Failure to Return: Why Families Don't Keep Immunization Appointments

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DESCRIPTION (provided by applicant): Despite great progress in childhood immunization coverage nationwide, children belonging to a racial or ethnic minority and those living in poverty continue to have coverage rates below the national average. These children are at further risk for poor health since under-immunization is a significant and independent predictor of other unmet primary care needs. This under-immunization also has important public health implications since a large underserved population of children living in close proximity, such as in a large urban area, could lead to an outbreak of a vaccine-preventable disease. Studies have looked at individual barriers to immunizations, yet few have provided a comprehensive look at the myriad, interrelated factors that affect immunization appointment keeping, beyond access and cost issues. This study adapts the medical home model to parental immunization appointments keeping behavior by examining the way in which three levels of factors, parent, provider and community, influence immunization appointment keeping among parents of children under 36 months of age in an inner city community. This qualitative and quantitative study will be conducted in the communities of Harlem and Washington Heights, New York City, two of the most disadvantaged in the nation. We will. recruit a systematic sample of parents who have a child under age 36 months and have attempted to obtain an immunization for their child in the past 6 months. We plan to enroll 375 Latino, Black and White families, including those above and below poverty level from three venues: community social service programs or day care/Head Start programs, community health clinics, and private pediatric practices. First, we will conduct separate focus groups of parents who have and have not missed immunization appointments to finalize the specific variables to be measured in a parental survey. Possible survey variables are: parental perception of ease of accessing health care services, experience with the health care system and immunization delivery, satisfaction with the medical home, experience with last appointment made, beliefs about immunizations and preventive care, and socio-demographic information. The survey will be pre-tested and translated to assure that the questionnaire is culturally and linguistically equivalent in both English and Spanish. We will also conduct surveys of community health centers and private pediatric offices to ascertain type of practice and provider, VFC status, access, continuity, cultural competency, and immunization practices. These responses will be used to control for the practice-level context when assessing the relation between parent responses and immunization appointment keeping. The analyses will include both bi-variate and multivariate models to assess the relative impact of parent, practice, and community factors on the probability of keeping immunization appointments. This study will generate information on parental barriers to immunization appointment keeping that can be utilized by providers to develop strategies to improve access to care and immunization delivery as well as by community programs to help empower parents in obtaining health care services.