Insights on Immunizations From Caregivers of Children Receiving Medicaid-Funded Services.

ISSUES AND PURPOSE. Despite numerous programs aimed at improving immunization rates among American children, under-immunization remains a significant problem. This study was conducted to gain insight into parents'/guardians' knowledge and attitudes regarding childhood immunizations.

DESIGN AND METHODS. Thirteen African-American mothers and grandmothers participated in semistructured, audiotaped focus-group interviews.

RESULTS. Four major themes emerged: health knowledge and beliefs about immunizations, system barriers that impede obtaining immunizations, facilitators that enhance obtaining immunizations, and suggestions for change.

PRACTICE IMPLICATIONS. Immunizations are one of the most important health advantages available to children. Therefore, nurses must become aware of the problem of underimmunization and work to address some of the concerns caregivers have identified in this study. The health and lives of the nation's children depend on it.

Key words: Immunizations, underimmunization

Even though immunizations have proved to be one of the most effective public health strategies of this century, past resurgences of vaccine-preventable diseases, specifically measles and pertussis, have generated concern in public, political, and medical arenas in recent years (Centers for Disease Control and Prevention [CDC], 1995). In response, numerous federal mandates and state programs have arisen to address the issue of underimmunization of our nation's children (Analysis, 1992). Fifty states and the District of Columbia now require completion of a basic series of immunizations in order to enroll a child in school, resulting in immunization rates of almost 98% for school-age children (CDC). At first glance this statistic is comforting--until one realizes that in many instances this is a case of parents playing catch-up to fulfill legal requirements for immunization before children will be permitted to attend school (Schmalz & Larwa, 1997). This practice of waiting to fully immunize a child at school entry does not provide protection against many life-threatening diseases of infancy and early childhood.

In 1998, the CDC's National Immunization Survey assessed vaccination coverage levels among American children born between February 1995 and May 1997. The findings showed that only 79.2% of these children (ages 19-35 months; median age 27 months) had the full series of immunizations for their ages as recommended by the Advisor Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians (CDC, 1999). In addition, numerous investigators (Freed, Bordley, & Defriese, 1993; Pruitt, Kline, & Kovaz, 1995; Zell, Dietz, Stevenson, Cochi, & Bruce, 1994) have reported that as few as 40% to 50% of preschoolers living in certain areas of the United States have received the complete series of recommended immunizations. This is an alarming situation since immunization levels in these pocket-of-need areas remain well below the recommended national goal of 90% coverage by the second birthday, as proposed in the U.S. Department of Health and Human Services' (2000) initiative Healthy People 2010. Further research has shown that children who are not immunized on time are likely to be poor, live in urban areas, and be members of racial and ethnic minority groups (Wood & Halfon, 1996). Other identified risk factors associated with immunization rates below the national average include low parental-educational level, inability to access appropriate transportation, single-parent family, lack of parental care, and a late start on the vaccination series (Pruitt et al.).

Much information has been gathered concerning the phenomenon of underimmunization of America's young children. Many studies have been conducted in different populations using various methods to assess immunization levels (Goldstein, Lauderdale, Glushak, Walter, & Daum, 1999; Pruitt et al., 1995; Vivier et al., 1999), to develop a profile to determine risk status (Bates, Fitzgerald, Dittus, & Wolinsky, 1994; Lowery et al., 1998; Salsberry, Nickel, & Mitch, 1994; Williams, Milton, Farrell, & Graham, 1995), and to examine barriers to immunizations (Gore et al., 1999; Houseman, Butterfoss, Morrow, & Rosenthal, 1997; Lannon et al., 1995; Pruitt et al.; Taylor & Cufley, 1996). These studies were conducted using diverse populations ranging from urban (Bates et al.; Goldstein et al.) to rural (Gore et al.; Lowery et al.) and poor (Goldstein et al.; Lannon et al.) to more affluent (Fielding, Cumberland, & Pettitt, 1994; Taylor & Cufley). Furthermore, the overwhelming majority of the previously cited studies used a predetermined, provider-developed, closed-ended form of inquiry to collect data (Fielding et al.; Salsberry, Nickel, & Mitch, 1993; Taylor & Cufley). This method of data collection limits the depth, range, and uniqueness of the findings.

Based on the review of literature and clinical experience, the researcher identified a need to develop a more thorough understanding of the factors that impede (or enhance) utilization of immunization services from the perspective of the consumer. It is only by looking at attitudes, beliefs, and perceptions through the lens of the actual user of services that culturally sensitive, community-based interventions can be designed that will have a significant positive impact on the immunization levels of young American children.

The purpose of this exploratory-descriptive study was to gain insight into parents'/guardians' knowledge and attitudes regarding childhood immunizations and their perceptions of the immunization services available to them in the community. To address this goal focus-group interviews were conducted that sought to identify previously unknown problems concerning immunizations, describe more thoroughly the factors that contribute to these problems, and generate parent/guardian-proposed ideas for more responsive interventions.

Research Questions

The following research questions …