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Factors influencing the immunization status of children in a rural setting
ORIGINAL ARTICLE
PH C
Factors Influencing the Immunization Status of Children in a Rural Setting Th a d Wi l s o n , P h D, R N , C S , F N P
ABSTRACT Introduction: The purposes of this study were to (a) assess parental perceptions of their decision making regarding children’s vaccinations and (b) describe parents’ evaluation of immunization services provided by rural clinics/offices. Methods: A qualitative design was used in this study, which was conducted in rural Missouri. Twelve mothers of children younger than age 3 years with fewer than the recommended number of immunizations were interviewed using a semistructured format. The interview results were analyzed using the constant comparative method. Results: The following parental perceptions were identified as factors related to immunizations in this rural setting: knowledge of communicable diseases and vaccines, misperceptions about communicable diseases and vaccines, past experiences, competing tasks, transportation, health care personnel, need for reminders, health system, and cost. Discussion: Two findings unique to this study were the importance of relationships with health care providers and the challenge of competing tasks. These findings, combined with the other factors identified, reinforced the importance of rural health care providers’ maintaining a strong relationship with clients, providing accurate and timely information, and ensuring a readily accessible health care system. J Pediatr Health Care. (2000). 14, 117-121.
May/June 2000
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ompared with other settings, in rural areas, fewer sources of health care are available, longer travel distances are required to access health care, and insufficient public health services are available to provide care to a population with higher rates of poverty and generally poorer health status indicators (Mason, Coates, & Millette, 1997). Therefore, it would seem logical that children living in rural America would have lower immunization rates than their urban counterparts. However, data indicate that although immunization rates in rural areas remain below federal goals for the year 2000, the rates are comparable to those in urban settings (Feldman, Andrew, Gilbert, Bracken, & Thompson, 1994; Mason, et al., 1997; Steiner, Lowery, Siegel, Barton, & Goodspeed, 1996). To identify factors influencing parental decisions related to vaccinations and to identify ways to improve services in a rural setting, a qualitative study assessing parental perceptions of childhood vaccinations and immunization services in rural areas was conducted in the Midwest. The pediatric health care provider’s understanding of these factors may improve the immunization status of children in rural America. REVIEW OF LITERATURE A great deal has been written about the inadequate immunization rates of 2year-olds in the United States. In a comprehensive review of research regarding factors associated with immunization rates, Santoli, Szilagyi, and Rodewald (1998) reported that whereas some factors were supported by strong evidence, other factors were not supported. Three factors often noted in the literature but not supported by strong scientific evidence were parental attitudes, provider attitudes, and ability to access a primary care provider. The authors found strong evidence to support 5 factors associated with low immunization rates: (a) socioeconomic factors (poverty and cost to families and providers), (b) late start of vaccination, (c) information gap (patient and provider awareness), (d) provider practices (missed opportunities
Thad Wilson is Assistant Professor at the University of Missouri-Kansas City School of Nursing. Reprint requests: Thad Wilson, PhD, RN, CS, FNP, University of Missouri-Kansas City School of Nursing, 221 Health Science Bldg, 2220 Holmes, Kansas City, MO 64108-2676. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/1/103835 doi:10.1067/mph.2000.103835
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PH ORIGINAL ARTICLE C and lack of tracking or reminder systems), and (e) office/clinic factors (appointment requirements, inconvenient clinic hours, and long wait times). All but one of the 66 studies cited by Santoli, Szilagyi, and Rodewald (1998) were conducted in urban or suburban areas. Few studies have examined immunization factors specific to rural settings. Arecent statewide study by the Massachusetts Department of Public Health found that 76.5% of the 2-year-old children living in rural Massachusetts were fully immunized. This finding was similar to the overall state rate of 73.5% and was greater than the immunization rate of children in urban areas (Mason et al., 1997). The authors reported that immunization rates in rural areas were enhanced or detracted by certain health beliefs held by rural residents. The sense of community, the need to be productive, and a different perception of distance were identified as factors enhancing immunization rates. Lower income levels, no public health structure, and a high rate of personal and/or religious exemptions were identified as factors decreasing immunization rates. Other studies have encountered similar results. Feldman et al. (1994) found higher immunization rates among preschool children living in the less densely populated areas of Mississippi than among those living in more densely populated areas. Mainous and Hueston (1995) reported that federal programs that offer free childhood vaccines to physicians have a significant effect on increasing immunization rates in rural areas. The authors noted that in states with free vaccine distribution, no difference existed between the availability of immunizations at urban and rural physician practices. However, in states without free vaccine distribution, physicians in urban settings were more likely to have immunizations available than were rural physicians (87% vs 52%). Steiner et al. (1996) indicated that missed opportunities by providers in rural settings must be avoided to ensure proper vaccination of all children. Findings from two other studies support the argument that missed opportunities to immunize were more common in rural than in urban settings. Szilagyi et al. (1993) found that the mean number of missed opportunities was greatest among rural private practices compared with urban and suburban settings.
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Hueston, Meade, and Mainous (1992) reported that physicians practicing in rural Kentucky offered immunizations to patients less frequently than did physicians in urban practices. Cost of vaccine and administration was found to be a primary concern in both rural and urban settings.
A
dverse reactions from
past immunizations, such as fever, sore legs, and irritability, influenced immunization status.
Pruitt, Kline, and Kovaz (1995) conducted a study to identify factors influencing immunization status of children in rural areas. The study used a semistructured interview format that led to quantifiable data. The authors categorized their findings into predisposing, enabling, and reinforcing factors. Predisposing factors involved attitudes, beliefs, and perceptions. Infant illness, fear of needles, concern about adverse effects, and confusion about when immunizations were due were most commonly identified as negative predisposing factors. The knowledge about and necessity for immunizations were considered positive predisposing factors. The availability, accessibility, and affordability of health care services were considered enabling factors. No positive enabling factors were reported, but transportation problems, cost, waiting times, and inconvenient clinic hours were identified as negative factors. In the third category, reinforcing factors—the influence exerted by social support systems, health care providers, and the media—were evaluated. No negative reinforcing factors were identified. Parents, grandparents, and health care providers exerted a positive influence, with media having little influence. Research, while limited, has identified similar barriers in rural areas as in urban areas. However, parental perceptions related to obtaining immuniza-
tions have not been well described for rural residents. To expand the limited information available about factors influencing immunization rates in rural settings, a qualitative study was conducted in a rural area of Missouri. Specific purposes of this study were to assess parental perceptions of their decision making regarding children’s vaccinations and to describe parents’ evaluation of immunization services provided by rural clinics/offices.
METHODOLOGY, PROCEDURE, AND ANALYSIS A descriptive study, using qualitative data, was conducted to meet the purposes of the research. Data analysis was conducted using a grounded theory approach (Strauss, 1987). After Institutional Review Board approval of the study, parents of children were identified at 3 rural health department–sponsored immunization clinics and 3 private offices, all located in rural Missouri. Inclusion criteria for the study were that the subjects: (a) were a legal parent or guardian of one or more children receiving care at an identified setting, (b) were able to read and write English, (c) had at least one child between the age of 2 months and 4 years receiving fewer than the number of vaccines recommended by the Centers for Disease Control and Prevention (CDC) (1998), and (d) resided in an area with a population less than 10,000. Following identification, parents were contacted by telephone or in person and the research project was explained. For those willing to participate, an appointment was made for an interview. When feasible, the confidential interviews were held at non-health care facilities to decrease anxiety about the health care system. Interviews were held in homes, non-health care offices (insurance building), restaurants, and in health department rooms away from the immunization area. After obtaining written consent, a research assistant completed a sociobiographical data form and conducted a semistructured interview. Four graduate student research assistants participated in data collection and analysis after attending a half-day seminar on qualitative research techniques. The sociobiographical form included the parent/guardian’s age, race or ethnicity, years of education, routine health
JOURNAL OF PEDIATRIC HEALTH CARE
PH ORIGINAL ARTICLE C care source, payor source, availability of transportation, and distance from the site where immunizations are obtained. The interview format focused on the subjects’ feelings and experiences in obtaining immunizations for his or her children. The principal investigator and research assistants developed the questions based on extensive personal experience and a review of the literature. Two researchers familiar with qualitative design and two nurses knowledgeable about immunizations and health care systems reviewed the proposed questions. Minor revisions were made based on this review. Questions included the following: “Please describe any past experiences having your child immunized,” “What kinds of things have made it easy or difficult for you to have your child immunized?” and “What is your main source of information about immunizations?” Questions for clarification or validation were used as needed. The interviews were tape recorded and transcribed verbatim. In addition, field notes were written by the research assistants during the interviews to identify nuances of the subject or setting. Data analysis was conducted using the transcribed interviews and field notes. The data were analyzed using the constant comparative method described by Strauss (1987). Each research assistant conducted and transcribed a single interview and analyzed the data of that interview to establish categories based on similarity of content. Each research assistant shared his or her findings with the principal investigator, who (a) reviewed the data and categories for consistency, (b) examined the categories for underlying similarities, and (c) reduced the number of categories based on the similarities. Second and third interviews with analyses were conducted by the research assistants and reviewed by the principal investigator, constantly comparing the categories elicited from the data with previously obtained data. Saturation of the identified categories occurred after 12 interviews.
SAMPLE Of the 21 parents contacted, a convenience sample of 12 subjects agreed to participate in the study. The most common reason given by nonparticipants was the time commitment. All subjects
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were mothers of the immunized children. Subject ages ranged from 20 to 39 years, with a mean age of 27.5. Children’s ages ranged from 8 to 36 months, with a mean age of 22.23 months. Other sociodemographic information can be found in the Table. Among the 75% without a third-party payor, there was an overall sense that Medicaid, for which most were eligible, was an unacceptable “handout.” All parents stated that immunizations were provided at no cost to them. Distances driven to health care offices ranged from 2 miles to 30 miles with a mean of 10.75 miles.
RESULTS One purpose of this study was related to parents’ perceptions of decision making related to their children’s vaccinations. The following categories emerged: knowledge, past experiences, competing tasks, and transportation.
A
ll mothers stated that
often they were too busy with daily tasks or work and did not have adequate time for immunizing their children.
Knowledge Knowledge was further divided into two categories: (a) knowledge of communicable diseases and vaccines and (b) misperceptions about communicable diseases and vaccines.
Knowledge of communicable diseases and vaccines. Ninety-two percent of the mothers perceived immunizations as a benefit. There were universal views, such as, “I know they are necessary to keep [my child], and the world for that matter, from getting the diseases that the shots cover,” and “some countries still have diseases we no longer worry about due to immunizations.”
TABLE Sociodemographic data of participants Characteristic
No.
Payor source Self Medicaid Insurance Ethnicity Caucasian Other Source of primary care Private office Other/none Educational level Completed Junior High Completed High School Attended College Marital status Married Single Transportation Own car Family/other
9 2 1 11 1 10 2 2 6 4 8 4 9 3
Mothers also perceived personal benefits. For example, 83% of the subjects noted that immunizations keep their children from getting “sick.” Mothers were aware of the seriousness of the vaccine preventable diseases and wanted to protect their children against such maladies. Knowledge led two parents to postpone or avoid immunizations. One mother stated that she had “researched it and the only cases of polio in the United States were from the vaccine and not from getting it from other people.” Another questioned, “Why in the world do we still immunize our kids against these diseases that are rarely seen anymore?”
Misperceptions about communicable diseases and vaccines. Parents also had misperceptions about immunizations. Six mothers canceled appointments for immunizations because their child had a cold. “Children sick at all, shouldn’t get shots,” noted one mother. One parent had heard, “You shouldn’t let anyone kiss your child and you must be careful with dirty diapers after having the polio vaccine.” This belief led this mother to postpone her child’s immunizations until he was “out of diapers.”
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PH ORIGINAL ARTICLE C A few parents questioned the safety of some vaccines. One stated, “I don’t want my kids used as guinea pigs.” Another parent worried about what “they put in [the vaccine]” and commented that “the experts don’t seem to all agree” on what is safe. One mother expressed a philosophical belief that “God created the immune system, not vaccinations,” and therefore refused to vaccinate her children. The same mother also noted that when someone came in contact with a communicable disease, such as “hepatitis, that the body would be sick for three days and then build up an immunity to the disease.”
Wilson
Transportation Sixty-seven percent of the parents noted lack of transportation or inconvenient distance to the facility as a problem. Of the 9 subjects with a car, 5 came from one-car families. Scheduling the use of the car while maintaining transportation for work was noted to be difficult by 3 of these subjects. “It’s not that [the clinic] is so far away, it’s just getting the car that’s a hassle,” one exasperated mother stated. One parent stated that she had no transportation. In the rural settings for this study, there was no public transportation system, which is not unusual.
Past experiences Adverse reactions from past immunizations, such as fever, sore legs, and irritability, influenced immunization status. Fifty-eight percent of the mothers believed these reactions made it difficult to continue with the immunizations because they did not like to see their children experience these reactions. One parent said, “My first child had a bad reaction to the shots, so I was afraid to risk [my second child] having the shots.” Others had personal experiences that left negative impressions. “It’s not an easy thing for me to do, because last time I started bawling when he started bawling,” stated one subject. Another noted that “the shots hurt so bad that the kids get so apprehensive of anyone in a white coat and I just don’t want to go through that again.”
W
ithout access to a
mass transit system, rural residents in this study found access to a mode of transportation more challenging than the distance to a health care source.
Competing Tasks All mothers stated that often they were too busy with daily tasks or work and did not have adequate time for immunizing their children. One parent stated, “We have a lot to do in our lives, immunizations can easily slip through the cracks.” Another noted that “Even with the evening clinic, there is still little league, soccer, washing, cooking...There are just too many things to do.” Work was mentioned by 67% of the subjects as a competing factor. Either the mother needed to get time off work to take the child in for immunizations or another family member had to take off work to babysit the other children or provide transportation. In addition, one mother noted that “Not only do I miss a day to take [my child] in for shots, but I may have to take another day off if he gets sick.”
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Another purpose of this study was to evaluate services provided by rural clinics/offices in relation to immunization services. Analysis of the data revealed the following content areas—health care personnel, need for reminders, health system, and cost.
Health Care Personnel Of those with a primary health care provider, 70% stated that they relied on their primary health care provider for information and support. For example, one mother stated that “If my friends give me a bunch of papers about how bad immunizations are, I know I can call my nurse practitioner and find the truth.” Another noted that she “relied on her doctor to tell her when the shots were due. I trust her to stay on top of this.” Emotional support was also re-
ported by one mother, who said, “I really dread having my child get shots, but the nurse practitioner always pats me on the back and helps me get through it.” Seven mothers shared that the health care personnel, doctors and nurses, were kind and considerate and tried to make the experience as “painless as possible.” Knowing that their child would be cared for in a professional manner provided a positive influence on the mothers.
Need for Reminders Fifty-eight percent of the mothers expressed confusion about the immunization schedule. “As long as they send me reminders, I take my child in. Without reminders, I don’t know when shots are due. It’s too confusing,” shared one mother. One parent’s insight into this factor was that “The most important thing is to let the parents know what immunizations their child needs, when they should receive them, and what kind of reactions they can have. I can handle anything if I know what to expect.”
Health System Health system factors included inconvenient clinic hours, dates or locations, waiting lines, minor illness, and conflicting information. The inconvenience of clinic hours, dates of immunization clinics, and locations of clinics were reported by 75% of the parents. One parent declared, “It’s only in the mornings which does not fit my schedule.” Another noted that “The immunization clinic is only on Tuesdays and Thursdays.” Another mother complained that the clinic was only open during the days: “My husband and I work, so one of us has to take off. That makes it hard.” Waiting lines were an issue mentioned by 3 parents, including one who said, “I have not had much trouble, except waiting in line at the clinic.” One provider excluded children from timely immunization on the basis of minor illnesses. This situation was believed by the parents to add difficulty in receiving immunizations. One parent stated, “It seemed every time I took her to the doctor, she was sick and he wouldn’t give her shots.”
Cost Immunizations were provided free at all the sites used in this study. The Vaccine for Children program provided federal
JOURNAL OF PEDIATRIC HEALTH CARE
PH ORIGINAL ARTICLE C funding in addition to state and local funds. Free immunizations were mentioned by 92% of the subjects. Mothers stated that cost was not a factor in the lack of immunizations for their child and that the lack of cost was, in fact, an incentive to get vaccinations. One parent noted that “the doctors, government, and the drug companies work together to make it easy to get the shots.”
P
roviders should
advocate for reminder systems to help parents know when their children need immunizations.
DISCUSSION This study revealed two unique findings. First was the positive effect of health care providers. The sample in this study had not yet experienced managed care, and the majority still used a single health care provider source. It may be that the relationships developed over time between providers and families may be a strong, positive influence for preventive health care. Two studies support this finding from an alternative perspective. Houseman, Butterfoss, Morrow, & Rosenthal (1997) and Pruitt et al. (1995) found that when parents were treated poorly by health care staff, the parents did not desire to return with their children for further immunizations. The second new finding from this study was the influence of competing factors. Other studies have identified time as a competing factor, which may allude to priority setting for a parent. In this study, mothers did not talk about time, but they clearly identified employment and family tasks as taking priority over immunizations. When both parents work full time or transportation is available on a limited basis, the tasks of daily living may take priority over preventive health care.
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Findings from this study support previous research on factors influencing immunization rates in rural areas. Difficulties with the health care system and delay of immunizations due to illness matched results of research from both urban and rural settings (Pruitt et al., 1995; Santoli, et al., 1998; Steiner et al., 1996; Szilagyi et al., 1993). This study also supports the finding that parents do not see the cost of having their child immunized as a barrier when the vaccine and administration are free (Mainous & Hueston, 1995). Aparent’s knowledge about diseases preventable by vaccine and the value of immunizations was again found to influence immunization status (Pruitt et al., 1995). Transportation was noted as a negative influencing factor in this study. However, distance was not the major issue because the average number of miles to the health care provider was only 10.75. Seventy-five percent of the sample reported on the sociobiographical form that they used their own car to obtain health care, but more than half of these mothers came from families with only one car and the family had to plan ahead to schedule car time. Without access to a mass transit system, rural residents in this study found access to a mode of transportation more challenging than the distance to a health care source. This finding is similar to that found by Pruitt et al. (1995) and Mason et al. (1997).
IMPLICATIONS FOR PRACTICE Based on this study, individual pediatric health care providers need to emphasize education and relationships in their practice. While parents may understand the importance of immunizations, they may have misconceptions about contraindications, vaccine adverse effects, or vaccine safety. At every opportunity, practitioners need to provide accurate, up-to-date information. In addition, it is important that providers develop considerate relationships with parents and children so they feel comfortable within the health care system. Mothers strongly emphasized the need for reminder systems. The Advisory Committee on Immunization Practices (CDC, 1998) has recommended that reminder systems be routinely em-
ployed by agencies. Providers should advocate for reminder systems to help parents know when their children need immunizations. Support ongoing evaluation of your health care system. When parents feel pressured by all the competing demands of parenthood, it is critical that the health care system be affordable, accessible, and friendly. The health care systems in rural areas have problems similar to those of their urban counterparts. Even in rural settings with good provider/family relationships, the issues of inconvenient hours, dates, and locations along with waiting lines need to be addressed.
REFERENCES Centers for Disease Control and Prevention. (1998). Recommendations of the Advisory Committee on Immunizations Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians: Use of reminder and recall by vaccination providers to increase vaccination rates. Morbidity and Mortality Weekly Report, 47, 715-717. Feldman, S., Andrew, M., Gilbert, J., Bracken, B., & Thompson, F. (1994). Measles immunization of 2-year-olds in a rural southern state. Journal of the American Medical Association, 27, 1417-1420. Houseman, C., Butterfoss, F., Morrow, A., & Rosenthal, J. (1997). Focus groups among public, military, and private sector mothers: Insights to improve the immunization process. Public Health Nursing, 14, 235-243. Hueston, W., Meade, R., & Mainous, A. (1992). Childhood immunization practices of primary care physicians. Archives of Family Medicine, 1, 225-228. Mainous, A., & Hueston, W. (1995). Medicaid free distribution programs and availability of childhood immunizations in rural practices. Family Medicine, 27, 166-169. Mason, G., Coates, J., & Millette, B. (1997). Immunizations and rural health: Considerations for nurse practitioners. Clinical Excellence for Nurse Practitioners, 1, 428-436. Pruitt, R., Kline, P., & Kovaz, R. (1995). Perceived barriers to childhood immunization among rural populations. Journal of Community Health Nursing, 12, 65-72. Santoli, J., Szilagyi, P., & Rodewald, L. (1998). Barriers to immunization and missed opportunities. Pediatric Annals, 27, 366-374. Steiner, J., Lowery, N., Siegel, C., Barton, P., & Goodspeed, J. (1996). Immunization services in rural areas. The Journal of Family Practice, 43, 326-328. Strauss, A. (1987). Qualitative analysis for social scientists. Cambridge, United Kingdom: Cambridge University Press. Szilagyi, P., Rodewald, L., Humiston, S., Raubertas, R., Cove, L., Doane, C., Lind, P., Tobin, M., Roghmann, K., & Hall, C. (1993). Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status. Pediatrics, 91, 1-7.
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PH C
Factors Influencing the Immunization Status of Children in a Rural Setting Th a d Wi l s o n , P h D, R N , C S , F N P
ABSTRACT Introduction: The purposes of this study were to (a) assess parental perceptions of their decision making regarding children’s vaccinations and (b) describe parents’ evaluation of immunization services provided by rural clinics/offices. Methods: A qualitative design was used in this study, which was conducted in rural Missouri. Twelve mothers of children younger than age 3 years with fewer than the recommended number of immunizations were interviewed using a semistructured format. The interview results were analyzed using the constant comparative method. Results: The following parental perceptions were identified as factors related to immunizations in this rural setting: knowledge of communicable diseases and vaccines, misperceptions about communicable diseases and vaccines, past experiences, competing tasks, transportation, health care personnel, need for reminders, health system, and cost. Discussion: Two findings unique to this study were the importance of relationships with health care providers and the challenge of competing tasks. These findings, combined with the other factors identified, reinforced the importance of rural health care providers’ maintaining a strong relationship with clients, providing accurate and timely information, and ensuring a readily accessible health care system. J Pediatr Health Care. (2000). 14, 117-121.
May/June 2000
C
ompared with other settings, in rural areas, fewer sources of health care are available, longer travel distances are required to access health care, and insufficient public health services are available to provide care to a population with higher rates of poverty and generally poorer health status indicators (Mason, Coates, & Millette, 1997). Therefore, it would seem logical that children living in rural America would have lower immunization rates than their urban counterparts. However, data indicate that although immunization rates in rural areas remain below federal goals for the year 2000, the rates are comparable to those in urban settings (Feldman, Andrew, Gilbert, Bracken, & Thompson, 1994; Mason, et al., 1997; Steiner, Lowery, Siegel, Barton, & Goodspeed, 1996). To identify factors influencing parental decisions related to vaccinations and to identify ways to improve services in a rural setting, a qualitative study assessing parental perceptions of childhood vaccinations and immunization services in rural areas was conducted in the Midwest. The pediatric health care provider’s understanding of these factors may improve the immunization status of children in rural America. REVIEW OF LITERATURE A great deal has been written about the inadequate immunization rates of 2year-olds in the United States. In a comprehensive review of research regarding factors associated with immunization rates, Santoli, Szilagyi, and Rodewald (1998) reported that whereas some factors were supported by strong evidence, other factors were not supported. Three factors often noted in the literature but not supported by strong scientific evidence were parental attitudes, provider attitudes, and ability to access a primary care provider. The authors found strong evidence to support 5 factors associated with low immunization rates: (a) socioeconomic factors (poverty and cost to families and providers), (b) late start of vaccination, (c) information gap (patient and provider awareness), (d) provider practices (missed opportunities
Thad Wilson is Assistant Professor at the University of Missouri-Kansas City School of Nursing. Reprint requests: Thad Wilson, PhD, RN, CS, FNP, University of Missouri-Kansas City School of Nursing, 221 Health Science Bldg, 2220 Holmes, Kansas City, MO 64108-2676. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/1/103835 doi:10.1067/mph.2000.103835
117
PH ORIGINAL ARTICLE C and lack of tracking or reminder systems), and (e) office/clinic factors (appointment requirements, inconvenient clinic hours, and long wait times). All but one of the 66 studies cited by Santoli, Szilagyi, and Rodewald (1998) were conducted in urban or suburban areas. Few studies have examined immunization factors specific to rural settings. Arecent statewide study by the Massachusetts Department of Public Health found that 76.5% of the 2-year-old children living in rural Massachusetts were fully immunized. This finding was similar to the overall state rate of 73.5% and was greater than the immunization rate of children in urban areas (Mason et al., 1997). The authors reported that immunization rates in rural areas were enhanced or detracted by certain health beliefs held by rural residents. The sense of community, the need to be productive, and a different perception of distance were identified as factors enhancing immunization rates. Lower income levels, no public health structure, and a high rate of personal and/or religious exemptions were identified as factors decreasing immunization rates. Other studies have encountered similar results. Feldman et al. (1994) found higher immunization rates among preschool children living in the less densely populated areas of Mississippi than among those living in more densely populated areas. Mainous and Hueston (1995) reported that federal programs that offer free childhood vaccines to physicians have a significant effect on increasing immunization rates in rural areas. The authors noted that in states with free vaccine distribution, no difference existed between the availability of immunizations at urban and rural physician practices. However, in states without free vaccine distribution, physicians in urban settings were more likely to have immunizations available than were rural physicians (87% vs 52%). Steiner et al. (1996) indicated that missed opportunities by providers in rural settings must be avoided to ensure proper vaccination of all children. Findings from two other studies support the argument that missed opportunities to immunize were more common in rural than in urban settings. Szilagyi et al. (1993) found that the mean number of missed opportunities was greatest among rural private practices compared with urban and suburban settings.
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Wilson
Hueston, Meade, and Mainous (1992) reported that physicians practicing in rural Kentucky offered immunizations to patients less frequently than did physicians in urban practices. Cost of vaccine and administration was found to be a primary concern in both rural and urban settings.
A
dverse reactions from
past immunizations, such as fever, sore legs, and irritability, influenced immunization status.
Pruitt, Kline, and Kovaz (1995) conducted a study to identify factors influencing immunization status of children in rural areas. The study used a semistructured interview format that led to quantifiable data. The authors categorized their findings into predisposing, enabling, and reinforcing factors. Predisposing factors involved attitudes, beliefs, and perceptions. Infant illness, fear of needles, concern about adverse effects, and confusion about when immunizations were due were most commonly identified as negative predisposing factors. The knowledge about and necessity for immunizations were considered positive predisposing factors. The availability, accessibility, and affordability of health care services were considered enabling factors. No positive enabling factors were reported, but transportation problems, cost, waiting times, and inconvenient clinic hours were identified as negative factors. In the third category, reinforcing factors—the influence exerted by social support systems, health care providers, and the media—were evaluated. No negative reinforcing factors were identified. Parents, grandparents, and health care providers exerted a positive influence, with media having little influence. Research, while limited, has identified similar barriers in rural areas as in urban areas. However, parental perceptions related to obtaining immuniza-
tions have not been well described for rural residents. To expand the limited information available about factors influencing immunization rates in rural settings, a qualitative study was conducted in a rural area of Missouri. Specific purposes of this study were to assess parental perceptions of their decision making regarding children’s vaccinations and to describe parents’ evaluation of immunization services provided by rural clinics/offices.
METHODOLOGY, PROCEDURE, AND ANALYSIS A descriptive study, using qualitative data, was conducted to meet the purposes of the research. Data analysis was conducted using a grounded theory approach (Strauss, 1987). After Institutional Review Board approval of the study, parents of children were identified at 3 rural health department–sponsored immunization clinics and 3 private offices, all located in rural Missouri. Inclusion criteria for the study were that the subjects: (a) were a legal parent or guardian of one or more children receiving care at an identified setting, (b) were able to read and write English, (c) had at least one child between the age of 2 months and 4 years receiving fewer than the number of vaccines recommended by the Centers for Disease Control and Prevention (CDC) (1998), and (d) resided in an area with a population less than 10,000. Following identification, parents were contacted by telephone or in person and the research project was explained. For those willing to participate, an appointment was made for an interview. When feasible, the confidential interviews were held at non-health care facilities to decrease anxiety about the health care system. Interviews were held in homes, non-health care offices (insurance building), restaurants, and in health department rooms away from the immunization area. After obtaining written consent, a research assistant completed a sociobiographical data form and conducted a semistructured interview. Four graduate student research assistants participated in data collection and analysis after attending a half-day seminar on qualitative research techniques. The sociobiographical form included the parent/guardian’s age, race or ethnicity, years of education, routine health
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PH ORIGINAL ARTICLE C care source, payor source, availability of transportation, and distance from the site where immunizations are obtained. The interview format focused on the subjects’ feelings and experiences in obtaining immunizations for his or her children. The principal investigator and research assistants developed the questions based on extensive personal experience and a review of the literature. Two researchers familiar with qualitative design and two nurses knowledgeable about immunizations and health care systems reviewed the proposed questions. Minor revisions were made based on this review. Questions included the following: “Please describe any past experiences having your child immunized,” “What kinds of things have made it easy or difficult for you to have your child immunized?” and “What is your main source of information about immunizations?” Questions for clarification or validation were used as needed. The interviews were tape recorded and transcribed verbatim. In addition, field notes were written by the research assistants during the interviews to identify nuances of the subject or setting. Data analysis was conducted using the transcribed interviews and field notes. The data were analyzed using the constant comparative method described by Strauss (1987). Each research assistant conducted and transcribed a single interview and analyzed the data of that interview to establish categories based on similarity of content. Each research assistant shared his or her findings with the principal investigator, who (a) reviewed the data and categories for consistency, (b) examined the categories for underlying similarities, and (c) reduced the number of categories based on the similarities. Second and third interviews with analyses were conducted by the research assistants and reviewed by the principal investigator, constantly comparing the categories elicited from the data with previously obtained data. Saturation of the identified categories occurred after 12 interviews.
SAMPLE Of the 21 parents contacted, a convenience sample of 12 subjects agreed to participate in the study. The most common reason given by nonparticipants was the time commitment. All subjects
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were mothers of the immunized children. Subject ages ranged from 20 to 39 years, with a mean age of 27.5. Children’s ages ranged from 8 to 36 months, with a mean age of 22.23 months. Other sociodemographic information can be found in the Table. Among the 75% without a third-party payor, there was an overall sense that Medicaid, for which most were eligible, was an unacceptable “handout.” All parents stated that immunizations were provided at no cost to them. Distances driven to health care offices ranged from 2 miles to 30 miles with a mean of 10.75 miles.
RESULTS One purpose of this study was related to parents’ perceptions of decision making related to their children’s vaccinations. The following categories emerged: knowledge, past experiences, competing tasks, and transportation.
A
ll mothers stated that
often they were too busy with daily tasks or work and did not have adequate time for immunizing their children.
Knowledge Knowledge was further divided into two categories: (a) knowledge of communicable diseases and vaccines and (b) misperceptions about communicable diseases and vaccines.
Knowledge of communicable diseases and vaccines. Ninety-two percent of the mothers perceived immunizations as a benefit. There were universal views, such as, “I know they are necessary to keep [my child], and the world for that matter, from getting the diseases that the shots cover,” and “some countries still have diseases we no longer worry about due to immunizations.”
TABLE Sociodemographic data of participants Characteristic
No.
Payor source Self Medicaid Insurance Ethnicity Caucasian Other Source of primary care Private office Other/none Educational level Completed Junior High Completed High School Attended College Marital status Married Single Transportation Own car Family/other
9 2 1 11 1 10 2 2 6 4 8 4 9 3
Mothers also perceived personal benefits. For example, 83% of the subjects noted that immunizations keep their children from getting “sick.” Mothers were aware of the seriousness of the vaccine preventable diseases and wanted to protect their children against such maladies. Knowledge led two parents to postpone or avoid immunizations. One mother stated that she had “researched it and the only cases of polio in the United States were from the vaccine and not from getting it from other people.” Another questioned, “Why in the world do we still immunize our kids against these diseases that are rarely seen anymore?”
Misperceptions about communicable diseases and vaccines. Parents also had misperceptions about immunizations. Six mothers canceled appointments for immunizations because their child had a cold. “Children sick at all, shouldn’t get shots,” noted one mother. One parent had heard, “You shouldn’t let anyone kiss your child and you must be careful with dirty diapers after having the polio vaccine.” This belief led this mother to postpone her child’s immunizations until he was “out of diapers.”
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PH ORIGINAL ARTICLE C A few parents questioned the safety of some vaccines. One stated, “I don’t want my kids used as guinea pigs.” Another parent worried about what “they put in [the vaccine]” and commented that “the experts don’t seem to all agree” on what is safe. One mother expressed a philosophical belief that “God created the immune system, not vaccinations,” and therefore refused to vaccinate her children. The same mother also noted that when someone came in contact with a communicable disease, such as “hepatitis, that the body would be sick for three days and then build up an immunity to the disease.”
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Transportation Sixty-seven percent of the parents noted lack of transportation or inconvenient distance to the facility as a problem. Of the 9 subjects with a car, 5 came from one-car families. Scheduling the use of the car while maintaining transportation for work was noted to be difficult by 3 of these subjects. “It’s not that [the clinic] is so far away, it’s just getting the car that’s a hassle,” one exasperated mother stated. One parent stated that she had no transportation. In the rural settings for this study, there was no public transportation system, which is not unusual.
Past experiences Adverse reactions from past immunizations, such as fever, sore legs, and irritability, influenced immunization status. Fifty-eight percent of the mothers believed these reactions made it difficult to continue with the immunizations because they did not like to see their children experience these reactions. One parent said, “My first child had a bad reaction to the shots, so I was afraid to risk [my second child] having the shots.” Others had personal experiences that left negative impressions. “It’s not an easy thing for me to do, because last time I started bawling when he started bawling,” stated one subject. Another noted that “the shots hurt so bad that the kids get so apprehensive of anyone in a white coat and I just don’t want to go through that again.”
W
ithout access to a
mass transit system, rural residents in this study found access to a mode of transportation more challenging than the distance to a health care source.
Competing Tasks All mothers stated that often they were too busy with daily tasks or work and did not have adequate time for immunizing their children. One parent stated, “We have a lot to do in our lives, immunizations can easily slip through the cracks.” Another noted that “Even with the evening clinic, there is still little league, soccer, washing, cooking...There are just too many things to do.” Work was mentioned by 67% of the subjects as a competing factor. Either the mother needed to get time off work to take the child in for immunizations or another family member had to take off work to babysit the other children or provide transportation. In addition, one mother noted that “Not only do I miss a day to take [my child] in for shots, but I may have to take another day off if he gets sick.”
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Another purpose of this study was to evaluate services provided by rural clinics/offices in relation to immunization services. Analysis of the data revealed the following content areas—health care personnel, need for reminders, health system, and cost.
Health Care Personnel Of those with a primary health care provider, 70% stated that they relied on their primary health care provider for information and support. For example, one mother stated that “If my friends give me a bunch of papers about how bad immunizations are, I know I can call my nurse practitioner and find the truth.” Another noted that she “relied on her doctor to tell her when the shots were due. I trust her to stay on top of this.” Emotional support was also re-
ported by one mother, who said, “I really dread having my child get shots, but the nurse practitioner always pats me on the back and helps me get through it.” Seven mothers shared that the health care personnel, doctors and nurses, were kind and considerate and tried to make the experience as “painless as possible.” Knowing that their child would be cared for in a professional manner provided a positive influence on the mothers.
Need for Reminders Fifty-eight percent of the mothers expressed confusion about the immunization schedule. “As long as they send me reminders, I take my child in. Without reminders, I don’t know when shots are due. It’s too confusing,” shared one mother. One parent’s insight into this factor was that “The most important thing is to let the parents know what immunizations their child needs, when they should receive them, and what kind of reactions they can have. I can handle anything if I know what to expect.”
Health System Health system factors included inconvenient clinic hours, dates or locations, waiting lines, minor illness, and conflicting information. The inconvenience of clinic hours, dates of immunization clinics, and locations of clinics were reported by 75% of the parents. One parent declared, “It’s only in the mornings which does not fit my schedule.” Another noted that “The immunization clinic is only on Tuesdays and Thursdays.” Another mother complained that the clinic was only open during the days: “My husband and I work, so one of us has to take off. That makes it hard.” Waiting lines were an issue mentioned by 3 parents, including one who said, “I have not had much trouble, except waiting in line at the clinic.” One provider excluded children from timely immunization on the basis of minor illnesses. This situation was believed by the parents to add difficulty in receiving immunizations. One parent stated, “It seemed every time I took her to the doctor, she was sick and he wouldn’t give her shots.”
Cost Immunizations were provided free at all the sites used in this study. The Vaccine for Children program provided federal
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PH ORIGINAL ARTICLE C funding in addition to state and local funds. Free immunizations were mentioned by 92% of the subjects. Mothers stated that cost was not a factor in the lack of immunizations for their child and that the lack of cost was, in fact, an incentive to get vaccinations. One parent noted that “the doctors, government, and the drug companies work together to make it easy to get the shots.”
P
roviders should
advocate for reminder systems to help parents know when their children need immunizations.
DISCUSSION This study revealed two unique findings. First was the positive effect of health care providers. The sample in this study had not yet experienced managed care, and the majority still used a single health care provider source. It may be that the relationships developed over time between providers and families may be a strong, positive influence for preventive health care. Two studies support this finding from an alternative perspective. Houseman, Butterfoss, Morrow, & Rosenthal (1997) and Pruitt et al. (1995) found that when parents were treated poorly by health care staff, the parents did not desire to return with their children for further immunizations. The second new finding from this study was the influence of competing factors. Other studies have identified time as a competing factor, which may allude to priority setting for a parent. In this study, mothers did not talk about time, but they clearly identified employment and family tasks as taking priority over immunizations. When both parents work full time or transportation is available on a limited basis, the tasks of daily living may take priority over preventive health care.
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Findings from this study support previous research on factors influencing immunization rates in rural areas. Difficulties with the health care system and delay of immunizations due to illness matched results of research from both urban and rural settings (Pruitt et al., 1995; Santoli, et al., 1998; Steiner et al., 1996; Szilagyi et al., 1993). This study also supports the finding that parents do not see the cost of having their child immunized as a barrier when the vaccine and administration are free (Mainous & Hueston, 1995). Aparent’s knowledge about diseases preventable by vaccine and the value of immunizations was again found to influence immunization status (Pruitt et al., 1995). Transportation was noted as a negative influencing factor in this study. However, distance was not the major issue because the average number of miles to the health care provider was only 10.75. Seventy-five percent of the sample reported on the sociobiographical form that they used their own car to obtain health care, but more than half of these mothers came from families with only one car and the family had to plan ahead to schedule car time. Without access to a mass transit system, rural residents in this study found access to a mode of transportation more challenging than the distance to a health care source. This finding is similar to that found by Pruitt et al. (1995) and Mason et al. (1997).
IMPLICATIONS FOR PRACTICE Based on this study, individual pediatric health care providers need to emphasize education and relationships in their practice. While parents may understand the importance of immunizations, they may have misconceptions about contraindications, vaccine adverse effects, or vaccine safety. At every opportunity, practitioners need to provide accurate, up-to-date information. In addition, it is important that providers develop considerate relationships with parents and children so they feel comfortable within the health care system. Mothers strongly emphasized the need for reminder systems. The Advisory Committee on Immunization Practices (CDC, 1998) has recommended that reminder systems be routinely em-
ployed by agencies. Providers should advocate for reminder systems to help parents know when their children need immunizations. Support ongoing evaluation of your health care system. When parents feel pressured by all the competing demands of parenthood, it is critical that the health care system be affordable, accessible, and friendly. The health care systems in rural areas have problems similar to those of their urban counterparts. Even in rural settings with good provider/family relationships, the issues of inconvenient hours, dates, and locations along with waiting lines need to be addressed.
REFERENCES Centers for Disease Control and Prevention. (1998). Recommendations of the Advisory Committee on Immunizations Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians: Use of reminder and recall by vaccination providers to increase vaccination rates. Morbidity and Mortality Weekly Report, 47, 715-717. Feldman, S., Andrew, M., Gilbert, J., Bracken, B., & Thompson, F. (1994). Measles immunization of 2-year-olds in a rural southern state. Journal of the American Medical Association, 27, 1417-1420. Houseman, C., Butterfoss, F., Morrow, A., & Rosenthal, J. (1997). Focus groups among public, military, and private sector mothers: Insights to improve the immunization process. Public Health Nursing, 14, 235-243. Hueston, W., Meade, R., & Mainous, A. (1992). Childhood immunization practices of primary care physicians. Archives of Family Medicine, 1, 225-228. Mainous, A., & Hueston, W. (1995). Medicaid free distribution programs and availability of childhood immunizations in rural practices. Family Medicine, 27, 166-169. Mason, G., Coates, J., & Millette, B. (1997). Immunizations and rural health: Considerations for nurse practitioners. Clinical Excellence for Nurse Practitioners, 1, 428-436. Pruitt, R., Kline, P., & Kovaz, R. (1995). Perceived barriers to childhood immunization among rural populations. Journal of Community Health Nursing, 12, 65-72. Santoli, J., Szilagyi, P., & Rodewald, L. (1998). Barriers to immunization and missed opportunities. Pediatric Annals, 27, 366-374. Steiner, J., Lowery, N., Siegel, C., Barton, P., & Goodspeed, J. (1996). Immunization services in rural areas. The Journal of Family Practice, 43, 326-328. Strauss, A. (1987). Qualitative analysis for social scientists. Cambridge, United Kingdom: Cambridge University Press. Szilagyi, P., Rodewald, L., Humiston, S., Raubertas, R., Cove, L., Doane, C., Lind, P., Tobin, M., Roghmann, K., & Hall, C. (1993). Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status. Pediatrics, 91, 1-7.
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