A population-based study of access to immunization among urban Virginia children served by public, private, and military health care systems
A population-based study of access to immunization among urban Virginia children served by public, private, and military health care systems
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DOI：
10.1542/peds.101.2.e5
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发表时间：
1998-02-01
期刊：
影响因子：
8
通讯作者：
Sirotkin, B
中科院分区：
文献类型：
--
作者：
Morrow, AL;Rosenthal, J;Sirotkin, B
背景：自1990年以来，美国儿童免疫接种率有所上升。然而，全国调查数据表明，在一些州和城市地区，多达三分之一的2岁儿童缺乏至少一剂推荐剂量的白喉-破伤风-百日咳（DTP）、脊髓灰质炎或麻疹疫苗。在美国，免疫接种已成为预防性儿科保健的一项关键措施。为实现和维持到2岁时90%的儿童接受所有推荐免疫接种的国家免疫目标，必须审查卫生保健系统在提供免疫接种方面的作用。维吉尼亚东部城市拥有多样化的人口，他们从公共、私人和军事供应商和保险公司获得免疫服务。在进行这项调查时，弗吉尼亚州通过公共卫生诊所向所有儿童免费提供免疫接种服务，并向使用军事设施的军人家庭免费提供免疫接种服务。在12个月和24个月的代表性儿童样本中，调查儿童免疫接种服务的可及性和与免疫接种不足相关的卫生系统因素。1993年4月至9月，我们在弗吉尼亚州东部城市进行了一次家庭调查。在诺福克和纽波特纽斯，弗吉尼亚州，共有12770个家庭被选择纳入研究，使用概率比例大小的集群抽样。采用按大小概率比例抽样确保每个城市的儿童被纳入调查的概率相等。经过培训的采访者访问了选定的家庭，以确定其资格，定义为至少有一名12至30个月大的儿童居住在该家庭。在符合条件的家庭中，父母被要求参加一个标准化的15分钟的访谈。调查应答者被问及家庭人口统计资料，并被问及每个符合条件的儿童的免疫接种史、健康保险、所有免疫接种提供者的姓名和地点、通常的免疫接种提供者以及父母与该儿童一起获得免疫接种服务时遇到的任何问题。最新（UTD）免疫状况定义为在12个月（三次百白破和两次脊髓灰质炎免疫）和24个月（四次百白破、三次脊髓灰质炎免疫和一次麻疹-腮腺炎-风疹免疫）接种了所有推荐剂量的百白破、脊髓灰质炎和麻疹-腮腺炎-风疹免疫)。仅根据家长和提供者的记录评估儿童的免疫史。数据分析考虑了调查的聚类抽样设计（聚类内相关）。由于两个城市的免疫接种率差异不显著，为便于计算，采用非加权分析。通过Wald's chi(2)检验确定列联表的显著性。共有749名儿童（占符合条件家庭的91%）参加了调查。研究的儿童出生在1990年10月至1992年7月之间。获得705名儿童（94%）的免疫接种记录。87%的受访者是母亲，44%是非裔美国人，40%的儿童是军人家属，40%的儿童参加了妇女、婴儿和儿童（WIC）项目。65%的儿童在12个月时出现UTD， 53%在24个月时出现UTD。家长报告说，他们孩子通常的免疫接种提供者是私人医生（34%）；公共卫生、医院诊所或社区卫生中心（32%）；还有军事诊所或军事合同提供商（34%）。35%的答复者报告说，在获得免疫服务方面至少存在一个问题，使用私人医生作为儿童通常免疫提供者的人占29%，使用军事合同提供者的人占46%。总的来说，最常见的问题是诊所等待时间（12%），等待时间作为一个问题最常发生在使用军事合同提供商（22%）和公共卫生诊所（17%）的人身上。第二个最常见的问题是难以及时预约（10%），在使用军事设施的人中，预约问题从18%到24%不等，而在使用其他提供者的人中，这一比例为4%到6%。报告的其他一些问题包括占用工作时间、办公时间、成本和交通，其频率因通常提供商的类型而异。12个月和24个月儿童未发生UTD的家庭危险因素包括子女较多、单亲、高中以上教育程度不足、未成年母亲、非裔美国人以及在家中未找到儿童的免疫记录。通过多元logistic回归调整这些家庭因素后，与12个月未发生UTD显著相关的系统相关因素为未发生WIC（优势比[OR] = 2.1）。95%可信区间[CI] 1.4-3.3)，拥有制服服务平民健康和医疗计划（OR = 5.2; CI: 2.9-9.5）或医疗补助（OR = 2.7; CI: 1.4-5.3）保险，门诊等待时间较长（每小时，OR = 1.6; CI: 1.2-2.0），交通问题（OR = 2.6; CI: 1.3-5.2）；和24个月时不在WIC (OR = 2.0; CI: 1.1-3.7)，无法获得预约（OR = 4.5; CI: 1.8-8.6），以及使用军事合同诊所（OR = 5.6; CI: 2.6-11.9）。虽然并非所有报告的获得服务的问题都是免疫接种不足的独立风险因素，但发现报告的不同问题的总数与24个月时未接受UTD的儿童之间存在剂量-反应关系。这是第一项基于人群的免疫覆盖率与公共、私人和军队卫生保健系统可及性之间关系的研究。总体而言，三分之一的家长认为儿科免疫服务存在障碍，家长报告的获得服务的问题与免疫不足有剂量反应关系。最常见的报告问题是等待时间长和难以获得预约，但报告的问题的模式和严重程度在公共、私营和军事部门之间有所不同。尽管有免费的免疫接种，但父母们最常报告的是在公共和军队提供服务时遇到的问题。因此，家长并不一定认为免费和地理上可获得的儿科服务是无障碍的。尽管本研究是在WIC计划与免疫服务联系之前进行的，但WIC的登记与免疫接种率的显著提高有关。这一发现表明WIC作为弱势家庭获得医疗保健系统的一个点的重要性。在这一人群中，在卫生保健提供者和保险公司之间，免疫接种率存在显著差异，这种差异不容易用测量的人口特征或父母报告的获取障碍来解释，这可能部分归因于提供者做法的差异。在人口层面衡量免疫接种率和家长对服务的看法，对于改善免疫服务的可及性和质量至关重要。
Background Pediatric immunization rates have increased in the United States since 1990. Nevertheless, national survey data indicate that up to one third of 2-year-old children in some states and urban areas lack at least one recommended dose of diphtheria-tetanus-pertussis (DTP)-, polio-, or measles-containing vaccines. Immunization has become a key measure of preventive pediatric health care in the United States. To achieve and maintain the national immunization goal that 90% of children receive all recommended immunizations by 2 years of age, the role of the health care system in immunization delivery must be examined. Urban eastern Virginia has a diverse population that obtains immunization services from public, private, and military providers and insurers. At the time of this survey, immunization services in Virginia were available free to all children through public health clinics and to military families when using a military facility.Objective. To examine access to pediatric immunization services and health system factors associated with underimmunization in a representative sample of children at 12 and 24 months of age.Methods. We conducted a household survey in urban eastern Virginia from April through September 1993. A total of 12 770 households in Norfolk and Newport News, VA, were selected for inclusion in the study using probability-proportionate-to-size cluster sampling. Use of probability-proportionate-to-size sampling ensured that children within each city had equal probability of being included in the survey. Selected households were visited by trained interviewers to determine their eligibility, defined as having at least one child 12 to 30 months of age residing in the household. In eligible households, parents were asked to participate in a standardized, 15-minute interview. Survey respondents were asked about household demographics, and for each eligible child, the immunization history, health insurance, the name and location of all immunization providers, the usual immunization provider, and any problems the parent had experienced accessing immunization services with that child. Up-to-date (UTD) immunization status was defined as having all recommended doses of DTP, polio, and measles-mumps-rubella at 12 months (three DTP and two polio immunizations) and 24 months (four DTP, three polio, and one measles-mumps-rubella immunizations). The child's immunization history was assessed from parent and provider records only. Data analysis accounted for the survey's cluster sampling design tie, within-cluster correlation). Because the immunization rates of the two cities did not differ significantly, unweighted analyses were used for ease of computation. Significance was determined for contingency tables by Wald's chi(2) test.Results. A total of 749 children (91% of eligible households) participated in the survey. Study children were born between October, 1990, and July, 1992. Immunization records were obtained for 705 children (94%). Eighty-seven percent of respondents were mothers, 44% were African-American, 40% of children were military dependents, and 40% were enrolled in the Women, Infants and Children (WIC) program. Sixty-five percent of children were UTD at 12 months and 53% at 24 months. Parents reported that their children's usual immunization providers were private doctors (34%); public health, hospital clinics, or community health centers (32%); and military clinics or a military contract provider (34%). At least one problem accessing immunization services was reported by 35% of respondents, ranging from 29% among those who used a private doctor as their child's usual immunization provider to 46% among those using a military contract provider. Overall, the most commonly reported problem was clinic waiting time (12%), with reports of waiting time as a problem occurring most often among those using the military contract provider (22%) and public health clinics (17%). The second most common problem was difficulty obtaining a timely appointment (10%), with appointment problems ranging from 18% to 24% among those using military facilities compared with 4% to 6% among those using other providers. Some of the other problems reported were taking time away from work, office hours, cost, and transportation, with the frequency varying by type of usual provider.Household risk factors for children not being UTD at 12 and 24 months included having a greater number of children, single parenthood, lack of education beyond high school, teenage mother, African-American ethnicity, and not finding the child's immunization record at home, After adjusting for these household factors by multiple logistic regression, the system-related factors significantly associated with not being UTD at 12 months were not being in WIC (odds ratio [OR] = 2.1, 95% confidence interval [CI] 1.4-3.3), having Civilian Health and Medical Program of the Uniformed Services (OR = 5.2; CI: 2.9-9.5) or Medicaid (OR = 2.7; CI: 1.4-5.3) insurance, longer clinic waiting time (for each hour, OR = 1.6; CI: 1.2-2.0), and transportation problems (OR = 2.6; CI: 1.3-5.2); and at 24 months were not being in WIC (OR = 2.0; CI: 1.1-3.7), problems obtaining an appointment (OR = 4.5; CI: 1.8-8.6), and use of a military contract clinic (OR = 5.6; CI: 2.6-11.9). Although not all reported problems accessing services were independent risk factors for underimmunization, a dose-response relationship was found between the total number of different reported problems and children not being UTD at 24 months.Conclusions This is the first population-based study of the association between immunization coverage rates and access to public, private, and military health care systems. Overall, one third of parents perceived barriers to pediatric immunization services, and parent-reported problems accessing services had a dose-response association with underimmunization. The most commonly reported problems were long waiting times and difficulty obtaining appointments, but the pattern and magnitude of problems reported differed among public, private, and military services. Despite free immunizations, parents most often reported problems accessing public and military providers. Thus, parents did not necessarily consider cost-free and geographically available pediatric services to be barrier-free. Enrollment in WIC was associated with significantly increased immunization rates, although this study was conducted before linkage of the WIC program with immunization services. This finding suggests the importance of WIC as a point of access to the health care system for vulnerable families. In this population, significant variation in immunization rates was found among health care providers and insurers that was not readily explained by measured population characteristics or parent-reported access barriers, possibly attributable, in part, to differences in provider practices. Population-level measurement of immunization rates and parent perception of services is critical for improving access to, and quality of, immunization services.