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

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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

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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