the vaccination coverage rate

in Michigan has significantly increased from 61% in 1994

(Bouffard, 1995) to 73% according to the National

Immunization Survey data collected from July 1996 through

June 1997, it continues to fall short of the national goal

(one, 1998).

Multiple barriers to obtaining and receiving
immunizations may be grouped into three main categories:
parental barriers, provider barriers, and systems barriers
(Grover, 1996). Parental barriers are identified as
financial, lack of knowledge regarding immunizations and
concern about adverse effects (Grover, 1996; Kimmel, Madlon-
Kay, Burns, & Admire, 1996). Provider barriers include
missed opportunities to vaccinate. A missed opportunity to
vaccinate occurs when a child who needs immunization seeks
health care and either receives no immunizations or fewer
than needed. Missed opportunities occur in two ways:

1. the child does not receive immunization because of a
condition inaccurately perceived by the provider as a
contraindication or all indicated vaccinations are not
administered simultaneously, and

2. a child needing immunization, but seeking other health
care services, is not immunized because the
immunization status is not reviewed or the 6

vaccination is not administered (Orenstein, Atkinson,

6

Mason, & Bernier, 1990; Salsberry, Nickel, & Mitch,

1995).

In a study conducted by Salsberry, Nickel and Mitch
(1994), parents rated missed opportunity as the fourth
greatest barrier out of 17, behind cost, lack of insurance,
and office wait too long. Providers rated missed
opportunity as the third greatest barrier to immunization,
behind parents forgetting the immunizations or not knowing
when they are due.

Systems barriers include economics, limited clinic
hours, inaccessible clinic locations, insufficient clinic
staff, financial screening, and requirements for
appointments, physical examination, and enrollment in
comprehensive care well-baby clinics (Grover, 1996;
Orenstein et al., 1990; National Vaccine Advisory Committee,
1991). These barriers may discourage parents from obtaining
immunization services for their children.
W

The purpose of this study was to examine the adequacy
of immunization of rural children through thirty-five months
of age receiving immunizations at a local county health
department. This study was patterned after Ambrose (1995)
and Jurcich (1996) and addressed the questions:

1. What percentage of children from a local health
department in rural northern Michigan obtain complete
care, adequate care, or inadequate care with respect to

all immunizations through age two years as recommended

7

by the Advisory Committee on Immunization Practices

(acre) ?

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

3. 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 through age two years?

4. For the subset of children who received complete care
for the immunizations recommended to be given at two
months, what is the percentage of complete, adequate,
and inadequate care for subsequent immunizations?

Theoretical Framework

The.£tnz£ield_flndfil
The variables in this study were derived from

Starfield's model for assessing primary care (Starfield,

1992). This model provides a framework for measuring and

evaluating the attainment of primary care by examining the

structure and process of a health services system and the
influence exerted on the outcome of care.

Starfield (1992) acknowledged genetic structure, social
and physical environment, individual behaviors and health
services as factors which interact to determine the health
status of individuals and populations. The health services
system, although a less important determinant of health,

reflects the contribution of primary care.

8

Each health services system has three main components:
structure, process and outcome that are the principal
elements in the Starfield model (Figure 1). The fourth
component, the social and physical environment, interacts
with the previously mentioned components to influence the
desired health status and outcome of care.

Structure, as a variable, is defined as the resources
necessary to provide services and consists of nine
components. These nine components are: 1) personnel;

2) facilities and equipment; 3) management and amenities and
governance of services; 4) range of services; 5)
organization of services; 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 service system are composed
of two elements. The first element represents the
activities of the health care professional in the provision
of care. These activities include problem recognition,
diagnosis, treatment, and reassessment of the problem. The
second element consists of activities of the individual or
population in the receipt of care. These activities include
utilization, acceptance, satisfaction, understanding and
participation with the health care provided.

Outcome of care is the effect or impact that the

structure and processes of the health services system have

The Health Care System

 

STRUCTURE

 

Personnel

Facilities and Equipment
Range of Services
Organization

Management and Amenities
Continuity
Accessibility

Financing

Population Eligible

 

 

Provision
/ of care

PROCESS- I

Problem recognition
Diagnosis
Management
Reassessment

 

 

 

Persons

 

 

‘V

 

 

#4
le—v

 

 

 

k

Receipt
of care

 

Utilization
Acceptance and satisfaction
Understanding

Social
And
Physical
Environment

 

 

 

 

OUTCOME

 

Participation
Longevity
Activity

Comfort

Perceived well-being
Disease

Achievement
Resilience

 

 

 

Figure_12 Starfield Model: A Basis for Evaluating Primary

Care (Starfield, 1992).

10

 

on the health status of an individual or population.
Starfield (1992) identified seven components of health
status: longevity, activity, comfort, perceived well being,
disease, achievement and resilience.

The social and physical environments represent aspects
of the individual's and the health services system's
culture, society and environment that {Bfluence the
structure, process and outcome.
Annlisatien_nf_the_Starfield_uodel_tn_3tud¥

The conceptual definitions in this study were patterned
after those of Ambrose (1995) and Jurcich (1996). The main
variable from Starfield's model used in this study was
outcome, as shown in Figure 2. Variables interacting with
and influencing the outcome were structure, process, and
social and physical environment.

atzngtnzg. Structure is defined as the resources
necessary for a health services system to provide care. The
structural components in this study were the facilities,
equipment and the nurses administering immunizations as well
as the immunization records for selected subjects who
obtained vaccinations at a local health department in rural
northern Michigan. At each clinic visit, parents are asked
if their child has received any immunizations at another
site, such as a private health care office, since the last
visit. If parents are unable to provide documentation of

additional immunizations, a telephone call is made to the

11

 

STRUCTURE Immunization Records

 

 

 

 

 

 

 

 

 

 

 

 

 

For
\\ Crawford County/State of ‘
Michigan Residents
Reception of
Immunizations: Socio-
demographics:
DPT/DTaP 1-4
PROCESS 3:: 1'3 E Age .
Reception of Care . Rural Setting
Hlb 1’4 Medicaid/
\\ HBV 1'3 Non-Medicaid
A
Male/female children ‘1-

rural county health
department for
obtaining immunizations l

whose parents use I

 

 

 

 

 

 

\\ Biological Resilience
Measured by <~
OUTCOME Adequacy of Immunization:

Complete Care
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).

12

site where the immunizations were given to gain the
information. The additional immunizations are entered into
the computer at the health department and asterisked to
denote they were obtained elsewhere.

Ezeeeee. Process refers to obtainment of vaccinations
by the children (Figure 2). The parents or their designated
representative are also included in the process as they are
instrumental in determining when, where, and if the child
becomes vaccinated. In this study, the process was limited
to whether vaccinations were or were not obtained. Factors
such as missed opportunities, barriers and facilitators to
obtaining vaccinations, and the health seeking behaviors
taken by parents and children to receive vaccinations were
not addressed although they are a part of the process and
have an impact on the outcome.

Seeiel_end_2hyeieel_£nxitenment. Components of the
social and physical environment selected for this study were
age, sex, and insurance status. The defined service area of
health providers in Crawford County is federally designated
as rural. In rural areas, insufficient primary medical care
and public health services, increased rates of poverty, and
barriers such as transportation difficulties may inhibit
access to vaccinations and basic health care services
(Steiner, Lowery, Siegel, Barton, & Goodspeed, 1996). Each
of these components influences the structure, process and
outcome elements of the Starfield model. The structure

element is influenced by the community or population

13

eligible to receive the services provided by the health
services system. The health services system should be
knowledgeable regarding the sociographic and demographic
characteristics of the community or population in order to
maximize its potential. These characteristics also affect
the process element, receipt of vaccinations and the outcome
component, adequacy of vaccination.

Qnteeme. Outcome of care, also viewed as the impact on
health status, is affected by the structure of the health
system and the processes of care. Starfield (1992)
conceptualized immunizations under resilience, one of the
seven components of health status. She defined biological
resilience as the state of being appropriately immunized
against preventable diseases. Within this study, the
outcome of care was defined as the measurable adequacy of
immunization for the sample: complete care, adequate care,
and inadequate care (Figure 2).

Care was defined as complete when the child received
all vaccinations recommended by the ACIP at the prescribed
time through age two. Care was defined as adequate when the
child received all immunizations through age two but not at
the recommended times. Care was defined as inadequate when
the child had not received all recommended vaccinations
through age two.

Wm
The effectiveness of preventive health care, especially

immunizations, is well-documented (Orenstein et al., 1990).

14

Pruitt, Kline, and Kovaz (1995) focused on identifying
barriers to childhood immunization in a rural population.
In this study, 109 parents of infants and toddlers
identified as inadequately immunized or at risk for delayed
immunizations were interviewed. The number of children in
the family, the mother's age and the father's employment
correlated significantly with immunization delays. These
findings were consistent with other studies that found young
parental age, large family size, low socioeconomic status,
use of public clinics as the source of immunization, lack of
prenatal care, and late start of the immunization series to
be risk factors for poor or delayed immunization (Orenstein
et al., 1990; Robinson, Sepe, 8 Lin, 1993).

The primary reason identified by parents living in a
rural setting for delayed immunization was illness although
the Center for Disease Control and Prevention (CDC, 1989,
1994b) has recommended that children with minor illnesses
accompanied by fevers less than 38 degrees Centigrade
receive immunizations. Significant confusion existed about
when immunizations were due, reflecting the many changes in
immunizations over the last few years. Inconvenient clinic
hours, waiting time and cost of immunizations were also
identified as barriers (Pruitt et al., 1995).

Hueston, Meade, and Mainous (1992) assessed the
immunization utilization practices of 200 rural and urban
primary care physicians in Kentucky. The study noted that

urban and rural pediatricians were more likely to offer

15

immunizations to children in their practice, as were urban
family physicians and general practitioners. Rural family
physicians and general practitioners were less likely than
rural pediatricians to offer immunizations in their
practice. Sixty nine percent of urban physicians and 83% of
rural physicians stated they refer some patients to other
locations for routine immunization, usually the public
health department. Patient cost was the most common reason
for referral. The authors suggest therefore that rural
children may experience more missed opportunities for
immunization since rural children are more likely to receive
care from family physicians or general practitioners
(McManus 8 Newacheck, 1989) and many must make an additional
visit to the public health department for immunization.
Mainous and Hueston (1993) also investigated factors
influencing the use of primary care physicians and public
health departments for childhood immunization in urban and
rural areas. They utilized a telephone survey of adults
from 97 households with children under the age of 5 living
in the home for data collection. This study found that
individuals who received childhood immunizations at the
health department were more likely to be at or below the
poverty threshold and live in a rural area than those
individuals who received immunizations at a primary care
physician's office. These factors, which influence the

selection of the public health department for childhood

16

immunizations, may be associated with higher risks for
vaccine preventable childhood diseases (Hutchins, Escolan,
Markowitz, Hawkins, Kimbler, Morgan, Preblud, 8 Orenstein,
1989).

A retrospective review exploring the adequacy of
immunization for children two years of age who received
their immunizations at an urban/suburban county health
department found unacceptably low levels of immunizations.
Only 65% of the children began immunizations on time, no one
received all immunizations as recommended by the Advisory
Committee on Immunization Practices, the American Academy of
Pediatrics, and the American Academy of Family Practice, and
only 45% received all immunizations by age two years
(Ambrose, 1995). A similar study conducted by Jurcich
(1996) also revealed unacceptably low immunization rates.
Sixty percent of the children began immunizations on time,
6.9% received immunizations as recommended, and only 28.7%
received all immunizations by age two.
Wanna

Although approximately 27% of the population of the
United States lives in rural areas (Shreffler, 1996),
literature, data and research regarding rural health, health
services utilization and financing is very limited. Few
articles dedicated to either the overall health status of
rural children, immunization delivery or adequacy of
immunizations could be located. This study, although

generalization is limited, will provide additional

17

information regarding the adequacy of immunizations in rural
areas.
Methods

Remmnesisn

Modeled after Ambrose (1995) and Jurcich (1996), this
study was a retrospective review of immunization records.
It was a nonexperimental study using descriptive data to
investigate vaccination coverage levels of children through
the age of two whom received immunizations at a rural county
health department. Computerized vaccination records were
utilized to obtain the data. To obtain results for this
study, nominal and ordinal levels of measurement were
applied to the data.
Shuttle

This study used a randomly selected sample of 85
immunization records obtained from the local county health
department Vaccination Automated Control System (VACS)
database. Using a table of random numbers, sample cases
were randomly selected from 171 immunization records meeting
the following inclusion criteria:
1. Birth dates from January 1, 1994 through April 30,1995.
2. All records of children vaccinated at the local county

health department were eligible.

Crawford County is composed of a homogenous rural
population of 12,471 residents. The 1996 unemployment rate
of 7.1% was higher than the annual Michigan unemployment

average of 4.7% (Grayling Regional Chamber of Commerce,

18

1997) - According to the W
Beak, 32.2% of young children ages 0 to 4 years live in

poverty as compared to the state average of 26.6%.
Setting

The setting used was the District Health Department No.
10 clinic located in Crawford County. This site was
selected because it is a central site for immunizations in
Crawford County and services a significant proportion of the
children in the county.

i ll 1 E El 'li E y . l]

Ambrose (1995) developed the definition for adequacy of
care and operationalized it as follows using three levels:
complete care, adequate care, and inadequate care.

Adeqneey_ef_geze. Adequacy of care was defined as the
number of immunizations the child had received and the
intervals at 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, 1995) was used in this study as the
standard of care (Figure 3). The shaded bars in Figure 3
indicate that the specific vaccination is recommended
within that time period. For example, the fourth DTP is
recommended between ages 12 months and 18 months and DtaP
can be administered starting at 15 months.

Oral poliovirus vaccine was administered to the

19

 

 

AGE > Birth 2 4 6 12 15 18

mos mos mos mos mos mos
VACCINE V

 

 

 

Hepatitis B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

': - 9-3. 75:; 121;”: . 1'
.4"th I .. l

Diptheria, ,”W“”“-§£h}¥nig:p

1". I ”an (1.::. "V"; 35-». 5:-
Tetanus, DTP DTP DTP EMaEPat-‘ZIS‘P rm);
Pertussis :3ffl§i*?°mf” “ ”‘

*r I- -- ‘
H. Influenzae Hib Hib Hib ZQREP‘;'

type b

Polio OPV OPV

 

 

 

 

Measles, Mumps,
Rubella

 

 

 

 

 

 

 

 

 

 

 

 

£1gnze_2t Recommended childhood immunization schedule

from the ACIP, AAP, and AAFP. Adapted from CDC (1995).

children in this study. A total of one dose of inactivated
poliovirus vaccine (IPV) was administered parenterally. In
January 1997, the Advisory Committee on Immunization
Practices (ACIP) recommended a sequential parenteral-oral
vaccine schedule aimed at reducing the rate of vaccine-
associated paralytic poliomyelitis (CDC, 1997b). All the
subjects had either started or completed the OPV series

prior to this recommendation. Varicella vaccination was not

20

studied because it was not administered at the health
department during this period.

The variable, adequacy of care, was operationalized
with three levels: 1) Cemplete_§eze—4 DPT immunizations, 3
OPV immunizations, 1 MMR, and 3 or more doses of Hib
(4:3:1:3 series) and 3 Hepatitis B vaccinations received
through age two (35 months) and correctly spaced within 30
days of the ACIP recommended schedule; 2) Adequate_§eze—All
immunizations received through age two years, but not
properly spaced within 30 days of the recommended ACIP time
frame; and 3) Inedeqnete_§eze—Less than all of the
recommended immunizations completed through two years of
age.

The adequacy of care levels for the 4:3:1:3 series and
the Hepatitis B series will be reported separately to allow
comparison with data from the National Immunization Survey.

Parameters for each immunization variable were defined
employing three levels: 1) obtained on time and properly
spaced; 2) obtained through age two years, but not properly
spaced; 3) not obtained through age two years. This was
done to allow analysis of each series of immunization to
determine if any differences existed between individual
immunizations within a series and also between each series
of immunizations.

Ezepet_Speeing_ef_Deeee. Criteria for properly spaced
doses were based on the recommended childhood immunization

schedule plus or minus 30 days (Figure 3) along with the

21

minimum age for initial vaccination and minimum interval
between vaccine doses (Figure 4). When information on the
month and year of vaccination were available but not the
date, the 15th was designated as the date (Zell et al.,
1994).

Immunization records at District Health Department No.
10 are updated with the dates of immunizations given at
other facilities if the information can be verified by the
provider over the telephone or in writing. Any immunization
for which there were no data 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, later immunizations may have
been obtained at another source of health care and not
reported to the local health department. No conclusions
regarding the proper spacing of immunizations could be made
in these cases.
mmllectienmceduze

Immunization records of the children who received
immunizations at a local health department in rural northern
Michigan with birth dates between January 1, 1994 through
April 30, 1995 were obtained from the VACS computer
database. These records also contained the date of birth,
sex, and limited insurance data. Insurance data other than
Medicaid was not routinely collected on immunization
clients. Therefore, it was impossible to determine the

insurance status of the non-Medicaid population.

22

 

Minimum Minimum Minimum
Minimum age interval interval interval
Vaccine first dose dose 1 to 2 dose 2 to 3 dose 3 to 4

 

 

 

 

 

 

 

 

 

 

 

DTP (DT) 6 weeks 4 weeks 4 weeks 6 months
Combined
DTP/Bib 6 weeks 1 month 1 month 6 months
DTaP 15 months 6 months
Hlb (prlm-
ary series
HbOC 6 weeks 1 month I month 2 months +
age 12 mos
PRP-T 6 weeks 1 month 1 month 2 months +
age 12 mos
PRP-OMP 6 weeks 1 month 2 months +
age 12 mos
OPV 6 weeks 6 weeks 6 weeks
MMR 12 months 1 month
Hepatitis birth 1 month 2 months +
8 age 4 mos

 

 

 

 

 

 

£1gnze_1t Minimum age for initial vaccination and minimum
interval between vaccine doses, by type (CDC, 1995).

The immunization records were used as the instrument
for data collection. Each record was sequentially numbered
starting with one.

5! l' l' J E 1 . E E I
Data analysis was done using the SPSS statistical

analysis software. Frequency and percentage were used as

appropriate to describe the study results.

Analysis of data included the following:

1. Percent of records sampled that indicated complete,
adequate, and inadequate care for all immunizations
received.through age two (Research Question 1).

2. Percent of records sampled that indicated complete

care, adequate care, and inadequate care for each

23

immunization series (i.e. DTP/DTaP) the children
received through age two (Research Question 2).

3. Percent of records sampled that indicated adequate care
and inadequate care in the proper spacing for all
immunizations (Research Question 3).

4. Mean number of days from date of birth to date of
starting immunizations for those children who received
adequate and inadequate care (Research Question 3).

5. Percent of records sampled that indicated complete
care, adequate care, and inadequate care for the
subsequent immunizations if the first set at age two
months was complete (Research Question 4).

We
There are three limitations to this study. First, the

sample utilized was from a public health department clinic

in a rural setting and may not be representative of the
general population of the county and state. Data were
limited to children receiving immunizations at a local
county health department in rural northern Michigan. The
immunization status of children who receive immunizations
from a public health department clinic may differ from
children who receive their immunizations in the private
sector and, in general, from the immunization status of the
county and state population. Therefore, discussion of the
results of this study must be limited to children who
receive immunizations from a health department in a similar

county and may not be generalized to the overall population

24

of the county and state. Second, system, parental and

provider barriers to immunizing these children were not

available, therefore, conclusions regarding potential
influences on vaccination coverage levels are beyond the
scope of this study. Third, data were obtained solely from
health department computer records. No effort was made to
fill in missing data or verify records of immunizations
received from other providers that were entered by the
health department staff. This was beyond the scope of the
study.

W
The assumptions identified by Ambrose (1995) were used

for this study:

1. Immunizations against vaccine-preventable childhood
diseases are reasonably safe and efficacious.

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 the prevention
of some childhood diseases.

3. High vaccination coverage levels in the general
population benefit those immunized and the overall
population in the United States by decreasing the risks
of morbidity and mortality.

4. Subsequent immunizations in a series would not have

been given without evidence of prior immunization.

25

5. The data recorded at the local county health department

were accurate.
Protestinmfjumauights

The rights of the individuals whose 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 of this committee was
obtained prior to gathering the data (See Appendix A).

Permission was also obtained from the District Health
Department No.10 Medical Director to collect data (See
Appendix B). No data were used that could identify
individuals in the study and no identifying data was removed
from the clinic site. Once the immunization records were
obtained they were sequentially assigned numbers beginning
with one. All data were entered into the SPSS database by
this investigator. No identifying variables were entered
into the SPSS data bank. Confidentiality was
maintained.

Results

DescriptimLSamnle

The sample consisted of 85 immunization records from a
local county health department in rural northern Michigan.
As illustrated in Table 1, the majority of the sample were
male (58.8%) and the remaining female (41.2%).

The years of birth included in this study were 1994 and

1995. The majority of the sample (83.5%) was from 1994 due

26

Table 1.

 

 

WW

Characteristics Frequency Percent
Gender:

Male 50 58.8
Female 35 41.2
Insurance

Medicaid 50 58.8
None/Other 35 41.2
Gender and Insurance

Male and Medicaid 25 50.0
Female and Medicaid 25 50.0

 

to the exclusion criteria for birth dates from January 1,
1994 through April 30, 1995. The sample was fairly evenly
distributed throughout the months. May 1994 contained the
lowest number of immunization records with one (1.2%) and
August 1994 and September 1994 contained the most, each
containing eleven records (12.9%). The only insurance
information listed on the immunization records was Medicaid.
Fifty children (58.8%) were designated as Medicaid
recipients. The remaining children had either private or no
insurance.
W

The research questions presented in this study were
based on the concern that children are inadequately
immunized during the first few years of their life; a time

when they are most susceptible to the morbidity and

27

mortality associated with vaccine preventable diseases. The
outcome in this study was measured by the level of care
received with respect to the immunizations received through
two years of age: complete, adequate, or inadequate care.

Queetien_1. What percentage of children from the local
county health department in rural northern Michigan obtained
complete care, adequate care, or inadequate care with
respect to all immunizations through age two years as
recommended by the ACIP, AAP, and AAFP?

The percentage of children receiving complete care for
the 4:3:1:3 series was 32.9% (n=28); adequate care, 56.5%
(n-48); and inadequate care 10.6% (n89)(Not listed in a
table). This sample obtained an adequate immunization
coverage level of 56.5% and when combined with the complete
care results, the percentage of children receiving all
immunizations through age two increased to 89.4%.

The overall vaccination coverage level for the
Hepatitis B Vaccine series was 90.6% with 51.8% of the
children receiving complete care and 38.8% adequate care.

The overall vaccination coverage level for Hib as a
series of 3 or more vaccinations was 93.2%. If the Hib
series data had been analyzed as a series of 4 vaccinations
as was done by Jurcich (1996), the overall vaccination
coverage level would have declined to 81.2%. A series of
three or more doses provides herd immunity therefore the
National Immunization Survey data reflects 3 or more Hib

doses as acceptable vaccination coverage.

28

Queetien_z. For each 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, and inadequate
care is listed in Table 2. The percentages of complete care
ranged from 38.8% (n=33) for the DTP series to 76.4% (n-65)
for the MMR vaccination. The level of adequate care ranged
from 21.2% (n=18) for the MMR vaccination to 51.8% (n-44)
for both the DTP and the Hib series.

Ninety-four percent of the sample received the OPV
series as either complete care (45.9%) or adequate care
(48.2%). Ninety percent of the sample received the HBV
series as either complete care (51.8%) or adequate care
(38.8%).

The majority of children received the recommended
number of immunizations as either complete or adequate care
in all series through age two. The DTP and HBV series
shared the lowest percentage (90.6%).

Queetien_2. What patterns of immunizations are evident
for those children receiving adequate or inadequate care
with respect to initiation of immunization and the spacing
of those immunizations through age two years?

Table 3 reports the findings for each individual
immunization. The following patterns were noted for DTP,
Hib, OPV, and HBV where more than one vaccination is

recommended to complete the series. First, the vaccination

29

Table 2.
WWW

 

Immunization Series .Adequacy of Care Frequecy Percent

 

 

DTP Complete 33 38.8
Adequate 44 51.8
Inadequate 8 9.4
Hib Complete 36 42.4
(3 or more doses) Adequate 44 51.8
Inadequate 5 5.9
OPV Complete 39 45.9
Adequate 41 48.2
Inadequate 5 5.9
MMR Complete 65 76.4
Adequate 18 21.2
Inadequate 2 2.4
HBV Complete 44 51.8
Adequate 33 38.8
Inadequate 8 9.4
Table 3.

li I 1 E I i' 'i 1 I i l' [ =35]

 

 

Immunization..Adequacy Level Frequency Percent
DTP1 Complete 56 65.9
Adequate 29 34.1
Inadequate 0 0.0
Missing 0 0.0
DTP2 Complete 42 49.4
Adequate 41 48.2
Inadequate 0 0.0
Missing 2 2.4
DPT3 Complete 37 43.5
Adequate 44 51.8
Inadequate 1 1.2
Missing 3 3.5
DPT4 Complete 60 70.6
Adequate 17 20.5
Inadequate 2 2.4
Missing 6 7.1

30

Table 3 (cont.)

 

 

Immunization..Adequacy Level Frequency Percent
Hibl Complete 54 63.5
Adequate 31 36.5
Inadequate 0 0.0
Missing 0 0.0
Hib2 Complete 41 48.2
Adequate 42 49.4
Inadequate 0 0.0
Missing 2 2.4
Hib3 Complete 37 43.5
Adequate 43 50.6
Inadequate 2 2.4
Missing 3 3.5
Hib4 Complete 43 50.6
Adequate 27 31.8
Inadequate 1 1.2
Missing 14 16.5
0PV1 Complete 56 65.9
Adequate 29 34.1
Inadequate 0 0.0
Missing 0 0.0
0PV2 Complete 43 50.6
Adequate 40 47.1
Inadequate 0 0.0
Missing 2 2.4
0PV3 Complete 60 70.6
Adequate 20 23.5
Inadequate 2 2.4
Missing 3 3.5
MMR Complete 65 76.5
Adequate 18 21.2
Inadequate 1 1.2
Missing 1 1.2
HBV1 Complete 54 63.5
Adequate 29 34.1
Inadequate 1 1.2
Missing 1 1.2
HBVZ Complete 46 54.1
Adequate 33 38.8
Inadequate 3 3.5
Missing 3 3.5
HBV3 Complete 65 76.5
Adequate 12 14.1
Inadequate 4 4.7
Missing 4 4.7

 

31

coverage rate ranged from 63.5% to 65% for DTP1, Hib1, 0PV1,
and HBV1 vaccinations and was 76.5% for the MMR vaccination
as received according to the recommended schedule.

Secondly, with subsequent immunizations (i.e., DTP2, DTP3,
Hib2, Hib3, 0PV2 and HBVZ) coverage rates successively
declined. The decline for vaccinations received according
to the recommended schedule was the least between Hib2 and
Hib3 (4.7%) and was greatest between DTP1 and DTP2 (16.5%).
However, those immunizations with an extended range of
recommended age for vaccination (i.e. DTP4, Hib4, 0PV3, and
HBV3) showed an increase in coverage rates for immunizations
obtained according to the recommended schedule. The most
dramatic increase was 27.1% between DTP3 and DTP4. The
smallest increase (7.1%) was between Hib3 and Hib4. The
data consistently demonstrate an increase in the receipt of
vaccination at the adequate level of care through two years
when immunizations are not received according to the
recommended schedule and vice versa.

Interestingly, when the percentages for each of the
individual immunizations received according to ACIP
recommendations and through two years of age are added,
there is a successive decline in coverage level throughout
each series. The decline throughout the series is greatest
for the Hib vaccination. Vaccination for Hibl is 100% and
decreases to 82.4% with Hib4. The vaccination series
experiencing the least decline in coverage level is OPV that

begins at 100% and declines to 94.1% with 0PV3. Also, the

32

percentage of missing data increases with each subsequent
immunization.

Children with Medicaid listed as their insurance were
two and one half times less likely (20.0% versus 51.4%) to
receive the 4:3:1:3 series as complete care in accordance
with ACIP recommendations than children not on Medicaid.
Those on Medicaid were twice as likely to receive the
4:3:1:3 immunization series as adequate care. The
percentage of children receiving inadequate care for the
4:3:1:3 series in both groups was similar (10.0 versus
11.4%).

Table 4 reports the mean number of days for children to
receive the initial set of immunizations and the resulting
level of adequacy of care achieved for all recommended
series of immunizations. For the children receiving their
initial set of immunizations according to ACIP guidelines
(n-55), 28 received complete care (50.9%), 27 received
adequate care (49.1%), and no one received inadequate care
for all recommended series of immunizations. For children
receiving the initial set of immunizations later than ACIP
recommendations (n=30), 21 children (70.0%) received
adequate care and 9 children (30.0%) received inadequate
care for all recommended series of immunizations. These
results do not wholly support that the continued morbidity
and mortality of vaccine preventable diseases is due, in
part, to a failure to immunize children at an early age

resulting in inadequate immunity to childhood disease.

33

Table 4.

WWW
WW5

 

 

Initiation of Mean Number Adequacy of Care
Immunizations of Days Complete Adequate Inadequate
Initial set ~ ; . .. m.§.. _-.-
received by 98.9 days 32.9% 56.5% 10.6%
all subjects n=28 n=48 n=9
(n=85)

Initial set

received at 68.5 days 50.9% 49.1% 0.0%

2 months per n=28 n=27 n=0
ACIP guideline

(n=55)

Initial set

received later 154.7 days 0.0% 70.0% 30.0%
than ACIP n= n=21 n=9
recommendation

of 2 months

(n-30)

 

Questign_4. For the subset of children who received
complete care for the series of immunizations recommended at
two months of age (first set), what is the percentage of
complete, adequate, and inadequate care for subsequent
immunizations?

Fifty-five children (50.9%) in the sample received
complete care for the first DTP, Hib, OPV, and HBV according
to the recommended schedule. Table 5 lists the percentages
for the level of adequacy for each series and for all

immunizations through age two for the subsets of children

34

Table 5 .

W
W

 

 

 

Immunization .Adequacy' ‘First Set First Set
Series Level at 2 months at > 2 months
(N-SS) (N-30)
n % n %
All Series Complete 28 50 . 9 0 0 . 0
(except HBV) Adequate 27 49 . 1 2 1 70 . 0
Inadequate 0 0 . 0 9 3 0 . 0
DTP Complete 33 60.0 0 0.0
Adequate 22 40.0 22 73.3
Inadequate 0 0 . 0 8 26 . 7
Rib Complete 36 65.5 0 0.0
Adequate 19 34.5 25 83.3
Inadequate 0 0 . 0 5 16 . 7
OPV Complete 39 70.9 0 0.0
Adequate 16 29.1 25 83.3
Inadequate 0 0.0 5 16.7
MMR Complete 48 87.3 17 56.7
Adequate 7 12.7 11 36.7
Inadequate 0 0 . 0 2 6 . 7
HBV Complete 42 76.4 2 6.7
Adequate 11 20.0 22 73.3
Inadequate 2 3.6 6 20.0

 

who received the first set of immunizations according to the
recommended schedule and those who received the first set
after two months of age.

Twenty-eight (50.9%) of the children receiving complete
care for the first set of immunizations continued to receive

immunizations for all series according to the recommended

35

schedule. 0f the remaining children in this subset, twenty-
seven (49.1%) received subsequent immunizations for all
series through two years of age and no one failed to
complete all series. The only immunization series that
reflected adequate care was HBV.

All the children (n=55) who received the first set of
immunizations per the recommended schedule had completed all
series through age two. Only 70.0% of the children (n-21)
who received the first set of immunizations after two months
completed all series of immunizations through age two.
Overall, children who started immunizations per the
recommended schedule were more likely to have received
complete or adequate care through two years of age.

Discussion

The major finding of this study was that the overall
immunization coverage in this sample of clients from a
county health department in rural northern Michigan for the
4:3:1:3 series (4 DTP, 3 Hib, 1 MMR, and 3 Polio) was
89.4%). This result is near the national goal of greater
than or equal to 90% of two -year old children achieving
series complete coverage for all recommended vaccines. If
Hib4 was included in the measurement as was done by Jurcich
(1996), the overall immunization rates drops substantially
to 81.2%, a decline of 8.2%. The Hepatitis 8 series
immunization level in the same population was 90.6%, far

exceeding the national goal of 70%.

36

The percentage of children in this study achieving
series complete coverage (complete and adequate care) for
all recommended vaccines was higher than reported by the CDC
(1998) in the National Immunization Survey (NIS) for the
state of Michigan (73%) and the city of Detroit (63%). Data
for each county are not reported by the NIS. The results of
the current study can not be readily compared with others in
the literature due to multiple differences in the sample
other than the NIS done for the state of Michigan (CDC,
1998).

The Ambrose (1995) and Jurcich (1996) studies using
health department records are similar to this research. The
research by Ambrose revealed 45% of children up to age two
years received adequate care and 55% received inadequate
care for the 4:3:1 series (4 DTP, 3 Polio, and 1 MMR).

These were the recommended immunizations for that time. The
study by Jurcich showed 6.9% of the children received
complete care, 28.7% received adequate care and 64.4%
received inadequate care for the 4:4:1:3 series (4 DTP, 4
Hib, 1 MMR, and 3 Polio) of immunizations recommended by the
ACIP. The immunization coverage level for receiving all
recommended immunizations by age two was only 35.6%.

Many reasons can be identified for the results of this
study. The National Immunization Survey for the period
April to December 1994 found only 61% of children age 19 to
35 months in Michigan were fully immunized (4:3:1 series).

This result was significantly lower than the national rate

37

of 75% fully immunized. Michigan had the lowest
immunization coverage rate of all 50 states for 1994. This
distinction attracted the attention of media, professional
organizations, and state and federal funding. Increased
services by the Michigan Department of Public Health at the
local level which included educational programs, assessments
of immunization levels and consultative services were also
forthcoming (Bouffard, 1995).

This increased focus on childhood immunizations has led
to a significant improvement from 61% to 73% in Michigan's
immunization coverage among two-year-old children. Unless
multiple factors continue to be addressed, increased
immunization rates will be temporary.

A major factor, which may have also affected the
results of this study, is the inability to track the
immunization status of children. A number of children
receiving inadequate care had missing data that could have
been due to the child receiving vaccinations from another
health care provider. No effort was made to fill in missing
data. These children may have been fully immunized but,
within this study, there was no provision for validating
this possibility. Therefore all records were included in
the study.

An immunization tracking system, called the Michigan
Childhood Immunization Registry (MCIR), is being established
statewide and will contain birth records for all children

born in Michigan on or after January 1, 1994. This record

38

keeping system, for children who receive immunizations in
Michigan, will allow authorized users to receive up-to-date
immunization information and submit new data as it becomes
available. Participation in the MCIR is mandatory and state
law requires that health care providers submit immunization
records to the registry unless a parent or guardian objects
(Smith, 1998). Use of this system will facilitate tracking
of the immunization status of children under the age of
twenty years and eliminate the problem of missing data for
childhood immunizations received in Michigan. When
functional, the MCIR should improve the completeness of
records and ability to accurately assess the immunization
status of children in Crawford County and throughout the
state.

In this study, 56.5% received adequate care and 10.6%
received inadequate care. Barriers to immunizing children
are well documented in the literature and include cost,
failure of insurance to cover immunizations, missed
opportunities, number of vaccinations, limited access to
health care and inadequate public awareness (Gamertsfelder,
Zimmerman, & DeSensi, 1994; Hinman, 1991; Salsberry,
Nickels, & Mitch, 1994). Barriers to complete care may also
be due to health care provider practices such as missed
immunization opportunities, overly cautious interpretation
of vaccine contraindications and lack of administration of

simultaneous vaccines (Gamertsfelder et al., 1994).

39

Barriers specific to this rural population in Crawford
County which may result in inadequate or delayed
immunization are low socioeconomic status and limited access
to health care, especially the availability of health care
providers who administer immunizations and transportation to
these sites. The health department is one of the few sites
in the county administering childhood vaccinations.
Immunization at the health department requires a separate
visit and additional time to obtain well-child care at a
primary care provider's office. These additional visits, in
addition to access problems, could result in a decreased
level of immunization coverage.

The rates for complete and adequate care for each
individual series of immunizations, excluding MMR, vary
slightly. This may be due to similar recommended schedules
for each series. The DTP, Hib (3 or more doses), and OPV
have higher percentages of adequate care than complete care.
The HBV series and MMR reflect the opposite. The MMR is a
single vaccination recommended for administration at 12 to
15 months of age. It is often given at 12 months, a common
age for a well child visit and to receive other recommended
vaccinations. The first dose of HBV is usually given at
birth in Crawford County, the second and third doses are
recommended for administration at 2 and 12 months
respectively. The recommended schedule for the MMR and HBV

vaccines coincides with the recommended time frame for

40

administering additional childhood vaccines which may
account for the higher rate of complete care.

One half of the children who received their first set
of immunizations according to the recommended schedule at
two months had complete care for all recommended
immunizations. This number (n=28) represents one-third of
the entire sample. Timely receipt of the initial doses of
vaccines recommended to be administered at two months of age
was associated with a higher level of vaccination coverage.
In this study, of the 55 children who received the initial
immunizations at two months, 50.9% received complete care
and 49.1% received adequate care. This finding is
consistent with existing research.

Rapid changes in vaccine recommendations have resulted
from the development of new vaccines, changes in the
epidemiology of vaccine preventable diseases, and other
scientific findings (Peter, 1992). The recommended
childhood immunization schedule continues to increase in
complexity with the recent additions of varicella and
rotavirus vaccines. with the increased number and type of
vaccinations, it is imperative that children begin and
continue to receive immunizations as recommended to ensure
high levels of vaccination coverage.
WI]:

The findings of this research support the theoretical
framework adapted from Starfield (1992) for evaluating the

structure of the health system and processes of primary care

.41.

and the resulting outcome or effect on health status.
Starfield (1992) conceptualized biological resilience, one
of the components of health status, as the state of being
appropriately immunized against preventable diseases. A
level of immunization (89.4%) which provides herd immunity
reflects that the health status of two-year-old children in
Crawford County is not compromised by the risk of
contracting vaccine-preventable diseases.

u. . ... -. ,. .. -. - . - \ .-; . - H-.

The purpose of this study was to determine the adequacy
of immunization for children through age two years who
received their immunizations at a public health department.
The main findings in this study include 1) immunization
rates slightly below the national goal of 90%; and 2) higher
rates of complete and adequate care associated with starting
immunizations on time according to the recommended schedule.

Eighty thousand four hundred of Michigan's toddlers
remain inadequately immunized and at risk of contracting
vaccine preventable diseases and succumbing to the inherent
morbidity, mortality and potential disability (Michigan
League for Human Services, 1998). The advanced practice
nurse (APN) in primary care can have a positive impact on
improving immunization coverage and overall child health
through clinical, educational and research avenues.

As a clinician, the APN should routinely identify
children with risk factors for delayed immunizations such as

large family size, low socioeconomic status, single parent

42

status, young parental age, and low educational level of
either parent (Bates, Fitzgerald, Dittus, & Wolinsky, 1994;
Bobo, Gale, Thapa, & Wassilak, 1993). Studies have shown
that poverty is significantly associated with failure to
complete immunizations while the other risk factors
correlate with delayed initiations of the immunization
series and failure to immunize according to the recommended
schedule (Bates et al., 1994). Once identified, these
children and their parents can be the focus of continuing
intense efforts to achieve adequate immunization and improve
other aspects of preventive care and health promotion.

Ideally, parental education on childhood immunization
should be initiated prenatally by the APN or in
collaboration with the prenatal care provider. Parents
should be informed of the benefits, risks, and adverse
effects of each vaccine and given a copy of the recommended
immunization schedule. Reinforcing the importance of
initiating and receiving subsequent immunizations on time
for all children along with scheduling an appointment for
the next recommended immunization may help to maintain and
further improve levels of immunization coverage. Lack of
knowledge regarding the importance of vaccines has been
identified as the most important barrier to immunizations
(Kimmel et al., 1996).

Many newborn infants in Michigan receive the first
Hepatitis B vaccination in the hospital prior to discharge

presenting an additional opportunity for the APN and parents

43

to discuss care of the infant including immunizations and
well child visits. Knowledge of the importance of on time
immunizations and the risks of morbidity and mortality due
to under vaccination would allow the parents to make
informed decisions regarding illness prevention practices
for their child. To facilitate educating parents, the APN
should establish an ongoing relationship of trust in which
to assess parental beliefs and attitudes regarding
immunization and address parental concerns.

In addition to educating parents, community education
and participation may help improve parental awareness of the
need for timely childhood vaccination. The APN can
disseminate information through parenting classes, infant
and child day care settings, prenatal classes and church
groups such as the health ministry. Organizations such as
the Kiwanis Club or food establishments such as McDonald's
can be approached to provide incentives for immunization
such as story books or food coupons.

The APN should review a child's immunization status at
every appointment not only well child visits and vaccinate
as indicated. The scheduling of programs such as the Women,
Infants, and Children (WIC) Program in conjunction with an
immunization clinic would increase accessibility and improve
vaccination coverage levels in this population. At District
Health Department No. 10, the immunization status of all
children seen during the WIC clinic is assessed and

vaccinations are given as indicated. These practices work

44

 

to eliminate missed opportunities and ensure the child is
adequately immunized.

Periodic audit of pediatric client records is another
tool the APN can use to monitor and improve childhood
immunization rates. These audits serve to verify compliance
with receipt of recommended immunizations, identifies the
immunization coverage rate within the practice and
reinforces the importance of immunizations to physicians and
primary care staff. If all vaccine doses fOr which a child
is eligible have not been administered, a recall system,
such as a mailed reminder, should be initiated. A mailed
reminder is cost effective and can serve to increase the
immunizations received and influence immunization seeking
behavior in families whose children do not have up-to-date
immunizations (Young, Halpin, Johnson, Irvin, & Marks,
1980). Once MCIR is completely operational, the audit
process should be easier and more accurate since it will
include data from public and private health care providers.

Education of physicians and other health care
professionals, in addition to parents and the community, can
also increase immunization levels among children. The
Standards for Pediatric Immunization Practices recommended
that providers receive education on current immunization
recommendations. The APN can educate the primary care
providers and clinic staff about current immunization
research and practices. Education would include inservices

regarding changes in the recommended immunization schedule,

45

current standards of immunization practices, true
contraindications to vaccine administration and the
importance of simultaneous administration of multiple
vaccine injections to decrease missed opportunities.

An equally important role for the APN, in addition to
clinician, researcher and educator is as an advocate. The
APN can disseminate information and research findings, both
positive and negative that impact vaccination coverage
levels, and seek policy changes, legislation and funding to
improve the status of childhood immunization.
W

This study revealed several areas for further research.
Currently research regarding rural health and the assessment
of childhood immunization status and child well being is
limited. Further development of research in this area would
allow specific subgroups to be targeted and interventions
developed to improve overall vaccination coverage levels.
Another area for research is the relationship between
poverty and under vaccination. Additionally, assessment of
vaccination coverage rates and concurrent assessment of
perceived parental and provider barriers to immunization
should receive further research. Many parents are concerned
about the number of injections their children receive when
vaccines are administered simultaneously. The ACIP
recommendation of a sequential parenteral-oral poliovirus
vaccine schedule further increases the number of injections.

Future research should investigate whether parental concerns

46

regarding multiple injections impacts the implementation of
this recent recommendation. Controversy regarding the
safety of whole-cell pertussis vaccines has also raised
parental concern. This concern prompted the development of
acellular pertussis vaccines which are less likely to cause
adverse effects. Research is indicated to determine if
parental concern regarding the safety of the pertussis
vaccine has changed.' Further study in these areas could
help the APN, health care professionals and other
governmental agencies understand how and why many children
do not receive immunizations according to the recommended
schedule.
WW

Immunizations are a vital part of comprehensive well
child care, and vaccination coverage levels of children are
an indicator of the quality of preventive health services
(Grover, 1996). Undergraduate and graduate nursing
programs, with the event of managed care and the emphasis on
controlling health care costs, must emphasize the importance
of health promotion and preventive health services.
Immunizations, as one focus, require initial in-depth
instruction and frequent updating throughout nursing
programs due to rapid changes in vaccine technology and the
ACIP schedule for immunization. Students must become
thoroughly knowledgeable regarding the ACIP schedule for and
contraindications to vaccine administration. They must also

develop an awareness of opportunities to vaccinate infants

47

and children regardless of the clinical setting and for
educating parents, caregivers, and the community about the
importance of and need for immunizations. As missed
opportunities to vaccinate.decrease due to the efforts of
nurses at all levels, vaccination coverage levels will
continue to improve and eventually will surpass the goal set
by Healthy People 2000.

Summary

3

This research assessed the adequacy of immunization
status for children through two years of age. The levels of r
complete, adequate, and inadequate care were evaluated for a
sample of records of children receiving immunizations at a
local county health department in rural northern Michigan.
The level of complete care in this study was 32.9%, adequate
care 56.5%, and inadequate care 10.6%. The findings of this
study do not support the findings of other studies that
current immunization levels fail substantially below the
Healthy People 2000 goal of at least ninety-percent of two
year-old children completing the basic immunization series.
Specifically, this study identified that children who
received their first set of vaccinations at age two months
as recommended were more likely to complete all
immunizations through age two years than the children who
received their first set of immunizations at a later date
than recommended.

The findings of this study will assist the APN in

monitoring and improving the vaccination coverage rates for

48

children through the age of two through the roles of

clinician, educator, researcher and advocate. Maintaining
and increasing current vaccination coverage rates is vital
to further decrease the morbidity, mortality and potential

disability associated with vaccine preventable diseases.

49

LIST OF REFERENCES

LIST OF REFERENCES

Centers for Disease Control and Prevention (1994c).
Vaccination coverage of 2-year-old children-United States,

1993. W09) . 705-
709.

Centers for Disease Control and Prevention (1995).
Appendix A. In w. Atkinson, J. Gantt, M. Mayfield & L.

Furphy (Eds.),

(pp. A-1-A-49). Atlanta, GA:
Epidemiology Program Office, Centers for Disease Control and
Prevention.

Centers for Disease Control and Prevention (1997a).
National, state, and urban area vaccination coverage levels
among children aged 19- 35 months-United States, January-

December. 1995 WW
(3), 176- 182.

Centers for Disease Control and Prevention (1997b).
Poliomyelitis prevention in the United States: Introduction
of a sequential vaccination schedule of inactivated
poliovirus vaccine followed by oral poliovirus vaccine.

WWW?” . 1-25.

Centers for Disease Control (1998). National, state and
urban area vaccination coverage levels among children aged
19-35 months-United States, July, 1996-June 1997. Morbidity

11W“) . 108-116-

Cherry, J., Baraff, L., & Hewlett, E. (1989). The past,
present, and future of pertussis: The role of adults in
epidemiology and future control. Hestern_1gnrna1_gf
W 319-328-

Gamertsfelder, D., Zimmerman, R., & DeSensi, E. (1994).
Immunization barriers in a family practice residence clinic.

WW) . 100-
104.

Goeppinger, J. (1993). Health promotion for rural

populations: Partnership interventions. £amily_and_£gmmunity
W(1) ' 1’10.

50

Grayling Regional Chamber of Commerce (1997). Grayling
Grayling, MI:
Journalism Department of Grayling High School.

Grover, G. (1996). Immunizations. In C. Berkowitz
(86-). 2ediatrics1_A_nrimaz¥_care_annroach (pp. 62-67).
Philadelphia: W.B. Saunders Company.

Harris, R. 8 Leininger, L. (1993). Preventive care in

rural primary care practice. Can;er_finpplement+_12(3), 1113-
1118.

Hinman, A. (1988). Public health considerations. In
Plotkin, S., 8 Mortimer, E. Jr. (Eds.), flagging: (pp. 587-
611). Philadelphia: W.B. Saunders.

Hinman, A. (1991). What will it take to fully protect
all American children with vaccines? Ame:igan_1gnznal_gfi_thg
Disenses_of_£hildren1_1451 559-562-

Hueston, W., Meade, R., 8 Mainous, A. (1992). Childhood
immunization practices of primary care physicians. Archixgg

of_Eamil¥_Hedicine1_11 225-228-

Hutchins, S., Escolan, J., Markowitz, L., Hawkins, C.,
Kimbler, A., Morgan, R., Preblud, S., 8 Orenstein, W.
(1989). Measles outbreak among unvaccinated preschool-aged
children: Opportunities missed by health care providers to
administer measles vaccine. Pediatrics+_81(3), 369-374.

Jurcich. P- (1996). Adennac¥_of_immunization_h¥_ane
tug; Unpublished master's thesis, Michigan State University,
Lansing.

Kimmel, S., Madlon-Kay, D., Burns, 1., 8 Admire, J.
(1996). Breaking the barriers to childhood immunization.
' (5), 1648- 1656.

Knollmueller, R. (1994). Rural health care and health
care reform. 2ublic_Health_nursing1_11(3). 143-144.

Mainous, A. III, 8 Hueston, W. (1993). Factors
influencing the use of primary care physicians and public
health departments for childhood immunization. Kentucky

Medica1_Association_louznali_211 395-398.

Markowitz, L., Preblud, S., 8 Orenstein, W. et al.
(1989). Patterns of transmission in measles outbreaks in

the United States, 1985-1986. Hgn_England_1gnrna1_gf
ugdiging, 329, 75- 81.

51

Marks, J., Halpin, T., Irvin, J., Johnson, D., 8
Keller, J. (1979). Risk factors associated with failure to
receive vaccinations. Pediatzigst_§4(3), 304-309.

McManus, M., 8 Newacheck, P. (1989). Rural maternal,

child, and adolescent health. Health_$gzyices_neseazght
21(6), 807-848.

Michigan League for Human Services (1996). Kid§_ggnnt
Kalamazoo, Michigan: Lawton
Publishing.

Michigan League for Human Services (1998).K1d§_ggnnt

in_Michican_1221:1228_data_book1 Kalamazoo, Michigan: Lawton
Publishing.

National Center for Health Statistics (1996). Healthy
nsnn1e_znnn_rexiewi_1225:12261 Hyattsville. MD: Public

Health Service.

National Immunization Program, Centers for Disease
Control (1994). Reported Vaccine-Preventable Diseases-United
States, 1993, and the Childhood Immunization Program.

Morbiditx_and_Mortalit¥_fleekl¥_nsnnrt1_13(4). 57-60.

National Vaccine Advisory Committee (1991). The measles
epidemic: The problems, barriers, and recommendations.

Journal_of_the_American_Medical_Association1_2§6(11), 1547-

Orenstein, W. (1997). Immunization rates up! Disease

down! Immunization_Action_Newei_A(1). 3. 14-16-

Orenstein, W., Atkinson, W., Mason, D., 8 Bernier, R.
(1990). Barriers to vaccinating preschool children. Jgnrnal

of_Health_care_for_the_Eoor_and_nnderserxed1_l(3). 315-329-

Peter, G. (1992). Childhood immunization. The_flen
Enn1And_Innrnal_91_nedicine+_lzl(25)p 1794-1800-

Pruitt, R., Kline, P., 8 Kovaz, R. (1995). Perceived
barriers to immunization among rural populations. 1gnznal_gf

Community—Healfh_Nnrsin§1_12(2). 65-72.

Robinson, C., Sepe, S., 8 Lin, K. (1993). Th
President's Childhood Immunization Initiative-A summary of

the problem and the response. Pnblig_nea1th_nepgrtst_lnfi(4),
419-425.

Salsberry,P., Nickel, J., 8 Mitch, R. (1994).
Inadequate immunization among 2-year-old children: A profile

of children at risk. Journal_of_2ediatric_Nursin91_2(3)p
158-165.

52

Salsberry, P., Nickel, J., 8 Mitch, R. (1995). Missed
opportunities to immunize preschoolers. Appligd_an§ing
Research1_8(2). 56- 60-

Shreffler, M. (1996). An ecological view of the rural
environment: Levels of influence on access to health care.

Adxances_in_Nnrsing_Science1_1a(4), 48-59.

Slifkin, R., Clark, S., Strandhoy, S., 8 Konrad, T.
(1997). Public-sector immunization coverage in 11 states:

The status of rural areas. The_Jaurnal_of_Rural_Health1
13(4), 334-341.

Smith, R. (1998). MI-VFC and MCIR: Do they confuse you?
(3), 11.

Starfield, B- (1992) Primar¥_care1_concent1
gyalnatignt_and_pgligyt,New York: Oxford University Press.

Steiner, J., Lowery, E., Siegel, C., Barton, P., 8
Goodspeed, J. (1996). ImmunizatiOn services in rural areas.

The_J2urna1_nf_£amil¥_£ractice1_43(4). 326-328-0-8-

U. S. Department of Health, Education, and Welfare
(1979) Hea1thx_nean1e1_The_snrsenn_neneral_s_report_on
’ ‘ Washington, D.C.:
U.S. Government Printing Office.

U. S. Department of Health and Human Services: Public

Health Service (1992).
Boston: Jones

and Bartlett Publishers.

Zell, E., Dietz, V., Stevenson, J., Cochi, S., 8 Bruce,
R. (1994). Low vaccination levels of U. S. preschool and

school age children. Journal_of_the_American_Medical
Associatien1_211(11). 833-839-

53

APPENDIX A

UCRIHS Approval

 

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RESEARCH
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MICHIGAN STATE

L) P4 l \I E I! S I 1' Y

May :4. 199a

10: Linda 3 nce
A230 Li a Sciences

RE: IRBI: 98-284
TITLE: ADEQUACY OF IMMUNIZATION FOR RURAL CHILDREN
THROUGH AGE TWO YEARS
REVISION REQUESTED: N/A
CATEGORY: l-I
APPROVAL DATI: 05/13/98

The University Committee on Research Involving Human 8ubjects'(UCRIHS)
review of this project is complete. I am pleased to adv1se that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain informed consent are ap ropriate.
Egrefore. the UCRIHS approved this project and any rev sions listed
a ve.

RIIIWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t a original a roval letter or when a
project is renewed) to seek usdate certification. There is a
max mum of four such expedite renewals ssible. Investigators
wishing to continue a reject beyond the time need to submit it
again or complete rev ew.

REVISIONS: UCRIHS must review any changes in grocedures involving human
subjects. rior to in tiation of t a change. If this is done at
the time o renewal, please use the reen renewal form. To
revise an ap rovsd protocol at an 0 her time during the year
send your wr tten request to the CRIHS Chair. requesting revised
approval and rsferencin the project's 1R8 a and title. Include
in request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS]

CHANOII: Should either of the followin arise during the course of the
work, investi ators must noti UCRIHS promptly: 1) roblems
(unexpected a de effects comp aints. e c ) involv ng uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

can be of any future help please do not hesitate to contact us
(517)355-21so or FAX (517)4 i- 171.

  
  
 
  

Vld E. Wright, Ph.
IRS Chair
3":de

cc: Barbara A. McNamara

554

APPENDIX 8

District Health Department No. 10 Approval

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