title: A population-based study of access to immunization among urban Virginia children served by public, private, and military health care systems.
abstract: BACKGROUND
  Pediatric immunization rates have increased in the United States since 1990. Nevertheless, national survey data indicate that up to one third of 2-year-old children in some states and urban areas lack at least one recommended dose of diphtheria-tetanus-pertussis (DTP)-, polio-, or measles-containing vaccines. Immunization has become a key measure of preventive pediatric health care in the United States. To achieve and maintain the national immunization goal that 90% of children receive all recommended immunizations by 2 years of age, the role of the health care system in immunization delivery must be examined. Urban eastern Virginia has a diverse population that obtains immunization services from public, private, and military providers and insurers. At the time of this survey, immunization services in Virginia were available free to all children through public health clinics and to military families when using a military facility.
  
  
  OBJECTIVE
  To examine access to pediatric immunization services and health system factors associated with underimmunization in a representative sample of children at 12 and 24 months of age.
  
  
  METHODS
  We conducted a household survey in urban eastern Virginia from April through September 1993. A total of 12 770 households in Norfolk and Newport News, VA, were selected for inclusion in the study using probability-proportionate-to-size cluster sampling. Use of probability-proportionate-to-size sampling ensured that children within each city had equal probability of being included in the survey. Selected households were visited by trained interviewers to determine their eligibility, defined as having at least one child 12 to 30 months of age residing in the household. In eligible households, parents were asked to participate in a standardized, 15-minute interview. Survey respondents were asked about household demographics, and for each eligible child, the immunization history, health insurance, the name and location of all immunization providers, the usual immunization provider, and any problems the parent had experienced accessing immunization services with that child. Up-to-date (UTD) immunization status was defined as having all recommended doses of DTP, polio, and measles-mumps-rubella at 12 months (three DTP and two polio immunizations) and 24 months (four DTP, three polio, and one measles-mumps-rubella immunizations). The child's immunization history was assessed from parent and provider records only. Data analysis accounted for the survey's cluster sampling design (ie, within-cluster correlation). Because the immunization rates of the two cities did not differ significantly, unweighted analyses were used for ease of computation. Significance was determined for contingency tables by Wald's chi2 test.
  
  
  RESULTS
  A total of 749 children (91% of eligible households) participated in the survey. Study children were born between October, 1990, and July, 1992. Immunization records were obtained for 705 children (94%). Eighty-seven percent of respondents were mothers, 44% were African-American, 40% of children were military dependents, and 40% were enrolled in the Women, Infants and Children (WIC) program. Sixty-five percent of children were UTD at 12 months and 53% at 24 months. Parents reported that their children's usual immunization providers were private doctors (34%); public health, hospital clinics, or community health centers (32%); and military clinics or a military contract provider (34%). At least one problem accessing immunization services was reported by 35% of respondents, ranging from 29% among those who used a private doctor as their child's usual immunization provider to 46% among those using a military contract provider. Overall, the most commonly reported problem was clinic waiting time (12%), with reports of waiting time as a problem occurring most often among those using the military contract provider (22%) and public health clinics (17%). (ABSTRACT TRUNCATED)
authors.affiliation: Center for Pediatric Research, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk, VA 23510-1001, USA.
authors.forename: A L
authors.initials: AL
authors.lastname: Morrow
authors.forename: J
authors.initials: J
authors.lastname: Rosenthal
authors.forename: H D
authors.initials: HD
authors.lastname: Lakkis
authors.forename: J C
authors.initials: JC
authors.lastname: Bowers
authors.forename: F D
authors.initials: FD
authors.lastname: Butterfoss
authors.forename: R C
authors.initials: RC
authors.lastname: Crews
authors.forename: B
authors.initials: B
authors.lastname: Sirotkin
mesh_terms: D002675:Child, Preschool; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006306:Health Surveys; D006772:Hospitals, Military; D016304:Hospitals, Private; D006779:Hospitals, Public; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data*; D007223:Infant; D008297:Male; D011159:Population Surveillance; D011787:Quality of Health Care; D011897:Random Allocation; D014505:Urban Population / Q000706:statistics & numerical data*; D014768:Virginia