Costs of developing childhood immunization registries: case studies from four All Kids Count projects.

We conducted case studies using structured interviews at four sites to understand the financial resources needed to implement childhood immunization registries. The total cost of planning and implementing a central registry ranged from $2.4 million to almost $7 million over the first five years. In addition, substantial investment by individual or group providers often was required. Registries are large information systems that require considerable investment of developmental resources, regardless of the number of children eventually entered into the system. Given the substantial investment that a registry represents, the realistic anticipation of such resource needs is important to successful planning and implementation.

Parental knowledge, attitudes, and demand regarding a vaccine to prevent varicella.

BACKGROUND: Maintenance of high immunization rates is challenged by frequent changes to the recommended immunization schedule. This study assessed parent-reported knowledge of, attitudes about, and demand for a new vaccine against varicella. METHODS: Six months following licensure of the varicella vaccine, a cross-sectional study was conducted by mailed survey among a sample of parents of 23- to 35-month-old children. Effective response rate was 65%. RESULTS: Three quarters of parents had heard about the vaccine to prevent varicella. The lay media was the most frequently mentioned source of information. Thirteen percent of parents had already obtained the vaccine for their child, another quarter planned to get it, and one half were undecided. The most frequently cited factor influencing parents who had obtained or intended to obtain the vaccine was their doctor's recommendation. For those undecided or not inclined to get the vaccine, insufficient information about the vaccine was the most frequently listed factor. CONCLUSION: Publicizing a new vaccine through the media may be effective in raising public awareness, but detailed information about the vaccine and the recommendation of providers is still important in a parent's decision about the vaccine for their child.

The role of state policies and programs in buffering the effects of poverty on children's immunization receipt.

OBJECTIVES: This study assessed the influence of public policies on the immunization status of 2-year old children in the United States. METHODS: Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up. RESULTS: Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states. CONCLUSIONS: While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.

Enforcement of age-appropriate immunization laws.

BACKGROUND: The state of North Carolina has statutes that require age-appropriate immunization as recommended by the U.S. Public Health Service. Provisions of this statute allow for criminal misdemeanor charges and injunctions to be brought against parents who do not have their children immunized on time. The decision to invoke the age-appropriate immunization statute rests with the health director of each county. This study was performed to determine if the county health directors were aware of this statute and whether they had ever utilized it to enforce age-appropriate immunization. METHODS: All health department directors in the state of North Carolina (N = 86) received letters inviting them to complete a 20-minute structured phone interview at a time of their convenience. Specific questions addressed their knowledge of the statutes and the specific penalties available. Additional questions addressed their attitudes and beliefs about the law and what they believed the state government could do to assist in enforcing the law. RESULTS: Interviews were completed for 75 of the 86 (87%) county health departments or districts. All respondents reported they were aware, prior to receiving the materials informing them of the study, that the state required children to be immunized on time. Over 95% reported they knew the law required age-appropriate immunization and 100% were aware of school/licensed day-care requirements. The vast majority (83%) of county health directors believe that criminal misdemeanor charges and injunctions should be brought against parents for failing to have their child age-appropriately immunized. However, only 5% (n = 4) of health directors reported that their county had ever brought criminal misdemeanor charges, and none had filed an injunction against a parent whose child was not immunized on time. CONCLUSIONS: Despite the presence of legal statutes, there have been only rare efforts to compel age-appropriate immunization through enactment and enforcement of criminal penalties on parents. Much of the hesitancy for such efforts likely comes from the fear of the confusing, hard-to-understand legal procedures and from the potential negative impact on public opinion that these tactics may create. Although such actions should be taken only as a last resort, they may be necessary on some occasions.

Vaccine-associated liability risk and provider immunization practices.

OBJECTIVE: To explore the effect of concern about vaccine-associated malpractice litigation on provider immunization practices and attitudes. DESIGN: A cross-sectional mail survey. PARTICIPANTS: One thousand one hundred sixty-five pediatricians and 1849 family physicians. MAIN OUTCOME MEASURES: Physicians' perceptions of the legal and financial risks of providing immunizations and of the liability protection afforded by state programs and their current immunization practices. RESULTS: The response rate was 72% for pediatricians and 63% for family physicians. Overall, less than 30% of the respondents believed that federal and state programs protect them against vaccine-related lawsuits, with pediatricians more likely to believe so (32% vs 21%, P < .0001). Pediatricians were also more likely than family physicians to believe that the diphtheria, tetanus, and pertussis vaccine could be administered safely to children with a family history of seizures, a minor respiratory tract illness, or a previous local reaction to the vaccine. Liability issues were not significantly associated with any of the outcome variables, except that those physicians who believed that the whole-cell diphtheria, tetanus, and pertussis vaccine increased their risk for lawsuits were less likely to indicate that the diphtheria, tetanus, and pertussis vaccine was safe for children with a family history of seizures (P < .001). CONCLUSIONS: Liability-related variables were not independently associated with most immunization behaviors examined. This raises the question as to whether physicians cite liability as a reason for not immunizing children with acute and chronic illnesses, when their concerns are actually otherwise. These data suggest that educational efforts focused on liability issues alone will have little effect on inappropriate delaying of immunization for these children. Rather, education is needed regarding inappropriate contraindications themselves.

Adopting immunization recommendations: a new dissemination model.

OBJECTIVE: This paper presents a new approach for understanding factors related to physician adoption of clinical guidelines, using children's vaccine recommendations as a case study. METHODS: The model traces sequential steps, from awareness to agreement to adoption and, finally, adherence to the guideline. Movement through these stages can be catalyzed or retarded by many influences, grouped into two major categories: environmental characteristics of the physician's practice, and information characteristics of the guideline. Environmental characteristics include sociocultural factors, professional characteristics, and practice organization factors. Information characteristics include the guideline's relative advantage, complexity, and compatibility with existing guidelines and protocols, as well as mechanisms of guideline dissemination. IMPLICATIONS: This model can be used to identify characteristics that will likely impede or facilitate guideline adoption, and to focus dissemination efforts on key issues.

Prospects for childhood immunization registries in public health assessment and assurance: initial observations from the All Kids Count initiative projects.

This article offers an overview of selected evaluation findings from the initial implementation year of the Robert Wood Johnson Foundation's All Kids Count childhood immunization initiative in which demonstration projects were funded to develop community-based immunization registry and follow-up systems in 14 sites throughout the United States. The basic components of these systems, the process through which these registries were developed, efforts to secure the participation of private sector providers, the prospects for system success at the community level, and the potential for these immunization programs to influence other aspects of primary health care for children are addressed.

The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations.

OBJECTIVES: This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times. METHODS: Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states. RESULTS: The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations. CONCLUSIONS: These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.

Pediatrician and family physician agreement with and adoption of universal hepatitis B immunization.

BACKGROUND: The purpose of this study was to assess (1) rates of agreement with and adoption of the universal hepatitis B vaccine recommendation among practicing pediatricians and family physicians in nine selected states; (2) physicians' attitudes related to hepatitis B immunization; and (3) physicians' perceptions of parental attitudes regarding the hepatitis B vaccine series. METHODS: Self-administered questionnaires were mailed to 3014 pediatricians and family physicians in selected metropolitan areas and non-metropolitan areas of nine states. Outcome variables were agreement with and adoption of the hepatitis B vaccine recommendation. Predictor variables included physicians' characteristics, practice type and location, and proportion of managed care and Medicaid patients. Other variables that were studied include physicians' attitudes related to hepatitis B immunization, sources of immunization recommendation information, personal completion of the hepatitis B immunization series, and physicians' impressions of parental attitudes about the vaccine. RESULTS: Pediatricians were more likely than family physicians to report that they knew "a lot" about the recommendation (95% vs 84%), agreed with it (83% vs 57%), and have adopted it into practice (90% vs 64%). More physicians in both specialties had adopted the recommendation than actually agreed with it. Doubt about long-term protection from the vaccine was a strong predictor of not agreeing with or adopting the recommendation. Parental resistance to or request for hepatitis B vaccine affected the likelihood of physicians adopting it. CONCLUSIONS: Pediatricians and family physicians continue to differ in both agreement with and adoption of universal hepatitis B immunization. Two years after the recommendation was made, less than two thirds of all family physicians have adopted this recommendation. Adoption is likely influenced by practice policy, physician attitudes, and perceived parental opinions. We recommend that as new vaccines are approved and recommended, research be conducted to explore and address issues germane to physician agreement and adoption.

Interaction between high-risk infants and their mothers: the NCAST as an assessment tool.

Using the NCAST Feeding, Teaching, and HOME Scales, we tested 37 high-risk infants matched with 37 healthy infants on gender, race, and socioeconomic status. All infants were 8 months old. A one-to-one matched case-control design was used to determine whether increased risk of impaired mother-infant interaction was associated with case status. Conditional logistic regression was used to control for possible confounding and to evaluate interaction. Of the 37 high-risk infant-mother dyads, 25 had a low score on one or more scales while only 10 of the control dyads had a low score on one or more of the three scales. The Feeding scale was the only assessment in which the association found in the univariate analysis persisted after adjusting for other variables. Because of its low cost and high efficiency, the NCAST battery appears to be valuable for directing more specialized intervention services in a high-risk infant population.