Elsevier

Social Science & Medicine

Volume 48, Issue 8, April 1999, Pages 1011-1027
Social Science & Medicine

Predictors of childhood immunization completion in a rural population

https://doi.org/10.1016/S0277-9536(98)00410-9Get rights and content

Abstract

Despite the availability of effective vaccines, immunization rates among two-year old children continue to be low in many areas of the United States including rural West Virginia. The goal of this study was to identify barriers to childhood immunization in rural West Virginia and determine factors that were important in the completion of the childhood immunization schedule. A telephone survey was used to collect data from a randomly selected sample of 316 mothers, of two-year olds, from 18 rural counties of West Virginia. Results indicated that two-thirds or 65% of the children in the study sample had completed their recommended immunizations by two years of age. Immunization barriers identified in this study include: living in health professional shortage areas, lack of health insurance, negative beliefs and attitudes regarding childhood immunizations, problems accessing the immunization clinic, and a perception of inadequate support from the immunization clinic. Results of the structural equation modeling, using LISREL-8, indicated that 20% of the variation in immunization completion (R2=0.197) was explained by attitude towards immunization and perceived support received from the immunization clinic. Furthermore, 42% of the variation in attitude towards immunization (R2=0.419) was explained by immunization-related beliefs, and 28% of the variation in immunization-related beliefs (the R2=0.277) was explained by general problems faced during immunization and perceived clinic support. The study concluded that positive immunization-related beliefs and attitudes, support from the immunization clinic, and ease of the immunization seeking process are important factors in the timely completion of the childhood immunization schedule.

Introduction

Immunization with vaccines provides protection from infectious diseases, including some that are potentially life threatening. Epidemiological investigations of recent outbreaks of vaccine preventable diseases have indicated incomplete immunization as a major reason for the incidence of these diseases. In the United States, the incidence of mumps, diphtheria, tetanus, pertussis, measles, and poliomyelitis has declined by more than 97% in the last few decades as a result of vaccines (Orenstein, 1992). The decline in these vaccine preventable diseases has correlated strongly with rising rates of immunizations in school-age children. Health statistics suggest immunization rates are 95% or more in school-age children which have been primarily attributed to school immunization laws in each state (Hinman, 1988). Because all states require up-to-date immunizations for day care or school entry, the vast majority of school-age (5–6 years of age) children are fully immunized. However, the same is not true for children who do not go to day care, or preschool children (less than 5 years of age), a large portion of whom are not adequately immunized on time. A survey conducted in March 1992 by the West Virginia Immunization program indicated that, at the second birthday, only 48.2% of the children had completed the recommended primary series of immunizations (4 DTP, 3 OPV, and 1 MMR). Furthermore, immunizations were significantly lower at eighteen months with only 26.5% of the children achieving the desired immunization status. Thus, low immunization coverage in children under two years of age has been a serious problem and public health concern in the state of West Virginia.

Section snippets

Significance of childhood immunization

Despite the extent of state, federal, and private efforts to increase childhood immunization rates, much needs to be done to achieve the Healthy People 2000 goal of 90% immunization coverage in children before age two. Childhood immunizations are recommended because, despite the decline in the incidence of infectious diseases, these diseases still exist and can be potentially life-threatening. In the measles epidemic from 1989–1991 there were 55,000 reported cases, 11,000 hospitalizations, and

Childhood immunization barriers

Low immunization coverage indicates the existence of important barriers in the immunization delivery process. To investigate and catalog the barriers to childhood immunization, the Institute of Medicine conducted a workshop in December, 1993 titled, ``Overcoming Barriers to Immunization'' (Institute of Medicine, 1994). This workshop reviewed past studies and made recommendations on the basis of the workshop presentations and discussions. Childhood immunization barriers that were identified at

Immunization as a preventive health behavior

Preventive health behavior has been defined as ``any activity undertaken by a person who believes himself to be healthy for the purpose of preventing disease in an asymptomatic stage'' (Kasl and Cobb, 1966). Childhood immunization is a preventive health behavior that is directed toward the child by the parent. In this sense, childhood immunization behavior can be defined as a preventive child health behavior in which the parent gets the child immunized for the purpose of preventing infectious

Hypothesized study model

Based on the previously mentioned information, a model was hypothesized to explain immunization completion on the basis of immunization barriers. In addition, the model was also used to test inter-relationships among the various immunization barriers and the direct and indirect effects of immunization barriers on immunization completion. It was hypothesized that mothers' perceived clinic support and attitude towards immunization would directly affect immunization completion. Furthermore, it was

Study objectives

The specific objectives of this study were as follows:

Methods

The study sample consisted of mothers of two-year old children from 18 rural counties in rural West Virginia. The study sample was identified from a birth record file (matched with death record files to screen and remove records of deceased children) obtained from the West Virginia Birth registry for 1992 which represented 99.99% of all births in West Virginia for the year 1992. The 18 rural counties were selected as they were designated rural according to the US Census data, and because they

Statistical methods

The trends in the extent of time taken to complete the various sets of immunizations in the 4DTP:4HIB:3Polio:1MMR series were graphically analyzed. Percent completion of each of the immunizations in the series were also calculated to determine the utilization pattern of the various vaccinations. Furthermore, immunization completion was calculated by counting the number of immunizations the child has had in the last 2 years with the maximum being 12 (4 doses of the DTP vaccine, 3 oral polio

Results

A total of 316 usable responses, 269 using the telephone survey and 47 using the mail survey were obtained and used for data analysis. Prior to data analysis, a survey response analysis was performed.

Discussion

This study investigated the problem of childhood immunizations from a socio-behavioral perspective. The results are significant in terms of obtaining an understanding of the behavioral processes underlying mothers' childhood immunization-seeking behavior. Childhood immunization is a preventive health behavior that is directed toward the child by the parent. Several frameworks have been posited by researchers to study preventive health behaviors in an attempt to influence it (Becker and Maiman,

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