THESIS HURS 1998 N317p c.2 Navaroli, LaTroy. Parental perceptions of barriers to child 1998. Parental Perceptions of Barriers to Child Immunizations in Two Rural Communities in Erie County, Pennsylvania By LaTroy Navaroli Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: Jtjuith Schilling, CRNP, P Committee Chairperson Edinboro University of Pennsylvania Date7 Alice Conway, RN, PhD u Committee Member Edinboro University of Pennsylvania bat/ j jMUUt Diana Zenewicz, RN,, MSN Committee Member Hamot Medical Center 5 ’ Date C• Table of Contents Content Page Abstract i Chapter I. Introduction. 1 Statement of the Problem. 2 Research Question. 3 Theoretical Framework. 3 Definitions of Terms. 5 Assumptions. 5 Limitations 5 Summary. 6 Chapter II. Review of Literature. 7 Importance of Vaccination. 7 Immunization Rates. 8 Barriers to Immunization. 8 Summary. Chapter HI. Research Methodology. 14 15 Hypothesis 15 Research Design. 15 Procedures for Data Collection. 15 Sample. 16 Informed Consent. 16 Instrumentation. 16 Pilot Study 18 Data Analysis 19 Summary. 19 Chapter IV. Results. Participants 20 20 Demographics. 21 Knowledge about Immunizations. 23 Barriers. 25 The CHECK Project. 30 Statistical Analysis. 30 Chapter V. Discussion 32 Conclusions 32 Additional Data. 35 Recommendations. 37 References .40 Appendixes. 44 A. Letter of Permission 44 B. Interview Script. 45 C. Survey. 46 Table Of Tables Table Page Table 1. Age of Participants Youngest Child by Area. 21 Table 2. Age of Participants by Area. 22 Table 3. Parental Perceptions of Youngest Child's Age when Immunizations Began. 24 Table 4. Parental Perceptions of Youngest Child's Age when Immunizations Complete.24 Table 5. Distance Travelled to Obtain Immunizations by Area. 26 Table 6. Parental Perceptions of Barriers to Immunization by Area. 27 Table 7. Parental Perceptions of Barriers to Well-Child Care by Area. 28 Table 8. Parental Recommendations to Improve Access to Well-Child Care 29 Table 9. Methods of Payment for Health Care Services for Children by Area. 30 Table 10. Household Size by Area. 35 Table 11. Media Use by Area 35 Table 12. Where Health Information is Obtained by Area. 35 i Parental Perceptions of Barriers to Child Immunizations in Two Rural Areas in Erie County, Pennsylvania Abstract Research indicates that the rate of immunizations of preschool children living in rural areas is lower than 90%. These too-low rates have been attributed to many factors in the literature. The need was identified for research into what barriers, if any, parents encounter in getting their children the appropriate immunizations. The objective of this study was to discover if parents living in Wattsburg and Corry, in Erie County Pennsylvania, perceived any reasons for difficulty in getting their preschool children the immunizations they need. Interviewers were trained to use the interview questionnaire in order to maximize interviewer consistency, and to protect the subjects' anonymity. The target population was parents or primary caregivers of children under the age of 7 who resided in either Wattsburg or Corry in rural northwestern Erie County, Pennsylvania. The sample was a convenience sample. The 51 subjects were interviewed using a structured script and survey questionnaire, at three grocery stores located in the two areas of interest. Coupons and magnetic coupon holders were given as incentives to the parents to encourage completion of the interview. Subjects consisted of anyone who was the parent or primary caregiver of a preschool child under the age of seven and willing to complete the interview. The survey consisted of 34 questions designed to elicit both qualitative and quantitative data. The use of a small accidental sample was a limitation of this study. Results of this study confirm the hypothesis. Some parents of preschool children in these two areas do report barriers to immunizations and well child care. 1 Chapter I Introduction Vaccination against infectious diseases dates back centuries. The Greeks and Turks pricked uninfected individuals with needles that had been inserted into an infected persons sores. However, because of unsterile needles and the use of live microorganisms, these treatments were sometimes fatal. Modem methods of vaccination began with Edward Jenner's approach to smallpox. He noticed that milkmaids and farmhands who had contracted cowpox seemed immune to smallpox. He demonstrated that inoculating one person with a needle coated with purulent matter from a cowpox lesion provided them with protection from smallpox (Bellig, 1995). By the end of the 19th century additional vaccines had been developed against typhoid, cholera, and plague. The 20th century has added diphtheria, tetanus, pertussis, polio, measles, rubella, rabies, Hemophilus influenza, varicella, and hepatitis A and B to the list of vaccine preventable diseases (Peters, 1997). Today, vaccination of infants and children is often regarded as a hallmark of preventive medicine and health maintenance. The rates of immunization are considered by some to be indicators of the adequacy of health care delivery (Marks, Halpin, Irvin, Johnson, & Keller, 1979) and an index of a nation's health. Unfortunately, the United States lags behind many developed and developing countries with respect to immunization levels of preschool children (Zylke, 1991; Szilagyi et al., 1996). State mandating of completion of an immunization series by the time a child enters school has resulted in immunization rates of 95% or more across the United States. However, 2 children are still being infected and are dying of these vaccine-preventable diseases, primarily among the younger group consisting of infants and toddlers (Pruit, Kline, & Kovaz, 1995). Studies have detected a critical problem in achieving age-appropriate immunization of preschool children in this country (Hutchins, et al., 1989; Woods & Mason, 1992, Centers for Disease Control, 1994). Nurse Practitioners often work in primary care settings and are in positions to affect positive outcomes with regard to this problem. Statement of the Problem Research has demonstrated that preschool children are not adequately immunized in a timely manner. The result is increased rates of infection with vaccine preventable diseases during the preschool years. The Children's Defense Fund (1993) identified Erie County, Pennsylvania as having the highest percentage of minority children living in poverty of all United States cities with a population over 200,000. The Erie infant mortality rate was also one of the highest in the state (T. Bartasavich, personal communication, February 18,1998). Results of data analyzed from the National Health Interview Survey indicated that school age children in families with incomes below the poverty level were more likely to be nonusers of all preventive care when compared to the children of more affluent families. Also, children in low-income families without Medicaid were most likely to not receive preventive care (Newacheck & Halfon, 1988). There are many different reasons for late vaccinations. The barriers specific to timely immunizations of Erie County children have not been investigated. These barriers need to be identified before they can be minimized and overcome. 3 Research Question This study will answer the following research question: What barriers, if any, exist to timely immunizations of preschool children in Wattsburg and Corry in Erie County, Pennsylvania? Theoretical Framework Infants and children require care from others because they are in the early stages of development physically, psychologically, and psychosocially. The focus of Dorothea Orem’s nursing theory is that of self-care, or in the case of infant or child, that of dependent care (Orem, 1995). Self-care is defined as the care that individuals require each day to regulate their own functioning and development. These requirements are affected by, among other things, age and developmental stage. Dependent care, or the care required by infants and children, is the continuing health related personal regulatory and developmental care provided by responsible adults. Infants and children have an undeveloped self-care agency (Orem, 1995). These learned sequences of self-care undertaken to achieve foreseen goals must be performed by a caregiver. Dependent care is necessary for health and well-being. Dependent care activity, such as taking children for their vaccines, is activity that is undertaken by responsible, mature people to regulate the factors that can effect the health and life of a dependent member of the family. Immunization of infants and children are self-care requisites, that is, required actions undertaken to regulate factors that effect human functioning and development. These requisites, met through dependent care, are necessary to prevent significant morbidity and mortality as a potential consequence of 4 late or inadequate immunizations. The components of dependent care must be known to maximize the use of immunizations as an important health promotion tool. It must first be understood what obstacles interfere with the practices that the dependent care agent should utilize. To do this it must be clear how the dependent care components articulate with the infant's or child s needed vaccinations and the dependent care agents' pattern of daily living. It must be known what barriers exist to timely immunizations. Dependent care agency is the complex acquired ability to incorporate knowing and meeting the health deviation self-care requisites of infants and children, and needed adjustments in universal and developmental self-care requisites, into ongoing systems of infant care, child care, and parenting activities. An imbalance may exist between dependent care demands and the dependent care agents' ability to provide for the needs, resulting in the dependent care deficit of inadequate or delayed child immunizations (Orem, 1995). It is common today for parents to work outside the home and rely on family members or other caregivers to help tend their children. Orem (1995) addresses this by discussing the dimensions of the subsystem of the family, including the dependent-care systems that have been established to meet the therapeutic self-care demands of dependent family members. There may also be collaborative or compensatory arrangements between family members that have been established to meet the therapeutic self-care demands of dependent family members. The interactive patterns, along with the way the family is carrying out the functions related to self-care of 5 members, are unique characteristics of the whole and effect child immunization status. Definition of Terms The following terms are defined as they were used in this study: 1. Immunization is the process of providing vaccines designed to stimulate immunologic response in order to provide long-term protection from infectious diseases. 2. Barriers are factors that contribute to the prevention of adequate immunization of a preschool child. 3. Preschool children are those under 7 years of age. 4. Vaccine preventable diseases are infectious diseases that can be prevented with immunizations. Assumptions This study is based on the following assumptions: 1. The parent or caregiver of a child will answer survey questions honestly. 2. Identifying barriers to child immunization will enable health care providers to facilitate access to immunizations in rural areas of Erie County, Pennsylvania. Limitations Several limitations exist in this study: 1. Data was collected by an interview of 5 to 7 minutes. This time commitment was a deterrent to several potential participants who met the criteria but declined to complete the interview due to time constraints. 2. This study consisted of 51 participants. The sample may not have been representative of the populations of Wattsburg and Corry, Pennsylvania. 6 3. Incentives were offered to entice people to complete the interview. Some may have given false information to obtain the incentive. Conversely, the incentive may have had the opposite effect in that some may not have wanted to be viewed as completing the interview to receive the incentive, and so may have declined to participate. 4. Five different trained interviewers conducted these survey interviews. Interview techniques may have differed. Summary Immunizations are one of the most effective public health measures of this century. State mandating of completion of immunizations by the time of school entry has resulted in immunization rates of 95%. However, immunizations are not being completed within recommended time frames, and preschoolers are at risk from vaccine-preventable diseases. Dorothea Orem's theory of nursing (1995) discusses the needs of infants and children for dependent care. A parent or other caregiver may be the person who performs the dependent care activity of securing preventive health care services for a child. To meet dependent care requisites of children there may be obstacles to surmount that are unique to the family or situation. The dependent care agent’s ability to meet the dependent care demands of the child may be inadequate. To reduce or eliminate this dependent-care deficit in children in rural Erie County, factors affecting their immunization status must be understood. Nurse practitioners in the position of primary care providers are able to impact this problem, effectively promoting well-child care including immunizations and assisting in the removal of barriers faced by dependent care agents. 7 Chapter 2 Review of Literature Researchers are beginning to investigate the problem of inadequate immunization of preschool children, particularly two aspects: (a) understanding of the scope and magnitude of the problem, and (b) examination of reasons why children are not fully immunized. Such information is requisite for designing intervention programs. This review of literature will discuss the importance of immunizations, relay selected immunization rates from different areas in the United States, and discuss multiple barriers to immunization. Importance of Immunization Immunization in the United States has led to a marked decline in reported morbidity and mortality related to diseases that can be prevented by immunization (Orenstein, Atkinson, Mason, & Bernier, 1990). However, a measles epidemic occurred in the United States between 1989 and 1991 (National Vaccine Advisory Committee, 1991). This was attributed to failure to immunize and resulted in 55,000 cases of measles, over 100 deaths, and $20 million in hospital costs. Most of these cases were among children under the age of 5 who were unimmunized. In 1993, it was reported that the number of pertussis cases in the United States rose 55.5%, the largest increase since 1967. This again was attributed to unimmunized preschool children (Scudder, 1995). Understanding the causes of these low levels of childhood immunizations is critical to preventing outbreaks of immunization-preventable diseases. The development of strategies to address this problem requires an understanding of the reasons that 8 children are not being immunized (Hinman, 1991). Immunization Rates Data from 38 states between 1991 and 1992 showed that fewer than two-thirds of 2 year olds had received all recommended immunizations and that the median vaccination rate for all states was 56 %. The reported rates for some other cities were: 18 % in Houston, 38 % in New York City, and 35 % in Washington, D.C. (Graham, 1993). In comparison with the national goal of age appropriate immunization of 90% of all 2 year old children by the year 2000 (U.S. Public Health Service, 1992), immunizations rates were 48 % in San Diego, 28 % in Dallas, and 31 % in Detroit (Woods & Mason, 1992). Retrospective analysis of public school data collected in Norfolk, Virginia indicated that only 45% of children had obtained recommended immunizations by age 2 years (Houseman, Butterfoss, Morrow, & Rosenthal, 1997). Barriers to Immunization The first large study to ascertain risk factors associated with failure to receive recommended immunizations was conducted in Ohio (Marks, Halpin, Irvin, Johnson, & Keller, 1979). Parents of 1,003 2 year old children were surveyed about immunization status. It was found that one predictor of inadequate immunization was either a mother’s or father’s education level below twelfth grade. It was also discovered that family size inversely correlated with completion of the immunization series. Lower rate of vaccination were seen in larger families where a child had at least three siblings. The National Vaccine Advisory Committee (1991) identified four known barriers to successful immunization of all children: a) missed opportunities for administering 9 vaccines, b) shortfalls m the healthcare delivery system with barriers to immunization, c) inadequate access to care, and d) incomplete public awareness of, and lack of request for, immunization. These conclusions were the result of a 1990 survey of 54 immunization program managers in different states. The major barrier identified in the survey included resource and/or policy barriers that limited access to immunizations. Policy barriers included immunizations being available by appointment only, requirement for physical examination prior to immunization, need for physician referral for vaccination, requirement for enrollment in well-baby clinics in order to be immunized, and vaccine administration fees. Other problems cited included insufficient clinic personnel, inadequate clinic hours, and too few clinic locations. Hispanic families also reported cultural and language barriers and inappropriate health education materials. In addition, inefficient tracking systems did not track or notify families when immunizations were due. The high cost of immunizations to private physicians was often passed on to parents because most insurers failed to cover immunization (National Vaccine Advisory Committee, 1991). A study done of nine areas in the United States in 1991 included a predominantly rural area of West Virginia (Kyle & Coulter, 1995). In examining barriers to immunizations in this study it was identified that the rural area was faced with different obstacles to adequate and timely immunizations than were the eight urban sites also studied. Transportation was a key factor faced by rural families, as well as other social, cultural, and economic barriers that prevented them from seeking well-child care. Parents’ and health care providers’ perceptions of barriers to immunizations were 10 explored with a survey of 90 private medical practitioners and 302 parents of 2 year old children in a large city in Ohio (Salsberry, Nickel, & Mitch, 1993). Parents most frequently identified barriers such as cost, lack of insurance coverage, and long office waits. Providers were more likely to report barriers concerning parents forgetting immunizations or not knowing when they were due. To measure the impact of the barrier of missed opportunities for immunizations, a 1993 study performed a retrospective chart review in seven primary care sites (Szilagyi et al, 1993). These included five urban or suburban and two rural practices near Rochester, New York. Medical charts of 1124 children revealed that 20% were undervaccinated by at least 12 months. Despite the fact that they had attended the clinic during that 12 month period, no immunization had been given. In 28% of the visits during which a missed opportunity occurred, there was no contraindication for immunization of the child. It was concluded that missed opportunities for immunization occurred frequently and contributed significantly to the underimmunization of preschool children. Standards were developed by a 35 member working group convened by the Centers for Disease Control and Prevention (Shalala, 1993). Participants were drawn from both public and private sections and state and local health departments. This group recognized that practices of health clinics and private medical offices could impede the full and timely immunization of children. They recommended that physical examinations and temperature readings not be prerequisites for immunization, nor should enrollment in a well-baby program, if it delays immunization. Also recommended to 11 reduce missed opportunities were administering vaccines simultaneously when indicated instead of requiring repeat single vaccine administration visits, and not delaying immunization due to minor illnesses that are not true contraindicators to vaccine administration. It was recommended that health care providers utilize every encounter with children as an opportunity to check and update immunizations. A profile of children at risk for inadequate immunizations was compiled by researchers in Columbus, Franklin County, Ohio (Salsbeny, Nickel, & Mitch, 1993). The 299 survey respondents were more educated and affluent than the general population. Only 31.1 % of their children were age-appropriately immunized. Parents reported the same barriers as were most commonly encountered. These included costs of immunizations, failure of insurance to cover them, lack of time, and long office waits. Also named as obstacles were lost records, lack of knowledge of when immunizations were due, immunizations not received because of a minor illness of a child, immunizations being scheduled separately from regular check-ups, transportation problems, and difficulty with care for other children . The influence of birth order on receipt of recommended immunization was examined by Schafer and Szilagyi (1995). They concluded that second bom children were likely to be immunized later than first bom children. Second bom children with an older sibling who was delayed in receiving immunizations were also at special risk for delayed immunization. It was suggested that as families have more children, they need more organization to come to a medical setting and may find it more difficult to travel to obtain routine preventative care for their children. 12 An examination of barriers perceived by mothers of poor children to immunization was performed in North Carolina. Structural barriers related to scheduling and the appointment itself were mentioned frequently by mothers. They complained about lack of flexibility of scheduling times and the long waiting time after arriving for an appointment. For some families, a chaotic home environment posed a serious barrier. Several mothers stated that it was difficult to schedule an appointment 6 weeks in advance when they were not even sure where they would be living. Transportation and employment conflicts, as well as the fear of vaccinating a sick child, were frequently mentioned (Lannon, et al., 1995). Perceived barriers to childhood immunization in rural South Carolina were examined in an area of low immunization rates for infants and toddlers (Pruitt, Kline, & Kovaz, 1995). Surveyed were parents of 48 infants and toddlers at risk for delayed immunizations. Barriers listed included fear of needles, fear of more than one injection at a time, and fear of side effects. The primary reason for delayed immunization was minor illness. There was also widespread confusion about when immunizations were due. Parents reported problems with transportation, inconvenient clinic hours, and waiting time at the office. Cost was perceived as a barrier, as was perceived poor treatment of their child by a healthcare provider. Difficulty finding child care for siblings also was cited as an obstacle to be overcome. Physicians’ knowledge level about appropriate contraindications to immunizations is an important factor in missed opportunities for timely immunizations, as is knowledge of the appropriate time frames for immunizing a child that is behind 13 schedule (Zimmerman, Giebink, Street, & Janosky, 1995). Also related to the health care provider is the barrier identified in a study of 95 urban patients (Watson et al., 1996). It was found that opportunities to immunize children were missed because of a lack of immunization history. To screen and subsequently immunize patients, a provider must be able to access the patients medical record or rely on the caregiver's recall of the immunization history. Without appropriate documentation of previous immunizations, the opportunity to vaccinate is lost. In 1993, six focus groups were conducted with 41 mothers in Norfolk, Virginia to discuss their views regarding immunizations (Houseman, Butterfoss, Morrow, & Rosenthal, 1997). These participants perceived many barriers to immunizations. Concerns were expressed about the safety and side effects of immunizations. Difficulty obtaining appointments due to lack of telephones or busy telephone lines were described by mothers. Once again, concerns about child care for siblings were expressed, as well as transportation difficulties and the inconvenient location of provider offices. A long wait in a chaotic office full of sick children, only to face health care workers that projected poor attitudes toward both parent and child, were causes for both dreading and delaying a trip for immunizations of a child. In Erie County the immunization tracking project component of the CHECK Project compiles data on the immunization status of Erie County children. Currently, 33% of all children in Erie County are registered on this tracking system. Per this system, as of February 1, 1998, 61.4% of two year old children in Erie County registered on the system had been immunized adequately and appropriately for their age (N. K. Rhea, M.H.S.A., personal communication, April 23, 1998). 14 Summary The many barriers to the timely immunization of preschool children have been well investigated in urban areas. However, only three studies were found that examined the barriers unique to rural areas (Kyle & Coulter, 1995; Szilagyi, et al., 1993; Pruitt, Kline, & Kovaz, 1995). None examined the two rural areas of interest in this study, Wattsburg and Corry, Pennsylvania. A necessary step in determining a way to improve immunization rates in Erie County is to ascertain the barriers unique to these northwestern Pennsylvania areas. 15 Chapter ITT Research Methodology This chapter will describe the research design and procedures followed in this study. The survey participants comprising the sample will be described. The instrument utilized to gather the desired data will also be explained. Hypothesis Parents perceive barriers to timely immunization of preschool children in Wattsburg and Corry in Erie County, Pennsylvania. Research Design A descriptive study was conducted with a quota sample from the target population. The target population was parents or primary caregivers of children under the age of 7 who resided in either Wattsburg or Corry in rural northwestern Erie County, Pennsylvania. The sample was an accidental sample. The subjects were interviewed using a structured script and survey questionnaire, at three grocery stores located in the two areas of interest. Procedures for Data Collection The surveys were completed via a structured interview. Interviewers were members of the Immunization Coalition of Erie County, Edinboro University of Pennsylvania students, and volunteers. Interviewer training consisted of memorization of the introductory script to be spoken to the survey participant prior to each interview, and education about the confidentiality of the information obtained. This training was conducted prior to implementation of this study (Appendix B). The interviewers did not 16 give out any information to study participants, other than to clarify the meaning of questions. The participants were offered incentives to complete the interview. These consisted of coupons for grocery savings, magnetic coupon holders, and children's stickers. Sample The 51 study participants were parents or primaiy caregivers of children under the age of 7 years and living in either Wattsburg or Corry, Pennsylvania. The interviews were conducted at three grocery stores, once each in the morning and the afternoon on the following dates: August 16, 1997, November 5 & 6, 1997, and March 14 & 28, 1998. The intent was to capture a representative sample. Informed Consent All participants were assured that the survey was anonymous. They were not asked their names. Consent was assumed when the subject completed the interview. All data was reported in the aggregate. Instrumentation The survey (Appendix A) utilized was developed by the Community Partnership Commitee of the Immunization Coalition of Erie County (ICEC) as a project with the purpose of identifying barriers to the immunization of children in rural Erie County, Pennsylvania (T. Bartasavich, personal commmunication, February 18,1998). ICEC had identified the problem of underimmunized children in rural Erie County, PA. The ICEC is a component of the Comprehensive Health for Erie County Kids (CHECK) Project. 17 The research-based CHECK Project designed a system to track all children bom in Erie County and to assign them a medical "home". This "home" was a specific medical care site from which appropriate reminders were mailed to parents when children's immunizations were due. The CHECK Project survey was initially used to gather information on several different areas of Erie County: Union City, Corry, Wattsburg, Albion, and the city of Erie. The information gathered from the surveys was used to determine the barriers to immunizations in these specific areas of interest. When the data was examined after the research was thought to be completed, a deficit of information on residents of two of the areas was found. These areas were Wattsburg and Corry, Pennsylvania. This current study is designed to rectify this situation by providing the ICEC with additional survey data from these two areas. The CHECK Project survey was used with permission (Appendix A). Survey questions 1 through 3 were designed to ascertain that participants met the criteria for inclusion in the study. Question 4 determined the age of the participant's youngest child. Question 5 asked if the participant took their child to just one medical office for care. Questions 6 and 7 asked if participants took their child for immunizations, and if so, at what age. To determine what type of provider of immunizations and well-baby care was utilized, questions 8, 9,12 and 14, addressed these issues as well as determining the distance traveled to obtain immunizations and well-baby care. Question 10 explored participants' knowledge of how old their youngest child would be when they completed the recommended child immunization schedule. 18 Questions 9, 11, 13, 14, and 15 explored what specific barriers the survey participants may have encountered in trying to obtain appropriate imunizations for their child. Question 16 asked if the child had medical insurance, and if so, what type. Question 17 asked the interviewee to specify suggestions to make it easier to obtain child immunizations. Question 18 asked if the child was in day care. Questions 19, 20, and 21 ascertained the participants use of specific media: television, newspaper, and radio. Question 22 asked where the participant got their health information other than from their physician. Numbers 23 and 24 explored participant's access to computers and to the internet. Questions 25 through 30 and 32 asked for demographic data, including the participant's sex, age, household size, income, marital status, and educational attainment, and race. Questions 31 and 34 were open-ended, the former asking for suggestions to improve access to immunization and well-child care, and the latter for any additional comments. Question 33 inquired about the interviewee's knowledge of the existence of the CHECK project and asked if their child was enrolled in it Pilot Study A pilot study was conducted at a grocery store in Corry, Pennsylvania in which six surveys were completed with the participation of six parents of preschool children. The results were reviewed and some minor changes were made to the survey for clarity. Questions designed to gather more demographic and racial information, as well as to explore types of media most frequently used by respondents, were added. The final survey appears as Appendix B. 19 Data Analysis Data was first reported by frequency of response. Correlational coefficient analysis of data was completed to examine significant relationships between all of the variables. A chi-square test was done to determine the relationship between various responses. Comparisons were made concerning demographics. Male and female respondents' answers were investigated for significant differences. Comparisons were made between the two geographic areas with regard to identified barriers to immunizations and the most common avenues of communication via the media. Age groups of the participants, household sizes, and reported incomes were examined as an indicator of the representativeness of the sample. The possibility of a relationship between the incidence of reported barriers to child immunizations and any of the demographic data, such as age, race, income, and number of children under the age of 7, was explored. Summary A descriptive study was conducted with a quota sample from Wattsburg and Corry, in Erie County, Pennsylvania. Parents or caregivers of children under the age of 7 were surveyed via a structured interview. Questions were asked about their knowledge of immunizations for their child, and what barriers they may have encountered in obtaining needed immunizations and well-child care for their child. Open-ended questions were included to elicit information about perceived obstacles to vaccination that may not have been included in the interview choices. Data analysis included frequency of responses, correlational coefficients, and chi square tests. 20 Chapter IV Results This chapter describes the data collected to determine what barriers to immunization, if any, were perceived by the parents of preschool children in the rural areas of Corry and Wattsburg, in Erie County, Pennsylvania. The participant's age, sex, race, income, number of chldren under the age of 7, size of household, education level, insurance coverage, knowledge about immunizations, insurance status, whether the child is in day care, and distance to the provider were also determined. Data was entered into and analysed via the Statistical Package for the Social Sciences (SPSS). Results were reported first by frequency. Correlation coefficients were tabulated, and then chi squares were done to examine the significant differences between the two areas and the relationships between the different variables included in the survey. Participants The initial two survey questions determined the participants eligibility for the study. Data from those who did not meet the criteria of living in either Wattsburg or Corry and having at least one child under the age of 7 years was not included in this report. Of the respondents, 51 met these criteria. From Corry, 23 respondents were eligible, and from Wattsburg, 28 respondents. With the data from the two areas combined, the following information was obtained. Twenty-nine participants reported they had one child, 17 reported having 2 children, 4 had 3 children, and one had 4 children under the age of 7. No-one reported having more than 4 preschoolers. The age of the participants' youngest child was asked. 21 See the results of the responses in Table 1. Table 1 Age of Participants' Youngest Child by Area (n=51) Area Age Wattsburg Corry <2 mos. 1 0 2-3 mos. 0 1 4-5 mos. 1 3 6-11 mos. 4 5 12-18 mos. 3 3 18-23 mos. 3 0 2 years 0 3 3 years 2 3 4 years 5 2 5 years 5 3 6 years 4 1 Demographics In Corry, female respondents far outweighed males, with 17 females and only 5 males participating. In Wattsburg the respondents were more evenly distributed between 22 the sexes with 15 female and 13 male survey participants. All 51 of the survey respondents were white. Ages of the participants are listed in Table 2. Table 2 Age of Participants by Area (n=51) Area Age Wattsburg Corry 15-20 years 2 1 20-25 years 2 7 26-30 years 10 6 31-35 years 5 2 36-40 years 5 4 41-45 years 2 1 46-50 years 2 2 Of all the participants, 2 reported having completed the eighth grade, an additional 2 completed ninth grade, 1 finished tenth grade, 2 completed eleventh grade, and 17 reported having graduated from high school, with an additional 7 having obtained their GED. Five of the participants reported having had some college, seven had obtained their associates degree, one reported having a bachelor s degree, and one a Master s degree. Six reported having completed trade school. When data from the two areas was combined, reported yearly incomes of 23 respondents were as follows: twelve less than $10,000, six from $10,000 to $19,000, sixteen between $20, 000 and $34,000, twelve between $35,00 and $49,000, and two greater than $50,000 annually. Of all respondents, 38 reported that they were married, and 13 that they were not married. The survey participants were asked about the use of daycare for their children. Two respondents from Wattsburg and one from Corry report that they use some form of daycare, and 3 respondents from Wattsburg and 7 from Corry reported that they used a daytime babysitter. Thirty-seven participants reported not using any form of day care for their child on a regular basis. Knowledge about Immunizations Forty-three of the 51 study respondents reported that their child received wellbaby check-ups. Seven reported that their child did not receive well check-ups; four were firom Wattsburg and three were from Corry. Parents knowledge about immunization schedules was tested when the survey participants were asked when their child began and when they completed their immunization schedule. Responses varied (Tables 3 and 4). Some participants stated that their child began immunizations at an age not given as a choice on the survey. One response to this question in Wattsburg was the age of 1 month. In Corry other responses were the ages of 2 weeks, 3 years, and "when supposed to". To the question asking when their child would complete their immunizations, responses not listed as choices on the survey in Wattsburg were 6, 10, and 13 years; in Cony these additional responses were 18 months and 6 years. 24 Table 3 Parental. Pe.rceptions of Youngest Child's Age When Immunizations Began (n=51) Age Area one day 2 months 3 months Don't know Other Wattsburg 7 10 0 10 1 Corry 3 5 4 7 4 Table 4 Parental Perceptions of Youngest Child's Age When Immunizations were Complete Area Age Wattsburg Corry 12 months 2 2 24 months 1 3 3 years 0 1 4 years 2 1 5 years 12 8 other 3 2 Don't Know 8 5 25 With data from Wattsburg and Corry combined, 35 respondents reported that they took their children to a family doctor. Twelve went to a pediatrician, and four to a public health clinic to get immunizations. Barriers In response to the query about the perception of the distance to the health care provider being a problem, in Corry one respondent stated that it was, while 21 stated it was not. Of the Wattsburg respondents, 2 stated that distance was a problem, 26 that it was not, despite their statistically significant (p= 0.006) report of longer distances travelled to their health care provider (Table 5). Responses to questions asking specifically what barriers were encountered by parents when trying to obtain immunizations or well-child care for their child varied. Table 6 illustrates the responses with regard to immunization, and table 7 reflects the responses to the question about barriers to well-child care. Five participants did not respond to the question about what barriers were present to immunizations, and 6 did not respond to the question about barriers encountered to well-child care. The number of responses to questions about barriers may be greater than the number of participants because the participants were permitted to choose more than one response. There was not a significant difference among the number of barriers reported by caregivers of one child and those caring for more than one child. There was also no statistically significance difference in the total number of barriers reported by survey participants, regardless of income. 26 Table 5 Distance Travelled to Obtain Immunizations by Area (n=51) Distance Travelled Area 1 mile 1-10 miles 11-25 miles 26-50 miles Wattsburg 1 11 15 1 Corry 5 14 2 1 In the question asking the interiewee to choose what he/she would recommend to improve health care access, responses differed somewhat between the two communities (Table 8). Their answers totalled a number greater than the sample size because the particpants were permitted to choose more than one response. Some participants in Wattsburg chose the response "other” and gave an answer different than the choices offered on the survey. These other responses included a recommendation of morning hours to improve access to health care, and one respondent stated "a less confusing bill". The access card is a public assistance card available to children and parents that meet certain criteria of low income and lack of insurance. The card is designed to ensure they are able to obtain adequate health care services. When the survey was completed, those participants who reported no means by which to pay for their child’s immunizations were given the name and number of a contact at the CHECK project. They were offered assistance in obtaining and paying for health care for their child. 27 Table 6 Parental Perceptions of Barriers to Immunization By Area Area Barrier Wattsburg Corry Lack of transportation 1 1 Lack of insurance 1 0 Forgot appointment 1 0 Cannot get off work 1 1 Can't get an appointment 0 0 Have no babysitter 0 0 Illness 4 8 Cost 1 0 Unsure when shot is due 0 0 Other barrier 0 0 No barrier 16 12 Note, The number of responses may be greater than the number of participants because the participants were permitted to choose more than one response. 28 Table 7 Parental Perceptions of Barriers to Well-Child Care by Area Area Barrier Wattsburg Corry Lack of transportation 1 1 Lack of insurance 1 0 Forgot appointment 1 0 Cannot get off work 1 1 Can't get an appointment 0 0 Have no babysitter 0 0 Illness 5 4 Cost 1 0 Unsure when child needs check-ups 0 1 Other barrier 0 0 No barrier 16 15 Note. The number of responses may be greater than the number of participants because the participants were permitted to choose more than one response. Six participants did not answer this question. 29 Table 8 Parental Recommendations to Improve Access to Well-Child Care Area Wattsburg Corry Evening hours for shots 6 9 Evening hours for doctor visits 3 9 Weekend hours for shots 5 10 Weekend hours for doctor visits 0 1 Reminders for appointments 1 4 Transportation services 1 1 Childcare services 0 1 Lower costs 2 4 More information about when to get immunizations 3 4 other 2 0 Recommendation Note. The number of responses may be greater than the number of participants because the participants were permitted to choose more than one response. An open ended question inquired about any additional suggestions that participants could offer for improving access to immunizations and well child care. Recommendations from the Corry participants included the offering of evening hours for 30 Table 9 Methods of Payment for Health Care Services for Children by Area (n=51) Method of Payment Access Card Private insurance Wattsburg 10 16 2 Corry 12 10 0 Area No insurance health care, convenient transportation, and provider locations closer to home. From Wattsburg came these suggestions: transportation, convenience (unspecified as to what this is in regard to), cost, evening appointments, and weekend hours. The CHECK Project Three of the parents from Wattsburg and five of the parents from Corry reported that they had heard of the CHECK project prior to participating in this study. Two study participants were unsure if they had known of the CHECK Project. No children from either area were reported as being enrolled in the program. Statistical Analysis There was no statistically significant difference between the two areas in the number of barriers reported. There was, however, a significant difference in the number of miles driven, with respondents from Wattsburg reporting a longer drive to reach a primary care provider than was reported by respondents from Corry (p=0.006). However, there was no statistical difference in the number of survey participants reporting that the 31 distance they travelled to their health care provider was perceived by them as being a barrier to health care or immunizations. There was not a statistically significant difference between the areas of Wattsburg and Corry with regard to the responding preschool caregiver's age, marital status or gender. Marital status did not predict whether the child had private insurance or an access card. Marital status also did not predict the likelihood of a child's caregiver choosing to obtain the child's care from a private physician (family health care provider or pediatric specialist) or from a public health clinic. 32 Chapter V Discussion The purpose of this study was to determine if parents of preschool children in the rural areas of Wattsburg and Corry in Erie County, Pennsylvania perceive any barriers to obtaining immunizations for their children. A structured interview was used to collect data from the 51 research participants. If they perceived barriers, this study was designed to ascertain their nature. This chapter discusses the conclusions reached as a result of analysis of the data obtained with the survey. It also gives recommendations for further research based on the findings of this study. Conclusions The hypothesis of this study has been supported. Barriers were perceived by the parents and primary caregivers interviewed in Wattsburg and Corry, Pennsylvania. The barriers that were identified by at least one resident of Wattsburg or Corry, Pennnsylvania included the following: lack of transportation, lack of insurance, forgetting an appointment, being unable to get off work, not having a babysitter for children, illness, cost, and being unsure when the child’s next ’’shots” were due. It is interesting to note that those interviewed from Wattsburg reported a significantly longer distance to the provider of their child s immunizations and well-child care than did the participants from Corry. Since those participants from Wattsburg did not identify this as a barrier, they may simply be accustomed to the distance. Twenty-eight participants stated that they encountered no barriers to immunizing their child, and 31 stated they encountered no barriers to well-child care. Five 33 participants did not respond to the question about what barriers were present to immunizations, and six did not respond to the question about barriers encountered to well-child care. This particular survey question did not have an answer that stated no barrier was experienced. Because most surveyors simply wrote in "no barriers" if this was stated by the survey participant, this was coded as an answer. However, some surveys were coded as "no answer given" to the two questions about specific barriers encountered. These participants may have not percieved any barriers. Having no answer on the survey to match their perception, they may have chosen not to respond at all. Therefore the number of participants perceiving no barriers to imunizations and well­ child care may be higher than is reported. In comparison with the literature, some similar barriers were found in the rural areas examined in this study that were seen in previous studies. Illness of a child was listed as a barrier frequently in the literature (Salsberry, Nickel, & Mitch, 1993; Lannon, et al, 1995; Pruitt, Kline, & Kovaz, 1995). Illness was the barrier listed most frequently in this study. Twelve participants listed illness as a barrier to immunization, and nine participants cited it as a barrier to well care of their child. Cost was identified as a barrier in the research examined (National Vaccine Advisory Committee, 1991; Salsberry, Nickel, & Mitch, 1993; Pruitt, Kline, & Kovaz, 1995), as well as by one of the survey participants in this study. In one of the three rural areas examined in the literature review, transportation was cited as a difficulty (Kyle & Coulter, 1995). This barrier is found to be common, and not unique to rural areas (Salsberry, Nickel, & Mitch, 1993; Pruitt, Kline & Kovaz, 34 1995; Houseman, Butterfoss, Morrow, & Rosenthal, 1997). In this study, 2 respondents stated that difficulty with tranportation was a barrier to immunization, and 2 that it was a barrier to well-child care. Lack of insurance coverage was mentioned in the literature as a problem (Salsberry, Nickel, & Mitch, 1993), and was reportedly perceived by one survey participants as a barrier in the Wattsburg area. Employment conflicts created difficulty when taking a child for immunizations and well-child care. This was reported by two survey participants, and was also identified in the literature (Lannon, et al, 1995). One respondent in Wattsburg admitted that forgetting an appointment had been a barrier to their child receiving appropriate immunizations and well-child care; one person in Corry reported being unsure of when their child was due for well care. Forgetting appointments and being unsure when they were due were also listed as barriers discovered in Salsberry, Nickel, & Mitch's research (1994). Difficulty obtaining an appointment and child care were cited as barriers in previous studies (Salsberry, Nickel, & Mitch, 1993; Pruitt, Kline, & Kovaz, 1995; Houseman, Butterfoss, Morrow & Rosenthal, 1997), but were not listed as difficulties by this sample. Missed opportunities, while commonly mentioned as a problem in the literature (National Vaccine Advisory Committee, 1991; Szilagyi, et al, 1993; Shala, 1993; Salsberry, Nickel, & Mitch, 1993; Zimmerman, Giebink, Street, & Janosky, 1995; Watson, et al, 1996), were not explored with this study. All survey participants, with the exception of 4, made recommendations regarding ways to facilitate access to immunizations and well-child care. If these 35 recommendations were based on their own perceived needs, the information gathered by previous questions asking about the participants perceptions about the barriers they faced may not have been effective in gathering the desired data. It may be assumed that these recommendations were made with other’s needs in mind. It was not possible to ascertain the differences or similarities of perceptions of barriers to immunizations by race due to the lack of participants of races other than white. This, however, is representative of the survey population. In 1990, the Wattsburg area residents were 100% white. Corry residents were 99.5% white, and 0.10% black (U.S. Bureau of Census, 1990). Dorothea Orem's nursing theory states that dependent care is the continuing health related personal regulatory and developmental care provided for children by adults. Imbalances were shown to exist in the two rural areas examined in this study between the dependent care demands and the dependent care agent's ability to provide for needs. This resulted in the dependent care deficit of inadequate or delayed immunizations. Dorothea Orem's theory is supported and can be appropriately applied to this situation encountered by surveyed parents of preschool children in Wattsburg and Corry. Additional Data Other information elicited by the survey included the size of the participant's household (Table 10), and their use of the media (Table 11). Table 12 illustrates the means by which the survey participants obtain health care information, other than from their health care provider. 36 Ten survey participants reported they had access to computers in the Wattburg area, and five of those also had access to the internet. In Corry, five used computers, and four also had access to the internet. Table 10 Household Size by Area (n=51) Number of People Living in the Household Area two three Wattsburg 0 Corry 0 four five six seven eight 4 14 6 2 2 0 0 9 11 1 1 1 0 0 eight Table 11 Media Use by Area Type of Media Most Frequently Used radio Area newspaper TV Wattsburg 13 4 11 Corry 11 5 7 In response to the question about where health information is obtained, 15 participants replied that they obtained health information through sources not listed as responses on the survey. Two respondents report receiving health information from their 37 Table 12 Where Health Information is Obtained By Area Area Where Health Care is Obtained Wattsburg Corry Friends 12 9 Brochures 3 1 Newspapers 1 2 Books 3 1 TV 2 2 Magazines 7 6 Other 9 6 Note. The number of responses may be greater than the number of participants because the participants were permitted to choose more than one response. mother, three male respondnents from their wives, two from family, one from the hospital at which the child was bom, one obtained infromation at work, one from the college she attended, one from the hospital at which she was employed, and four replied ’’other” as a source, but stated that they received health information only from their physician. Recommendations This study was limited in value by the small sample size. It is recommended that 38 further efforts be directed toward determining the specific barriers that are encountered by parents of preschoolers in rural northwestern Pennsylvania. The survey utilized in this study or a similar one would serve as an effective data gathering tool to further the body of knowledge in this area. Future research with this survey would benefit from clarification in the question asking if illness had ever proven a barrier to a parent in obtaining adequate immunization for their child. Of more value would be two questions; one asking about minor illness of a child, and another asking if illness of a parent or caregiver had prevented a trip to the health care provider's office for immunizations. It is further recommended that the sample size be larger than that of this study. Statistically significant trends may not have been seen in this study's results due to this problem. When more data has been obtained, it is recommended that means by which to alleviate these barriers be designed and implemented. It is important to the health of our children that immunizations be given in a timely manner. When parents of preschool children encounter difficulty in obtaining immunizations for their children, the children are at risk for vaccine preventable infectious diseases. Nurse practitioners working in primary care can impact this problem by using the knowledge about what barriers these parents face to design means by which to facilitate access to age appropriate immunizations for all children. This study revealed several means by which Nurse practitioners can impact the problems faced by parents in rural areas. The distance travelled to obtain child immunizations could be overcome by a Nurse practitioner staffed immunization clinics held monthly in different areas of rural northwestern Pennsylvania. These clinics could be funded by the state or local 39 govemmenl. Measured outcomes could be obtained as the percentage of children appropnately immunized for their age as tracked by the child's medical home via the CHECK Project. These climes could be held solely for immunizations initially, and if the service is effective in impacting the rate of immunization in the in the area, the clinics could expand their services to include the provision of well child care. 40 References Beellig, L. L. (1995). Immunization and the prevention of childhood diseases. Journal of Gynecological and Qbstectrical Nursing. 24(7) 669-677. Centers for Disease Control and Prevention (1994). Update: Childhood vaccine preventable diseases-United States. Morbidity and Mortality Weekly Report. 43(391 718-720. Graham, M. (1993). Public health: Unprotected children. The Atlantic Monthly, 4(3), 2-10. Hinman, A. R. (1991). What will it take to fully protect all American children with vaccines? American Journal of Diseases of Children, 115, 559-562. Houseman, C., Butterfoss, F. D., Morrow, A. L., & Rosenthal, J. (1997). Focus groups among public, military, and private sector mothers: Insights to improve the immunization process. Public Health Nursing, 14(4), 235-243. Hutchins, S., Gindler, J., & Atkinson, W. (1993). Preschool children at high risk for measles: Opportunities to vaccinate. American Journal of Public Health, 83, 862-67. Hutchins, S. S., Escolan, J., Markowitz, L. E., Hawkins, C., Kimbler, A., Morgan, R., Preblud, S. R., & Orenstein, W. A. (1989). Measles outbreak among unvaccinated preschool children: Opportunities missed by health care providers to administer measles vaccine. Pediatrics, 83, 369-374. Kyle, S. M., & Coulter, J. S. (1995). The national immunization campaign: Implementation in a rural setting. Nursing Qutlpok, 43(2), 62-65. Lannon, C., Brack, V., Stuart, J., Caplow, M., McNeill, A., Bordley, C., & 41 Margolis, P. (1995). What mothers say about why poor children fall behind on immunizations. Archives of Pediatric and Adolescent Medicine, 149, 1070-1075. Marks, J. S., Halpin, T. J., Irvin, J. J., Johnson, D. A., & Keller, J.R. (1979). Risk factors associated with failure to receive vaccinations. Pediatrics, 64(3), 304-309. National Vaccine Advisory Committee (1991). The measles epidemic: The problems, barriers, and recommendations. Journal of the American Medical Association, 266,(11), 1547-1552. Newacheck, P. W., & Halfon, N. (1988). Preventive care use by school age children. Pediatrics, 82(3, pt 2), 462-468. Orem, D. E. (1995). Nursing: Concepts of practice (5th ed.). Mosby: St. Louis. 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. Peters, S. (1997). The state of pediatric immunizations today. Advance for Nurse Practitioners, 5(2), 43-49. Pruitt, R. H., Kline, P. M., & Kovaz, R. B. (1995). Perceived barriers to immunization among rural populations. Journal of Community Health Nursing, 12(2), 65-72. Salsbury, 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(4), 213-224. Schaffer, S. J., & Szilagyi, P. G. (1995). Immunization status and birth order. 42 Archives of Pediatric and Adolescent Medicine. 149, 792-797. Scudder, L. (1995). The child immunization initiative: Politics and health policy in action. Nursing Policy Forum. 1(3). 20-29. Shalala, D. (1993). Giving pediatric immunizations the priority they deserve. Journal of the American Medical Association, 269( 14), 1844-1845. Szilagyi, P. G., Rodewald, L. E., Humiston, S., G., Raubertas, R. F., Cove,, L. A., Doane, C. B., Lind, P. H., Tobin, M. S., Roghmann, K. J., & Hall, C. B. (1993). Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status. Pediatrics, 91(1), 1-7. Szilagyi, P. G., Rodewald, L. E., Humiston, S. G., Pollard, L., Klossner, K., Jones, A. M., Barth, R., & Woodin, K. A. (1996). Reducing missed opportunities for immunizations. Archives of Pediatric and Adolescent Medicine, 150, 1193-1200. U.S. Bureau of Census (1990). Wattsburg & Corry; Race. Harrisburg, PA. State Data Centers. U.S. Public Health Service (1992). Healthy People 2000. Boston, MA.: Jones and Bartlett. Watson, M. A., Feldman, K. W., Sugar, N. F., Sommer, C. J., Thomas, E. R., & Lin, T. (1996). Inadequate history as a barrier to immunization. Archives of Pediatric and Adolescent Medicine, 150, 135-139. Woods, D. R., & Mason, D. D. (1992). Six areas lead national early immunization drive. Public Health Reports, 107, 252-256. Zimmerman, R. K., Giebink, G. S., Street, H. B., & Janosky, J. E. (1995). 43 Knowledge and attitudes of Minnesota primary care physicians about barriers to measles and pertussis immunization. Journal of the American Board of Family Practice, 8(4), 270-277. Zylke, J. W. (1991). Declining childhood immunization rates becoming cause for concern. Journal of the American Medical Association, 266(10), 1321-1322. 44 rcttKK I Srehensne Health for Erie County Kjds Appendix A P.O. Box 6328 * Erie, PA 16512-6328 « Phone (814) 877-4940 * FAX (814) 877-7590 Letter of permission from CHECK project. April 17, 1998 Ms. LaTroy Navaroli 1 New Street Warren, PA 16365 Dear LaTroy, The Immunization Coalition of Erie County (ICEC) and the Comprehensive Health for Erie County Kids (CHECK) Project permits the use of the County Outreach Project Survey for use with your thesis work at Edinboro University. Sincerely, Tammy Banasavich CHECK Project Coordinator Chair, Immunization Coalition of Erie County A PROJECT OF THE HEALTHCARE COST SUMMIT 45 Appendix B Interview Script Interview Form Instructions Please read each question to the interviewee and complete the interview form yourself. Circle the answer that best describes or fits the answer that the person gives. Some questions are asked more than once in a different form to offer validity to the study. Also, if there are categories, complete the form using the category that closest fits. Encourage comments and note them at the end of the form. Script for interviews I am with a local coalition in Erie County who is conducting a research project. We are surveying parents in the area. It will take approximately 5 to 7 minutes and for participating in the interview I would like to offer you a magnetic coupon holder, a discount coupon, and a sticker for your child. Please respond to the questions asked choosing the answer that best fits your family and/or you. There is no right or wrong answer. The survey is anonymous. Thank you for taking the time to provide us with valuable information. 46 Appendix C Survey County Outreach Project- Survey Target Areas: Wattsburg and Corry in Erie County, PA Please circle the following numbered respnses that best describes the answer given by the respondent for the following questions: 1. Are you a resident of Erie County? 1) yes 2) no (if no do not continue the interview) 2. Do you live in... 1) Wattsburg 2) Corry (if neither, do not continue the interview) 3. How many children do you have under the age of seven? 1) zero-7/"zero, do not continue the interview. 4) three 2) one 3) two 6) five or more 5) four 1) less than two months 4. What is the age of your youngest child? 3) 4-5 months 4) 6-11 months 6) 18-23 months 7)2 years 10) five years 11) six years 2) 2-3 months 5) 12-18 months 8) 3 years 9) four years All of the following questions pertain to your youngest child: 5. Does your child visit one doctors office for care? 1) yes 2)no 6. Does your child get baby shots? 1) yes 2)no (if no skip to question #12) 7. At what age did your youngest child begin their baby shots? 2) two months 5) six months 3) three months 6) don’t know 1) one day old 4) four months 7) other: please specify 47 8. Where do you take your child for shots? 3) Health Department 1) family doctor 2) pediatrician 4) other: please specify 9. How many miles do you drive to take your child for shots? 2) 1-10 miles 3) 11-25 miles 4) 26-50 miles 1) less than one mile 5) more than 50 miles 10. At what age will your youngest child finish getting all the recommended baby shots? 1) two months 2) four months 3) six months 4) twelve months 5) twenty-four months 6) three years 9) other 10) don’t know 7) four years 8) five years 11) Have any of the following prevented or delayed you from taking your child for shots? l)lack of transportation 2) lack of insurance 4) cannot get off work 5) can't get an appointment 6) do not have a babysitter 7) illness 9) unsure when next shot is due 3) forgot appointment 8) cost 10) other: please specify 12) Does your child see a doctor for w// baby check-ups? 1) yes 2) no 13. Have any of the following prevented you from taking your child for well baby check­ ups? 1) lack of transportation 2) lack of insurance 3) forgot to make an appointment 4) cannot get off work 5) can't get appointment 6) don't have a baby-sitter 8) cost 9) unsure of when my child needs check-ups 10) other: please specify. 7) illness 48 14. How many miles do you drive to take your child to see a doctor? 1) less than one mile 2) 1-10 miles 3) 11-25 miles 4) 26-50 miles 5) more than 50 miles 15. Is distance to the doctor a problem for you? l)yes 2) no 16. Does your child have medical insurance? 1) access card 2) private insurance: please specify which type 3) none 4) other 17. Which of the following would you recomend? 1) evening hours for shots 2) evening hours for doctor visits 3) weekend hours for shots 4) reminders for appointments 5) transportation services 6) childcare services 7) lower costs 8) more information about when to get baby shots 9) other: please specify 18. Is your child in day care? 1) yes 2) no 3) daytime baby-sitter 19. Which do you do more often? 1) listen to the radio 2) read the newspaper 3) watch TV 20. Which newspaper do you read regularly? 1) Erie Daily Times 2) Local paper: please specify 21. Which radio station do you listen to? 4) Rocket 1015) WXTA Country 98 8) WCTZ 9) other 1) Classy 100 2) JET 102 6) WWCB radio 3) Star 104 7) Froggy 94 49 22. Where do you get your health information other than your doctor? 2) brochures 3) newspaper 4) books 5) TV 6) Magazines: please specify 7) other: please specify 23. Do you have acces to a computer for personal use? 24. Do you have acces to the internet? 25. 1) male 26. Age? 1) friends l)yes 2) no l)yes 2) no 2) female 1) under 15 2) 15-20 3) 20-25 4) 26-30 6) 36-40 7)41-45 8) 46-50 9) 51 or above 27. Household size? 1) two 2) three 7) eight 28) Household income? 3) four 1) <10,000 2) divorced 30) What is the last grade you completed? 4) associates degree 5) six 6) seven 8) more than eight 2) 10,000-19,000 4) 35,000-49,000 29) Are you? 1) married 4) five 5)31-35 5) 50,000 and above 3) single 4) widowed 1) high school 2) GED 5) bachelors degree 7) business/trade school 3) 20,000-34,999 3) some college 6) masters degree 8) other: please specify. 31. Do you have any suggestions for improving access to baby shots and doctor visits? 32. Race? 1) white 2) black 4) other: please specify 3) hispanic 50 33. Have you ever heard of the Comprehensive Health for Erie County Kids Project, CHECK? 1) yes, child not enrolled 34. Other comments please: Initials of the interviewer Incentive Date Place of interview 2) yes, child is enrolled 3) not sure 4) no