search text   Advanced Search

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (18) Citing Articles via Google Scholar Google Scholar Articles by Taylor, J. A. Articles by Bocian, A. B. Search for Related Content PubMed PubMed Citation Articles by Taylor, J. A. Articles by Bocian, A. B. Related Collections Infectious Disease & Immunity

Association Between Parents’ Preferences and Perceptions of Barriers to Vaccination and the Immunization Status of Their Children: A Study From Pediatric Research in Office Settings and the National Medical Association

James A. Taylor, MD^*, Paul M. Darden, MD, Dennis A. Brooks, MD, MPH, MBA, J. W. Hendricks, MD^||, Richard C. Wasserman, MD, MPH^¶ and Alison B. Bocian, MS^#

^* Department of Pediatrics, University of Washington, Seattle, Washington
Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
^|| Pediatric & Adolescent Care, Tulsa, Oklahoma
^¶ Department of Pediatrics, University of Vermont, Burlington, Vermont
^# Division of Primary Care Research, American Academy of Pediatrics, Elk Grove Village, Illinois

-->

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Objectives. To assess the association between parents’ perceptions of various barriers to vaccination and their preferences regarding specific strategies designed to reduce missed vaccination opportunities and the immunization status of their children and to estimate the overall contribution of the perception of barriers on underimmunization among children who are vaccinated in pediatricians’ offices.

Methods. As part of a nationwide study on the immunization status of children followed by practicing pediatricians, parents of children who were 8 to 35 months of age and seen consecutively at 177 participating practice sites completed a survey on health beliefs regarding the vaccination process. In addition to demographic information, parents were asked to identify the most difficult thing about obtaining immunizations, as well as their preferences regarding the maximum number of vaccine injections that should be administered to their child at 1 visit and for receiving a needed immunization during an office visit for a mild illness. Immunization data on study children were abstracted from the practice medical record, and specific survey responses for each parent were compared with the immunization status of his or her child at 8 months of age using ² tests. For parental health beliefs associated with immunization status by bivariate analyses, the relative risks for underimmunization and population-attributable risk percentages of each belief were calculated after potentially confounding variables were adjusted for.

Results. Immunization data were collected on 13 520 children; 13 516 parents responded to at least 1 question regarding vaccination health beliefs. Two thirds of the responding parents indicated that their child should receive no more than 2 immunizations at 1 visit. However, there was no difference in the preferred maximum number of vaccines between parents of children who were fully immunized at 8 months of age and those of underimmunized children. Similarly, there was no difference in a stated preference for receiving a needed immunization during an illness visit. Overall, 74% of respondents indicated that there was "nothing" difficult about obtaining vaccines for their children. The most commonly cited barrier was concern about the side effects of vaccines, identified by 22.6% of parents. However, this barrier was not associated with immunization status. Each of the remaining barriers—including the confusing vaccination schedule, expense of vaccines, the inconvenience of the vaccination process, having a child who was often too ill to receive vaccines, religious objections, and other identified barriers—was statistically associated with immunization status, with adjusted relative risks for underimmunization ranging from 1.42 to 3.04. However, because each of these barriers was identified as important by <5% of parents, the population-attributable risk percentage for each was 2.5%. Overall, it was estimated that parental perception of barriers associated with immunization status accounts for 8.0% of the underimmunization observed among children who are vaccinated in the offices of primary care pediatricians.

Conclusions. Parental preferences regarding vaccination practices designed to reduce missed opportunities were not associated with the immunization status of their children. Although several barriers to vaccination were associated with immunization status, individual barriers were identified by a small minority of parents. Overall, parental perceptions of barriers to vaccination do not seem to be a significant cause of underimmunization in this population of children.

Key Words: immunization rates • practice-based research • parental health beliefs

Abbreviations: PROS, Pediatric Research in Office Settings • NMA, National Medical Association • DTaP, diphtheria-tetanus-acellular pertussis • IPV, inactivated poliovirus vaccine • OPV, oral poliovirus vaccine • RR, relative risk • PAR%, population-attributable risk percentage

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
In evaluating the causes of underimmunization that led to the measles epidemics of 1989 and 1990, the National Vaccine Advisory Committee concluded that significant barriers to immunization that made it difficult to vaccinate fully young children existed.¹ These barriers, which had been previously described, included missed opportunities for vaccination and impediments to immunization inherent in the delivery system.² Obstacles that parents needed to overcome also were identified and included limited and inconvenient hours for the administration of immunizations, inadequate access to care, and vaccine administration fees.

As a direct result of this assessment, the Standards for Pediatric Immunization Practices were published in 1993.³ These standards were designed to eliminate missed opportunities for vaccinations and reduce barriers for parents attempting to obtain immunizations for their children. Specific recommendations to eliminate missed opportunities included the simultaneous administration of all vaccines for which a child is eligible at each visit and the use of all clinical encounters, including visits for mild illnesses, for the provision of needed immunizations. Providers of immunizations were encouraged to make vaccines readily available with a minimal waiting time, with little or no cost to parents. This framework was strengthened by the findings of the Task Force on Community and Preventive Services. In their report, the task force reviewed the available evidence and recommended specific provider-based and community-based interventions that were found to increase immunization rates.⁴

Many of the barriers to immunization identified during the measles epidemics of 1989 and 1990 were most applicable to public health department clinics. At that time, it was estimated that 50% of all vaccines in the United States were administered in the public sector.¹ In the subsequent decade, there was a shift to providing more immunizations in office-based settings. A recent survey found that 73% of US children received all or some of their vaccines in a "primary care medical home;" 58% were immunized exclusively in private practice settings.⁵ Clearly, it is important to identify barriers to vaccination when provided in the office setting and to assess the impact of these barriers on the immunization status of the children seen there.

We therefore conducted a study in primary care pediatric practices to examine the influence of parental perceptions on immunization status. The primary objective of the study was to assess the association between parents’ perceptions of various barriers to vaccination and their preferences regarding specific strategies designed to reduce missed vaccination opportunities with the immunization status of their children. In addition, we wanted to estimate the overall contribution of the perception of barriers on underimmunization among children who are vaccinated in pediatricians’ offices.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Data for this project were collected as part of a national study on the immunization status of children who are followed by practicing pediatricians. The study was a collaboration of Pediatric Research in Office Settings (PROS), the practice-based research network of the American Academy of Pediatrics, and the Pediatric Section of the National Medical Association (NMA). At the time of the study, PROS consisted of >1400 pediatric practitioners in 48 states, Puerto Rico, and Quebec. The membership of the NMA Pediatric Section consists primarily of black pediatricians.

Detailed descriptions of the project have been published elsewhere.^6,7 Between March 1998 and January 2000, immunization information was abstracted from the medical records of a consecutive sample of children who were 8 to 35 months of age and seen in the office by 1 practitioner in each participating practice. Up to 120 children were enrolled from a practice. All of the practitioners from PROS and the NMA volunteered to participate in the project. At the time of the office visit, parents of study children were asked to complete a short survey. The survey included demographic items such as the age and race/ethnicity of the child and maternal education. Parents were asked whether they paid for their child’s vaccines totally out of pocket, had some payment such as administrative fee or insurance copayment, or had no expenditures for vaccines.

For assessing perceptions of barriers, parents were asked, "What is the hardest thing about making sure that your child receives all of the recommended vaccines?" A list of possible responses was provided and included inconvenience of bringing the child to the doctor’s office; expense of the immunizations; worries about side effects of vaccines, religious objections; the confusing vaccination schedule; having a child who is often too sick to receive immunizations when due; other concerns; or "nothing, it is not difficult to get my child immunized." Parents were asked to indicate any and all barriers that were important to them. Also included on the survey was a question about the maximum number of injections that the parent believed his or her child should receive at 1 visit, with possible responses ranging from "1" to "more than 5." Finally, parents were asked their preference for having their child receive a needed immunization during a visit for a mild illness or returning for the vaccine when he or she had recovered.

Responses to the question about barriers to obtaining immunizations were considered valid only when either 1 or more specific barriers were identified or the parent indicated that there was nothing difficult about obtaining vaccines for her or his child. The proportion of parents who identified a specific barrier as important was calculated by dividing the number of surveys on which that barrier had been checked by the number of valid responses.

The immunization status of study children at 8 months of age was the primary outcome of the project. As the time of the data collection period preceded the wide-scale availability of the pneumococcal conjugate vaccine, patients were defined as fully immunized when they had received 3 diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (DTaP)/diphtheria-tetanus, 2 inactivated poliovirus vaccine (IPV)/oral poliovirus vaccine (OPV), 2 Haemophilus influenzae type b, and 2 hepatitis B vaccines before the age of 8 months. In addition, immunization status at 19 months of age was determined for children who were 19 months old at the time that data were collected. To be classified as fully immunized at 19 months, a study patient had to have received 4 diphtheria-tetanus-pertussis/DTaP/diphtheria-tetanus, 3 IPV/OPV, 3 H influenzae type b, 3 hepatitis B, and 1 measles-mumps-rubella vaccine before that age.

For the analysis, the proportion of fully immunized children whose parents identified specific individual barriers as an important impediment to vaccinating their child was compared with the proportion identifying the same barrier in underimmunized patients using ² tests. A similar procedure was conducted to compare the proportions of parents of fully immunized and underimmunized children who indicated a preference for receiving a needed vaccine during a visit for a mild illness. A Mann-Whitney U test was used to assess the association between parental preference for maximum number of injections at 1 visit and the immunization status of their children; a response of "more than 5" was categorized as 6 injections for this analysis. Finally, the immunization status of children of parents who stated preferences for having their children receive 3 or more immunizations at 1 visit and receive a needed vaccine at an illness visit was compared with that of children of parents without 1 or both of these preferences using a ² test. For all of these analyses, P < .05 was considered statistically significant.

Logistic regression was used to assess the effect on underimmunization of parental health beliefs that were associated with immunization status by bivariate analyses. We previously presented data demonstrating that race/ethnicity, maternal education level, method of payment for immunizations, and year of birth were statistically associated with vaccination rates.⁶ Therefore, we controlled for the effects of these characteristics in assessing the independent effect of parental health beliefs on immunization status. In addition, generalized estimating equation techniques were used in these analyses to control for the effect of clustering patients into different practices.⁸ Because underimmunization was not a rare outcome (occurring in 20.5% of study children), the odds ratios calculated in the logistic regression models were converted to relative risks (RRs) using the method described by Zhang and Yu.⁹ Calculated RRs with 95% confidence intervals that did not include 1.0 were considered to be statistically significant.

Finally, to assess the overall impact of parental health beliefs on the immunization status of children who were vaccinated by practicing pediatricians, we calculated the population-attributable risk percentage (PAR%) for each parental belief as a cause of underimmunization. PAR% is a measure of the proportion of an adverse health outcome in a study population that is attributable to a specific exposure. The PAR% thus provides an estimate of the proportion of an adverse outcome that potentially would be eliminated if the exposure were eliminated.¹⁰ Similarly, the PAR% calculated for each barrier estimates the percentage of total underimmunization related to that barrier. It is important to note that the PAR% is not a measure of the percentage point decrease in the overall immunization rate. The proportion of parents who identified 1 or more barriers that were independently associated with underimmunization was also determined; the RR of any of these beliefs as a cause of underimmunization was computed as was the PAR%. The study was approved by the American Academy of Pediatrics Institutional Review Board.

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Immunization data on 13 520 children from 42 states and 177 practices were collected. Parents of 83 patients did not respond to the item regarding a preference for a needed vaccine, 78 recorded no response to the item on maximum number of injections at 1 visit, and 74 did not respond to the question about barriers. Thus, the sample size for the analyses were 13 437, 13 442, and 13 446 children, respectively. Characteristics of the 13 516 patients whose parents completed at least 1 section of the survey are shown in Table 1. As is seen in Table 1, 32.3% of the patients were from minority populations, and 33% of the mothers of study children were college graduates.

When asked the maximum number of vaccine injections that their child should receive at 1 visit, 66.6% of parents indicated 2 or fewer and 92.0% preferred 3 or fewer. Immunization status was not associated with parents’ preferences for the maximum number of injections to give their child. The median response for maximum of injections was 2.0 for the parents of both fully immunized and underimmunized children (P = .62).

A total of 13 366 parents responded to both the question about maximum number of vaccine injections at 1 visit and preferences regarding immunizations at illness visits. Among these, 2072 (15.5%) indicated preferences for 3 or more injections at 1 visit and having their child receive a needed immunization during a visit for a mild illness—a set of health beliefs that would minimize missed vaccination opportunities. The immunization rate at 8 months of age of the children of these parents was 79.1% versus 79.8% for those of parents with preferences that would tend to increase missed opportunities (P = .56).

Overall, parents identified few barriers to vaccinating their child. When asked what was the most difficult thing about making sure that their child received all of the recommended vaccines, the most common response was "nothing," cited by 74% of respondents. The most commonly cited barrier was concerns about the side effects of vaccines, identified by 22.6% of responding parents. However, as is shown in Table 2, the proportions of parents of fully immunized and underimmunized children who identified concerns about side effects as an important barrier were similar (P = .17). For the remaining barriers assessed, all were identified significantly more often by parents of underimmunized children than those of fully immunized children.

Logistic regression was used to assess the independent association with immunization status at 8 months of each parental health belief that had been found to be associated with this outcome in bivariate analyses (Table 3). The potentially confounding variables of year of birth, maternal education level, method of payment for vaccines, and race/ethnicity of the child were included in each model. The RR of each of these barriers was significantly more than 1.0, indicating that a parental perception of each of the barriers was associated with an increased risk that their child would be underimmunized. In addition, 1848 parents (13.7% of respondents) identified at least 1 of the barriers associated with immunization status as an important impediment to obtaining all recommended vaccines. Children of these parents were significantly more likely to be underimmunized than those of parents who did not identify at least 1 of these barriers (RR: 1.75; 95% CI: 1.59–1.92).

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

Many of the hypotheses regarding the importance of perceived barriers to vaccination have been derived from focus groups of parents. Lannon et al¹¹ conducted focus groups of mothers of children who were receiving care in county health department clinics in North Carolina. These mothers identified several barriers to obtaining immunizations for their children, including inconvenient clinic hours, transportation difficulties, confusing vaccination schedules, concerns over side effects of immunizations, and a belief that vaccines should not be administered to a child who is sick. McCormick et al¹² conducted 12 focus groups of parents of children who were younger than 5 years and from an urban area. Efforts were made to include parents from several different racial and ethnic groups and varying socioeconomic strata. Commonly identified barriers to vaccination included the inconvenience of leaving work to take their children to health care providers and limited access to well-child care services.

There are few studies in which the impact of perceived barriers on immunization status was assessed. In a previous study by 1 of the authors (J.A.T.), health beliefs of parents of children who received care at 2 Seattle, WA, area private pediatric practices were assessed.¹³ No statistically significant differences were found between parents of children who were fully immunized at 2 years of age and those of children who were underimmunized for any of the beliefs regarding barriers that were assessed. Results of a study on the parental characteristics and beliefs among children who are followed by private practitioners or in managed care organizations in Maryland indicated that neither parents’ knowledge nor attitudes about vaccines were associated with the immunization status of their children.¹⁴

Some investigators have concentrated on the effects of parental health beliefs on the immunization status of disadvantaged children. Bates and colleagues^15,16 evaluated risk factors for underimmunization at 3, 7, and 24 months of age among a cohort of infants who were born in a municipal teaching hospital. At baseline, 86% of the children were on Medicaid insurance and their mothers were mainly young and impoverished. These researchers found that underimmunization was significantly associated with financial barriers, family environment, and a history of inadequate prenatal care. There were no parental health beliefs that were consistently associated with a child’s immunization status. Strobino et al¹⁷ reported similar findings in a study of disadvantaged families who lived in Baltimore; there was little effect of parental attitudes on immunization status.

In a population-based study from Olmstead County, MN, 46% of surveyed parents indicated that there were some barriers to vaccinating their children adequately; however, only 3% reported major barriers.¹⁸ Parents of underimmunized children were significantly more likely to cite barriers such as transportation problems, having a child too ill to receive vaccines, not knowing when vaccines were due or when their child’s appointment was, and concerns about reactions to immunization than parents of children whose vaccinations were up-to-date. The authors of this study calculated the attributable risk of these barriers and estimated that 12.1% of underimmunization in the county might have been attributable to the perception of having a child too ill to receive needed vaccines, 14.1% secondary to confusion about the vaccination schedule, and 16.4% attributable to concerns about the risks of immunization. Overall, it was estimated that 29.2% of underimmunization in Olmstead County, MN, was attributable to parental perceptions of barriers.

Several differences in design could explain the findings of higher attributable risk percentages in the Minnesota study as compared with the current investigation. The most obvious differences were in the study samples. Our study included parents from 42 states rather than from a single county. In addition, for our study, we surveyed parents whose children were being seen for visits in practice settings and might therefore have fewer barriers to access to care than those in a population-based sample. In the Minnesota study, parents were surveyed by mail. The response rate was 49%, including only 26% of the parents of study children who were underimmunized.¹⁸ Because the parents of underimmunized children who were most hindered by barriers to vaccination may have been more likely to respond to the survey, the modest response rate may have biased the results somewhat.

One of the more surprising findings in our study was the lack of statistical association between parental concerns about vaccine safety and immunization status. Although nearly one quarter of the parents identified concerns about the side effects of vaccines as a barrier, the immunization rate of their children was similar to that of children of parents who did not indicate that this was a hindrance to vaccination. This finding is consistent with results of focus groups in which parents indicated that reports on the risks associated with immunizations are frequently sensationalized by the media.¹² The consensus of those focus groups was that these potential risks were not a sufficient reason to defer vaccinations in their children. Both the focus group results and the data from our study suggest a degree of sophistication by parents of young children. Despite the low incidence of vaccine-preventable illnesses in the United States and reports (usually unfounded) of significant morbidity associated with immunizations, parents are able to weigh accurately the risk-benefit ratio of vaccines. Alternatively, parents may follow the vaccination advice of their child’s pediatrician regarding immunizations, despite their personal misgivings.

We suggest 2 possible explanations for our findings that suggest that children of parents whose preferences would tend to increase missed vaccination opportunities were no more likely to be underimmunized than those of parents with health beliefs that might reduce missed opportunities. The most obvious explanation is that despite parental preferences, practitioners vaccinated their patients in accordance with the recommendations in the Standards for Pediatric Immunization Practices.³ However, another possibility is that the pediatricians in our study varied their vaccination practices in accordance with parental wishes.

Since this study was conducted, several changes in immunizations have taken place in the United States. While our data were being collected, there was a massive switch from OPV to IPV as the type of poliovirus vaccine administered.⁶ Subsequently, the pneumococcal vaccine was recommended for routine administration to all healthy infants.¹⁹ Both of these policies increased the number of injections needed to immunize preschool children fully; therefore, it is possible that parental preferences for fewer immunizations at 1 visit might currently have a more negative impact on immunization status than what we found in our study. In addition, because the average cost per dose of pneumococcal vaccine is $58.75,²⁰ concerns over the expense of immunizations may also have a more pronounced effect than previously for parents who pay for immunizations totally or partially out of pocket. The recent shortage of DTaP vaccine,²¹ by necessitating multiple visits to providers to receive all immunizations, might have since resulted in an increased parental perception of inconvenience associated with the vaccination process. Finally, since our data were collected, there have been several widely disseminated reports of serious side effects or potential toxicity associated with immunizations^22–25; parents may now have increased concerns about vaccine safety because of these well-publicized reports. Thus, the results of this study should be interpreted cautiously.

Despite the changes in immunization practice that have occurred subsequent to our study, we believe that our results remain valid and have important implications. The data from this national study indicate that neither parental perceptions of barriers nor preferences regarding vaccination practices are a significant cause of underimmunization among children who are followed by primary care pediatricians. It is unclear whether this lack of impact is related to the removal of systematic barriers to vaccination as suggested in the early 1990s, reliance by parents on their child’s primary care provider to be responsible for maintaining the immunization status of their children, or some other factors. However, the findings in this study suggest that future interventions designed to increase the immunization rate of US children be focused on the vaccination process as it occurs in private offices or similar community-based sites, particularly in light of the continuing trend for the provision of immunizations away from public health settings and toward the private sector. Such interventions should include specific provider- or practice-based initiatives directed at improving internal practice systems and evaluations of the interaction between the broader state and national immunization delivery systems and the protocols used by community-based providers in their practice-based systems.

	ACKNOWLEDGMENTS

 
This study was funded by the Centers for Disease Control and Prevention, National Immunization Program, and the Health Resources and Services Administration, Maternal and Child Health Bureau.

The following pediatric practices or individual practitioners completed this study: PROS (listed by AAP Chapter): Alabama, Drs Heilpern and Reynolds, PC (Birmingham), Stephen Brandt, MD (Ozark); Alaska, Anchorage Pediatric Group (Anchorage); Arizona, Orange Grove Pediatrics (Tucson), Cigna HealthCare (Tucson); California-1, Mika Hiramatsu, MD (Castro Valley), Anita Tolentino-Macaraeg, MD, and Arminda Tolentino, MD (Hollister), Shasta Community Health Center (Redding), Cantor, Giedt, and Kamachi (Salinas); California-4, Edinger Medical Group, Inc (Fountain Valley); Colorado, Cherry Creek Pediatrics (Denver), Rocky Mountain Youth (Denver), Julie Brockway, MD (Ft Collins), Gino Figlio, MD (Lamar); Connecticut, Jeff Cersonsky, MD (Southbury), Carol Rizzolo, RPA-C (Southington); Delaware, A.I. du Pont Institute Children’s (Middletown); Florida, Rose Joseph, MD (Fort Lauderdale); Georgia, Victor Lui, MD (Chamblee), The Pediatric Center (Stone Mountain); Hawaii, Jeffrey Lim, MD (Honolulu); Illinois, Southwest Pediatrics (Palos Park); Indiana, Northpoint Pediatrics (Indianapolis), Georgetown Medical Care (Indianapolis), Jeffersonville Pediatrics (Jeffersonville); Iowa, Integra Health Pediatrics (Cedar Rapids), Asha Madia, MD (Des Moines); Kansas, Ashley Clinic (Chanute); Kentucky, Michael Simon, MD, and Jennifer Crane, MD (Lexington); Maryland, O’Donovan & Ahluwalia, MD, PA (Baltimore), Children’s Medical Group (Cumberland), Shore Pediatrics (Denton), Shore Pediatrics (Easton), Maryland Clinical Associates PA (Towson); Massachusetts, Garden City Pediatrics (Beverly), Pediatric Associates of Norwood (Norwood), Worcester Pediatric Associates (Worcester); Michigan, Susan Hendrickson, MD (Bay City), Children’s Hospital of Michigan (Detroit), MiddleBelt Pediatrics HCA (Farmington Hills), Downriver Pediatric Associates, PC (Lincoln Park), Pediatric & Family Care of Rochester Hills, Mackinac Straits Primary Care (St Ignace), Orchard Pediatrics (West Bloomfield); Minnesota, Brainerd Medical Center (Brainerd), South Lake Clinic (Minnetonka); Missouri, Edith Colbert, MD (Chesterfield), Children’s Mercy Hospital (Kansas City), Northland Pediatric Associates (North Kansas City); Montana, Stevensville Pediatrics (Stevensville); New Hampshire, Exeter Pediatric Associates (Exeter), Pediatric & Adolescent Medicine (Kingston), Laconia Clinic (Laconia); New Jersey, Kids Care Pediatrics (Egg Harbor Township), Delaware Valley Pediatric Associates, PA (Lawrenceville); New Mexico, Presbyterian Family Health care-Rio Bravo (Albuquerque); New York-1, Pediatric Associates (Camillus), Panorama Pediatric Group (Rochester), Genesee Health Service (Rochester), Elmwood Pediatric Group (Rochester), Edward Lewis, MD (Rochester), Brighton Hill Pediatrics (Syracuse); New York-2, Andrea J. Leeds, MD, PC (Bellmore), Sonia Vinas, MD (Brooklyn), Huntington Medical Group, PC (Huntington Station); North Carolina, Eastover Pediatrics (Charlotte), Hendersonville Pediatrics (Fletcher); North Dakota, Altru Clinic (Grand Forks), Medical Arts Clinic (Minot); Ohio, Bryan Medical Group (Bryan), Raj Gupta, MD (Dayton), North Central Ohio Family Care (Galion), Drs Harris & Rhodes (Lancaster), Children’s Hospital Physicians Associates (Twinsburg), Comprehensive Pediatrics (Westlake), Wooster Clinic (Wooster), St Elizabeth Health Center (Youngstown); Oklahoma, Shawnee Medical Center Clinic (Shawnee), Pediatric & Adolescent Care, LLP (Tulsa); Oregon, NBMC (Coos Bay); Pennsylvania, Ches Penn Health Services (Chester), Erdenheim Pediatrics, PC (Flourtown), Praful Bhatt, MD (Lock Haven), Plum Pediatrics (Pittsburgh), Pennridge Pediatric Associates (Sellersville), Han Pediatrics, Crozer-Chester Medical Center (Upland), Reading Pediatrics, Inc (Wyomissing); Rhode Island, Marvin Wasser, MD (Cranston); South Carolina, Cheraw Pediatrics (Cheraw), Palmetto Pediatrics (Columbia), Grand Strand Pediatrics & (Surfside Beach); Texas, White Rock Pediatrics, PA (Dallas), Sarah Helfand, MD (Dallas), Winnsboro Pediatrics (Winnsboro); Utah, Gordon Glade, MD (American Fork), John Weipert, MD (American Fork), Alpine Pediatrics (American Fork), University of Utah Health Sciences Center (Salt Lake City), Mountain View Pediatrics (Sandy); Vermont, Judy Orton, MD (Bennington), CHP Brattleboro Pediatrics (Brattleboro), University Pediatrics (Burlington), Rebecca Collman, MD (Colchester), Mousetrap Pediatrics (Milton), Practitioners of Pediatric Medicine (South Burlington), CHP Timber Lane Pediatrics (South Burlington), Drs Joseph Hagan, Jr, MD, George Brown, MD, and Jill Rinehart, MD (South Burlington), St Johnsbury Pediatrics (St Johnsbury), University Pediatrics (Williston); Virginia, Drs Casey, Goldman, Lischwe, Garrett & Kim (Arlington), Fishing Bay Family Practice (Deltaville), Pediatric Associates of Richmond, Inc (Richmond), South Richmond Health Center (Richmond); Washington, Jemima Tso, MD (Chehalis), Columbia Basin Health Association (Othello), Redmond Pediatrics (Redmond), Rockwood Clinic (Spokane), Yakima Neighborhood Health Services, Inc (Yakima); West Virginia, Grant Memorial Pediatrics (Petersburg); Wisconsin, Beloit Clinic SC (Beloit), Gundersen Clinic (La Crosse), Gundersen Clinic-Whitehall (Whitehall).

NMA (listed here by state): California, Mayo De Lilly, MD (Los Angeles); Delaware, A.I. Dupont Pediatric Children’s Hospital (Wilmington); Florida, Manatee County Rural Health Services (Bradenton), Arlene Haywood, MD (Plantation); Georgia, Beverly Walker, MD (Albany), Marsha Glover, MD (Bainbridge), Evelyn Johnson, MD (Brunswick); Louisiana, Charmine Venters, MD (Baton Rouge); Maryland, Diana Abney, MD (Waldorf), Johns Hopkins Community Physicians (West Friendship); Missouri, William Pankey, MD (Kansas City), Jackie Wayne-Tenney, MD (Lees Summit), Homer E. Nash, Jr, MD (St. Louis); New York, Winston Price, MD (Brooklyn).

	FOOTNOTES

 
Received for publication Feb 25, 2002; Accepted Jun 12, 2002.

Reprint requests to (J.A.T.) 146 N Canal St, Suite 300, Seattle, WA 98103. E-mail: uncjat{at}u.washington.edu

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 

1. The National Vaccine Advisory Committee. The measles epidemic: the problems, barriers, and recommendations. JAMA.1991; 266 :1547 –1552[Abstract]
2. Orenstein WA, Atkinson W, Mason D, Bernier RH. Barriers to vaccinating preschool children. J Health Care Poor Undeserved.1990; 1 :315 –330[Medline]
3. Ad Hoc Working Group for the Development of Standards of Pediatric Immunization Practices. Standards for pediatric immunization practices. JAMA.1993; 269 :1817 –1822[CrossRef][ISI][Medline]
4. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med.2000; 18(1S) :92 –96[CrossRef][ISI][Medline]
5. Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics.1999; 104(2) . Available at: www.pediatrics.org/cgi/content/full/104/2/e15
6. Taylor JA, Darden PM, Brooks DA, et al. Impact of the change to inactivated poliovirus vaccine on the immunization status of young children in the United States: a study from Pediatric Research in Office Settings and the National Medical Association. Pediatrics.2001; 107(6) . Available at: www.pediatrics.org/cgi/content/full/107/6/e90
7. Taylor JA, Darden PM, Brooks DA, Hendricks JW, Baker AE, Wasserman RC. Practitioner policies and beliefs and practice immunization rates: a study from Pediatric Research in Office Settings and the National Medical Association. Pediatrics.2002; 109 :294 –300[Abstract/Free Full Text]
8. Diggle PJ, Kiang KY, Zeger SL. Analysis of Longitudinal Data. Oxford, UK: Clarendon Press; 1994:146–168
9. Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA.1998; 280 :1690 –1691[Abstract/Free Full Text]
10. Hennekens CH, Buring JE. Measures of disease frequency and association. In: Epidemiology in Medicine. Boston, MA: Little, Brown & Company; 1987:92–93
11. Lannon C, Brack V, Stuart J, et al. What mothers say about why poor children fall behind in immunizations: a summary of focus groups in North Carolina. Arch Pediatr Adolesc Med.1995; 149 :1070 –1075[Abstract]
12. McCormick LK, Bartholomew LK, Lewis MJ, Brown MW, Hanson IC. Parental perceptions of barriers to childhood immunization: results of focus groups conducted in an urban population. Health Educ Res.1997; 12 :355 –362[Abstract/Free Full Text]
13. Taylor JA, Cufley D. The association between parental health beliefs and immunization status among children followed by private pediatricians. Clin Pediatr.1996; 35 :18 –22[Abstract/Free Full Text]
14. Hughart N, Strobino D, Holt E, et al. The relation of parent and provider characteristics to vaccination status of children in private practices and managed care organizations in Maryland. Med Care.1999; 37 :44 –55[CrossRef][ISI][Medline]
15. Bates AS, Fitzgerald JF, Dittus RS, Wolinshky FD. Risk factors for underimmunization in poor urban infants. JAMA.1994; 272 :1105 –1110[Abstract]
16. Bates AS, Wolinsky FD. Personal, financial, and structural barriers to immunization in socioeconomically disadvantaged urban children. Pediatrics.1998; 101 :591 –596[Abstract/Free Full Text]
17. Strobino D, Keane V, Holt E, Hughart N, Guyer B. Parental attitudes do not explain underimmunization. Pediatrics.1996; 98 :1076 –1083[Abstract/Free Full Text]
18. Yawn BP, Zhiesen X, Edmonson L, Jacobson RM, Jacobsen SJ. Barriers to immunization in a relatively affluent community. J Am Board Fam Pract.2000; 13 :325 –332[Abstract]
19. American Academy of Pediatrics, Committee on Infectious Diseases. Policy statement: recommendations for the prevention of pneumococcal infections, including the use of pneumococcal conjugate vaccine (Prevnar), pneumococcal polysaccharide vaccine, and antibiotic prophylaxis. Pediatrics.2000; 106 :362 –366[Abstract/Free Full Text]
20. Vaccines for Children Program price list. National Immunization program Web site. Available at: www.cdc.gov/nip/vfc/cdc_vac_price_list.htm. Accessed December 26, 2001
21. Centers for Disease Control and Prevention. Notice to readers: update on the supply of tetanus and diphtheria toxoids and of diphtheria and tetanus toxoids and acellular pertussis vaccine. MMWR Morb Mortal Wkly Rep.2001; 50 :189 –190[Medline]
22. Intussusception among recipients of rotavirus vaccine-United States, 1998–1999. MMWR Morb Mortal Wkly Rep.1999; 48 :577 –581[Medline]
23. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet.1998; 351 :637 –641[CrossRef][ISI][Medline]
24. Dittmann S. Special address: safety of hepatitis B vaccination. Vaccine.2000; 18(suppl 1) :S10 –S11
25. American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Environmental Health. Thimerosal in vaccines—an interim report to clinicians. Pediatrics.1999; 194 :570 –574

This article has been cited by other articles:

				P. M. Darden, J. A. Taylor, D. A. Brooks, J.W. Hendricks, M. Massoudi, J. M. Stevenson, and A. B. Bocian How Should Immunization Rates Be Measured in the Office Setting? A Study from PROS and NMA PedsNet Clinical Pediatrics, April 1, 2008; 47(3): 252 - 260. [Abstract] [PDF]

				J. L Temte Should all children be immunised against hepatitis A? BMJ, March 25, 2006; 332(7543): 715 - 718. [Full Text] [PDF]

				K. M. Posfay-Barbe, U. Heininger, C. Aebi, D. Desgrandchamps, B. Vaudaux, and C.-A. Siegrist How Do Physicians Immunize Their Own Children? Differences Among Pediatricians and Nonpediatricians Pediatrics, November 1, 2005; 116(5): e623 - e633. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (18) Citing Articles via Google Scholar Google Scholar Articles by Taylor, J. A. Articles by Bocian, A. B. Search for Related Content PubMed PubMed Citation Articles by Taylor, J. A. Articles by Bocian, A. B. Related Collections Infectious Disease & Immunity

	Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2002 American Academy of Pediatrics. All rights reserved.