Perceived Barriers to Childhood Immunization among Rural Populations

Perceived Barriers to Childhood Immunization among Rural PopulationsAuthor(s): Rosanne Harkey Pruitt, Priscilla M. Kline and Rebecca Bolt KovazSource: Journal of Community Health Nursing, Vol. 12, No. 2 (1995), pp. 65-72Published by: Taylor & Francis, Ltd.Stable URL: http://www.jstor.org/stable/3427162 .

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JOURNAL OF COMMUNITY HEALTH NURSING, 1995, 12(2), 65-72 Copyright @ 1995, Lawrence Erlbaum Associates, Inc.

Perceived Barriers to Childhood Immunization Among Rural Populations

Rosanne Harkey Pruitt, PhD, RNCS, and Priscilla M. Kline, EdD, RN Clemson University College of Nursing

Rebecca Bolt Kovaz, MS, RN Anderson School District IV

Pendleton, SC

BACKGROUND

Recent statistics demonstrate a trend toward increasing numbers of underim- munized preschool children in rural areas of the United States. The problem has been particularly severe in three predominantly rural counties in the northwest re- gion of South Carolina. A Department of Health and Environmental Control (DHEC) report indicated that the immunization rates for infants and toddlers in these counties were about 50% despite additional efforts to improve the situation. A local health department official and former colleague expressed concern about the low rates and the possible futility of additional efforts without more information related to the actual barriers creating such dismal immunization rates. Failure to immunize these young children leaves them vulnerable to preventable childhood diseases and sequelae. Literature exists related to barriers in urban settings (Clem- ents, Wilier, MacCormack, Weigle, & Denny, 1990; Markland & Durand, 1976; Orenstein, Atkinson, Mason, & Bernier, 1990; Salsberry, Nickel, & Mitch, 1993), however, very little is known about barriers in rural settings.

LITERATURE

Immunizations have proven to be one of the most effective public health measures of this century. State mandating of completion of the immunization series by the time of school entry has resulted in immunization rates of 95% or better across the United States (Orenstein et al., 1990). However, children are still being infected and dying from these vaccine-preventable diseases-primarily among the infant and toddler group. Unfortunately, this age group compares poorly with immunization rates of approximately 40% to 50% across diverse populations. These young children are

Requests for reprints should be sent to Rosanne Pruitt, PhD, RNCS, Box 341703, 512 Edwards Hall, Clemson University, Clemson, SC 29634-1703.



66 Pruitt, Kline, Kovaz

also the ones most vulnerable to the consequences of these diseases (Lewis et al., 1988; Orenstein et al., 1990).

Several studies have focused on the identification of barriers to infant and toddler immunization in urban areas. Orenstein et al. (1990) identified several risk factors for low immunization rates including "low educational level of either parent, large family size, low socioeconomic status, nonwhite race, young parental age, single parent, lack of prenatal care and late start of immunization series" (p. 327). Others have found similar risk factors that suggest the need for further investigation of spe- cific populations to identify barriers within subgroups (Clements et al., 1990; Markland & Durand, 1976). Perceived barriers to infant and toddler immunization in three predominantly rural counties were investigated in this study.

STUDY DESIGN

A descriptive study was conducted with a random sample from the target population.' The sampling plan was stratified to improve the probability of obtaining a representative picture of the population.

A pilot study was conducted with parents of children attending a child develop- ment center for families identified as educationally high-risk by a local school district. The pilot study was used to test the appropriateness of the questions in order to obtain information relevant to the goals of the study and to determine the need for changes in the questions or format. No changes were made. Information obtained during the pilot study was incorporated into a sensitivity and interview training session for the six nurses who participated in the study to strengthen interrater reliability of the data collection. The interview format was selected to eliminate any literacy requirements for participants.

SAMPLING

The subjects were the parents of 148 infants and toddlers identified as inadequately immunized or who were at risk for delayed immunizations. The sample of parents (n = 109) was randomly selected from three sampling frames created from the fol- lowing sources in each county: subsidized housing projects, day care programs without mandatory immunization policies at that time, and the DHEC delinquent immunization lists.

DATA COLLECTION

Data collection consisted of semistructured interviews with questions that included previously identified barriers as well as open-ended questions to uncover unrecog- nized barriers. Questionnaires were coded to protect the anonymity of the partici-

'This study was funded by a grant from the American Nurses Foundation.



Perceived Barriers to Immunization 67

pants. Interviewers were registered nurses who participated in training sessions to heighten cultural sensitivity and to enhance aspects of interviewing and home visitation skills. The data were collected through home visitation in the housing projects, visitation to the selected day care centers and phone interview or home visitation of parents of children on the delinquent immunization list. Contacts were attempted several times during the day over several weeks. Home visits were attempted if there was no phone. Times were rearranged for several visits, however no parents refused to participate in the study. Data were collected over a 3-month period.

LIMITATIONS

Limitations included other events that focused on immunizations beyond the control of the study. The importance of childhood immunization was receiving increasing media attention at the time of the study; thus, a question related to the influence of media on immunization practices was incorporated into the interview. The self-report method of data collection has an inherent limitation related to the honesty of the responses. The interviewers were identified as registered nurses col- lecting data for a study to make recommendations to improve delivery of care.

MEASUREMENT OF VARIABLES

The PRECEDE PROCEED model for health promotion planning and evaluation provided the conceptual framework for the study (Green & Kreuter, 1991). Three multidimensional factors drawn from the conceptual framework were used to exam- ine behavioral and environmental factors that affected the activity of parents toward immunization. The interview guide was developed from the literature review and from discussions with a variety of health care providers. The semistructured format was designed to yield quantitative data to substantiate previously identified barriers and qualitative data to add new knowledge. The interview guide was organized to focus on three types of factors: predisposing, enabling, and reinforcing. Predisposing factors involve attitudes, beliefs, and perceptions. Enabling factors include the availability, accessibility, and affordability of health care. Reinforcing factors relate to the influences exerted by members of one's social support system, by health care providers, and by the media (Green & Kreuter, 1991). Descriptive statistics were used to analyze the quantitative component, and content analysis was used to analyze the qualitative component.

RESULTS

More than half of the sample was obtained from the DHEC delinquent immunization list. All families with children under 4 years of age were interviewed at the randomly selected housing project and day care program in each county. The three day




care programs randomly selected included a small private program for minority children, a parochial program, and a program consisting of multicultural groups within a college community. Approximately 62% of the mothers, and a similar number of fathers (61.5%), were employed. However, 34% of the mothers were un- married. Family income was less than $10,000 per year for 29.4% of the sample. Approximately 25% of the population had less than a high school education. Al- most 40% of the families were covered by Medicaid.

Pearson correlations were examined to identify statistically significant factors related to the immunization status of the children. The number of children in the family (r=.358), the mother's age (r=.206), and the father's employment (r = .195) correlated significantly with immunization delays (p < .05). These factors are consistent with studies in urban areas that have identified the risk factors of young parental age; large family size; and, possibly, low socioeconomic status.

BARRIERS TO IMMUNIZATION

Predisposing Factors

Predisposing factors involve attitudes, beliefs, and perceptions. The majority of subjects (89.6%, n = 133) were knowledgeable about the importance of immunization. Attitudes expressed were generally supportive of the necessity and importance of childhood immunization. Fear of needles, more than one injection at a time, and side effects were reported by approximately 17% (n = 19) of the group, with 50% admitting that those feelings delayed immunization visits (see Table 1).

The primary reason for delayed immunization was illness (49.5%, n = 73). Al- though the Center for Disease Control and Prevention (CDC; 1989, 1994) has for

TABLE 1 Predisposing Factors

Yes Responses

n % Attitudes

Fear of needles 19 17.4 Opposed to more than one shot per visit 19 16.5 Prior bad experience 5 4.6 Fear of side effects/reactions 27 24.8

Beliefs Shots unimportant Against religion Own remedies 1 0.9 Modern medicine can cure disease 4 3.7

Perceptions Delay shots because of illness 54 49.5 Partial series protection 3 2.8 Diseases are not a problem 1 0.9 Unsure when to get shots 5 4.6 Unsure where to get shots 3 2.8 Note. N= 109.




TABLE 2 Enabling Factors

Yes Responses

Barriers n %

Clinic distance 18 16.5 Time waiting 42 38.9 Need for appointment 20 18.5 Cost 24 22.2 Can't afford private doctor 18 16.5 Inconvenient to return for second visit

for shots after sick visit 16 14.8 Inconvenient hours 25 23.1 Unable to get off work 15 13.9 Not treated well 13 12.0 Transportation 15 13.9 Arrangements for other children 15 13.9

Note. N= 109.

some time recommended that children with minor illnesses accompanied by fevers of less than 380C (100.20F) receive immunizations, many children's immunizations were delayed due to chronic colds, ear infections, and even long-term prophylactic antibiotic use. In many cases, it was unclear who had discouraged the immunizations or if the action was a decision related to another child.

There was widespread confusion about when immunizations were due, which re- flects the multiple changes that have occurred in the last few years. Even those whose records were current often referred to the need for a "2-year-old shot." Grandparents and friends present during home visit interviews echoed this confusion.

Enabling Factors

Questions related to enabling factors were used to investigate perceptions of the availability, accessibility, and affordability of health care (see Table 2). Responses related to distance traveled varied among the parents in the three counties. Several parents in each county reported one-way distances of 15 to 30 miles. In several cases, the parents were aware of more convenient clinics but were more comfortable at the other locations. Many were unaware or unsure of the times and locations of monthly satellite clinics in their communities. Between 8% and 20% of the parents in each of the three counties reported transportation problems (14% of the parents overall, n = 20). Problems included having to rely on the vehicles of others and Medicaid policies prohibiting transportation for siblings not receiving services.

Inconvenient clinic hours were identified as barriers by 23% (n = 34) of the parents. This ranged from 15% to 32% among the three counties. Most of these parents worked or relied on others who worked for transportation. Difficulties in obtaining leave from work when their children were not ill were expressed by many of these parents.

Waiting time, especially for working parents, was identified as a problem by 40%




(n = 59) of the parents. Parents reported waiting from 20 min to 2 hr. Associated problems were the fussiness of the child or siblings and, in many cases, waiting for a physician visit in an office that did not administer immunizations or offered them at prohibitive costs, which required a second wait at the health department. In some cases, the child was seen for an illness, and a second appointment was required for follow-up and immunizations. There was a split over the use of appointments as a possible solution. The need to set up an appointment was perceived as an obstacle even though it is meant to decrease waiting time.

Cost was perceived as a barrier to receiving immunizations at physician's offices by approximately 20% (n = 30). Approximately 17% stated that they did not want to go to the health department, but they could not afford a private doctor. Immuni- zations are provided at no cost for preschoolers by the health department in each of the three counties.

Although the number was small, the most emotional responses came in relation to health care providers' treatment of those whose children's immunizations were delinquent. Cases of multiple obstacles related to the lack of transportation, child care for siblings, and other hurdles that had to be overcome were reported by parents. Details of scolding by someone during the visit were remembered as long as several years as a lasting impression of the visit.

Reinforcing Factors

Questions related to reinforcing factors probed the influence exerted by members of one's social support system, health care providers, and the media (see Table 3). Only 32.1% (n = 47) of the parents responded affirmatively to the question of the influence of other people on their immunization-seeking behavior. The category doctors received half of these responses, and parents and grandparents received most of the others. When questioned, most parents stated that because they received shots as

TABLE 3 Reinforcing Factors

Yes Responses

Influence n %

People Parent/grandparent 13 11.9 Husband/boyfriend 4 3.7 Family members 3 2.8 Friends 7 6.4 Church members 1 0.9 Doctor 17 15.6 Nurse 7 6.4 Other 3 2.8

Childhood experience 32 29.4 Media

Negative side effects 3 2.8 Disease outbreaks 11 10.1 Positive messages 15 13.8 Note. N= 109.




children, they knew it was important. Inherent in this answer is the role of parents and guardians in setting a positive example.

Responses to questions concerning the influence of the media revealed their lim- ited role as a reminder about immunizations. Only 2.8% (n = 4) of the parents indicated that news reports had discouraged immunization-seeking activities, although almost 25% (n = 37) indicated a fear of side effects or reactions. Ten percent indicated that a report of a disease outbreak was a motivator to seek immunizations.

There was widespread support for school immunization laws. All of the parents were aware of the laws, and 85.3% (n = 93) had positive attitudes toward them. The negative responses were related to governmental intrusion into parental activities or the feeling that the laws were necessary.

CONCLUSIONS AND RECOMMENDATIONS

There is a continued need for education about the importance of immunizations and schedules. Recent publications including the ages that shots are due without specifying the vaccines required of each age help to simplify the message for the public. The need for early immunizations is a particularly important message to relate to parents of the vulnerable toddler group. Health care providers must use their influence to educate and encourage parents about proper immunization practices.

Key among the barriers to immunization were the enabling or health care system factors. Factors related to costs, long waits, and waits with multiple providers must be addressed by the health care system. Well-publicized extended clinic hours are needed on a consistent basis.

Accurate, accessible, and current records are essential for maintaining a clear understanding of the immunization status and the needs of the population of children used in this study. In many cases, the researchers found that the use of multiple providers left incomplete records and inaccurate pictures of immunization status. Tracking systems with case management of children who are delayed or at high risk for delay should be put in place. Success will require cooperation among public and private providers.

Inaccurate beliefs about delaying immunization until a child is completely well have led to missed opportunities and seem to have become part of the lay population's modus operandi, which is often perpetuated by health care providers. New guidelines are now available from the CDC that clearly specify any contraindica- tions and widespread distribution should diminish this problem (CDC, 1994).

Although the number of incidents reported was small, the impact of insensitive treatment of children who have a delinquent immunization status should be noted. Fear of future negative encounters may escalate unaddressed health care needs in infants and small children.

We investigated the barriers to immunization of infants and toddlers in three predominantly rural counties. Future research is needed to validate these findings with other populations and to evaluate the success of community interventions. The im-




pacts of day care immunization laws and other policies are also important research areas.

This research study is unique in that a second intervention component was planned (based on the recommendations of the study findings) to address the identified barriers. The researchers were committed to facilitating long-term solutions by working on several projects in conjunction with other agencies. Initially, the investi- gators met with health care providers in each of the three counties to share the results of the study and recommendations of the participants. Twelve rural immunization clinics were organized in conjunction with the county health departments to reach underserved populations. A "mom/baby bib" program was established in each county with a training session for postpartum/nursery nurses who worked with new mothers and provided information on the importance of early immunization, the location and phone numbers of providers offering free or low-cost immunizations, and a baby bib with reminders for immunizations during the first year. Because of the rapidly changing immunization guidelines, the bibs include the ages for immunization in primary color blocks. The study and interventions that fol- lowed brought heightened awareness of the issues surrounding early childhood immunization to the population. It is hoped that better understanding of potential barriers may lead to improved immunization rates.

REFERENCES

Center for Disease Control and Prevention. (1989). Recommendations of the Immunization Practices Advisory Committee. MMWR, 38, 205-214, 219-227.

Center for Disease Control and Prevention. (1994). Recommendations of the Immunization Practices Advisory Committee. General recommendations on immunization. Morbidity and Mortality Weekly Report, 43, 9-10.

Clements, D., Wilier, C., MacCormack, J., Weigle, K., & Denny, F. (1990). Pertussis immunization in 8-month old children in North Carolina. American Journal of Public Health, 80, 734-736.

Green, L., & Kreuter, M. (1991). Health promotion planning: An educational and environmental ap- proach (2nd ed.). Mountain View, CA: Mayfield.

Lewis, T., Osborn, L., Lewis, K., Brockert, J., Jacobsen, J., & Cherry, J. (1988). Influence of parental knowledge and opinions on 12-month DTP vaccination rates. American Journal of Diseases of Children, 142, 283-286.

Markland, R., & Durand, D. (1976). An investigation of sociopsychological factors affecting infant immunization. AJPH, 66, 168-169.

Orenstein, W., Atkinson, W., Mason, D., & Bernier, R. (1990). Barriers to vaccinating preschool children. Journal of Health Care for the Poor and Underserved, 1, 315-329.

Salsberry, P., Nickel, J., & Mitch, R. (1993). Why aren't preschoolers immunized? A comparison of parents' and providers' perceptions of the barriers to immunization. Journal of Community Health Nursing, 10, 213-224.



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Perceived Barriers to Childhood Immunization among Rural Populations