Insights on Immunizations From Caregivers of Children Receiving Medicaid-Funded Services

ISSUES AND PURPOSE. Despite numerous programs aimed at improving immunization rates among American children, under-immunization remains a significant problem. This study was conducted to gain insight into parents' /guardians' knowledge and attitudes regarding childhood immunizations.
DESIGN AND METHODS. Thirteen African-American mothers and grandmothers participated in semistructured, audiotaped focus-group interviews.
RESULTS. Four major themes emerged: health knowledge and beliefs about immunizations, system barriers that impede obtaining immunizations, facilitators that enhance obtaining immunizations, and suggestions for change.
PRACTICE IMPLICATIONS. Immunizations are one of the most important health advantages available to children. Therefore, nurses must become aware of the problem of underimmunization and work to address some of the concerns caregivers have identified in this study. The health and lives of the nation's children depend on it.     

A Comparison of Chronic Pain Between an Urban and Rural Population

A community-wide survey of 302 parents of 2-year-old children and 90 private medical practitioners in a large midwestern city revealed low immunization rates (31%) and differences in parent and provider perceptions of barriers to preschool immunizations. Parents most frequently identified barriers of system factors such as cost, lack of insurance coverage, and long office waits. System barriers were reported across differing sources of immunizations (private physician as well as public clinics) and were pervasive across income groups. Providers were more likely to report barriers of parental difficulties with forgetting immunizations or not knowing when the immunizations were due. Even though providers identified parental shortcomings with scheduling as problematic, only one fifth employed tracking and reminder systems. Implications of findings for modifications of the delivery of immunization services and for parent education are discussed.     

Homeless Health Needs: Shelter and Health Service Provider Perspective

The effects of homelessness on health are well documented, although less is known about the challenges of health care delivery from the perspective of service providers. Using data from a larger health needs assessment, the purpose of this study was to describe homeless health care needs and barriers to access utilizing qualitative data collected from shelter staff (n = 10) and health service staff (n = 14). Shelter staff members described many unmet health needs and barriers to health care access, and discussed needs for other supportive services in the area. Health service providers also described multiple health and service needs, and the need for a recuperative care setting for this population. Although a variety of resources are currently available for homeless health service delivery, barriers to access and gaps in care still exist. Recommendations for program planning are discussed and examined in the context of contributing factors and health care reform.     

Contrasting experiences with child health care services by mothers and professional caregivers in transitional housing.

The study examined experiences of mothers and health care providers with preventive child health care services using qualitative methods at a primary care clinic located in transitional housing for homeless families in an urban community with predominantly Black American residents. Participants were 20 mothers and 4 health care professionals. Three major domains emerged: (a). the infrastructure of the clinic and health care delivery poses barriers to mothers' access and use of services for their children; (b). specialized, biomedical-driven care produces fragmented care delivery not responsive to the comprehensive nature of problems of mothers and their children; and (c). organizational strategies for improving access and use of health care services are directed by health care providers' value orientations. Findings support existence of infrastructural characteristics of the health care system that maintains differential value orientations and power structure, and care delivery processes that are non responsive to racially diverse and poor mothers.     

Pediatric immunization update 2002

The field of pediatric immunizations is growing and changing as new vaccines are becoming available and previous diseases are being eradicated. Due to the complexity and evolution of vaccine-preventable diseases, pediatric health care providers must routinely review the current childhood immunization recommendations. A review of immunology and the principles of vaccination provide background knowledge for information pertaining to disease transmission and the current recommended vaccine schedule. Vaccine administration guidelines and techniques are presented in table format. An overview of new vaccine research and development and a discussion of vaccine safety and immunization resources are also included.     

Kangaroo mother care: A literature review of barriers and facilitators to implementation in the neonatal intensive care unit

Kangaroo mother care (KMC) is a cost-effective, natural, safe, and evidence-based intervention that improves maternal-infant bonding, increases breastfeeding rates, and decreases the risk of mortality and morbidity in preterm infants. Although KMC is recommended to be the standard of care for preterm infants, there are significant implementation barriers. This literature review critically analyzes the barriers and facilitators to implementation from three health care system components: (1) health care facilities, (2) health care providers, and (3) parents. One independent author included 17 research-based articles from 2014 to 2021. Overarching themes identified were: availability of protocols, policies, and guidelines; access to training and support; access to resources; buy-in; and medical concerns. Recommendations to overcome barriers and increase uptake are: develop and disseminate KMC protocols, policies, and guidelines; provide quality training and support to health care providers; provide quality education and socio-cultural support to parents; and allocate resources to support KMC.     

Mexican-origin mothers' experiences using children's health care services

A focused ethnographic study in an urban Latino community in the western United States describes Mexican-origin mothers 'experiences obtaining and using health services for their children. Repeated interviews with mothers, participant observation, and children's medical records composed the data sources. Qualitative findings suggest access to health care begins in the household, where women negotiate a working diagnosis for the children's illness with family members and coalesce support for health care seeking. Immigrant mothers described more barriers to children's health care than more acculturated mothers. Quantitative analyses of medical records supported this finding, with children of the least acculturated mothers demonstrating fewer well-child visits, increased emergent visits, and lower levels of immunization completeness. The results suggest health care providers can better meet the needs of Latino families with children by offering better explanations about children's diagnoses and treatment plans and demonstrating personalismo, or a friendly, kind, and social approach to care.     

Barriers to Culturally Competent Human Immunodeficiency Virus Care Among the Black,Indigenous, and People of Color Community

Black, Indigenous, and people of color (BIPOC) are at a higher risk for human immunodeficiency virus (HIV) infection and face unique challenges in the United States health care system. Health care providers can understand the barriers to care for at-risk groups and identify interventions to improve health outcomes. Demographic, social, and economic factors all play a role in the health disparities regarding the HIV infection rate in these at-risk populations. There are many challenges in establishing early diagnosis of HIV infection and linking newly diagnosed people living with HIV (PLWH) to evidence-based care. Systemic barriers include a lack of access to testing resources, a lack of primary care provider training in HIV testing and counseling, and a delay of linkage to care of newly diagnosed PLWH to treatment. Delayed initiation of HIV treatment can increase morbidity and mortality and perpetuate HIV transmission. Consistent use of pre-exposure prophylaxis (PrEP) has proven to decrease the incidence of HIV transmission while maintaining a low side effect profile; however, PrEP usage among the BIPOC population is low, increasing the risk of HIV seroconversion. Increased testing, PrEP utilization, and linkage to care for PLWH promote viral suppression, reducing HIV transmission. Specific population-based interventions for prevention, testing, and treatment can encourage providers to empower patients to seek and remain in care. By decreasing racial disparities in the delivery of care, providers can help achieve viral suppression, improving the overall health outcomes among BIPOC communities.     

Parental refusal or delay of childhood immunization: Implications for nursing and health education

The purpose of this article is to review the current literature to ascertain reasons behind parental refusal or delay of childhood immunizations. Recurring themes highlighted issues involving parents and health care providers. Strategies to improve immunization compliance were proposed. Health care professionals and health educators were identified as instrumental in the effort to educate and positively influence immunization. As one of the most highly trusted members of the health care team, a nurse is vital to the success of this endeavor.     

Involvement of immunization-certified pharmacists with immunization activities

BACKGROUND: Immunization certification courses allow pharmacists to directly administer vaccines to their patients. However, the demographics and level of immunization involvement of immunization-certified pharmacists compared with those noncertified are unknown. OBJECTIVE: To document the demographics, professional activities, and job satisfaction of immunization-certified pharmacists compared with pharmacists not certified for immunization. METHODS: In a cross-sectional pilot study, immunization-certified pharmacists were compared with noncertified pharmacists via a postal-mailed questionnaire. The questionnaire consisted of demographic and practice site characteristics, involvement in immunization services, and a job satisfaction survey. RESULTS: Response rates were 48% (n = 101) and 36% (n = 158) for immunization-certified and noncertified pharmacists, respectively. Significantly more certified pharmacists were involved in immunizations (99% vs 24%; p < 0.001). Desire to improve the health care of the public and personal satisfaction were important factors that encouraged pharmacists to become certified to administer vaccines. Seventy-four percent of immunization-certified pharmacists directly administered the vaccines, primarily influenza (96%), pneumococcal (77%), hepatitis (55%), and diphtheria, pertussis, tetanus (19%). Adequate training, time, support from management and staff, and liability coverage were important factors that allowed pharmacists to incorporate immunizations into their practice. No significant differences in job satisfaction were observed between immunization-certified and noncertified pharmacists. CONCLUSIONS: Immunization-certified pharmacists are using their skills to administer vaccines to patients within their communities. Efforts to increase the number of these pharmacists throughout the US should be undertaken.     

Tetanus and the aged

Tetanus is primarily a disease of the aged. Even though the overall number of cases of tetanus has decreased since 1955, the number of cases of tetanus in people 50 years of age and older has remained constant. The national Center for Disease Control attributes the cases of tetanus in the aged to inadequate immunization levels. Tetanus is preventable and, theoretically, could be eradicated if the population was at an adequate immunization level. There are many reasons why older people are not adequately immunized. These reasons may include the inability to get to a health care facility due to physical disability or lack of transportation, ignorance of the importance of seeking health care for minor injuries, financial constraints and a knowledge deficit on the part of health care providers regarding the immunization needs of the aged. Health care providers can prevent tetanus in the aged through vigilance. All aged clients should be routinely assessed and immunizations updated as necessary. Tetanus will never be eliminated until universal active immunization has been achieved.     

Improving Immunizations in Children: A Clinical Break-even Analysis

IntroductionImmunizing the population is a vital public health priority. This article describes a resident-led continuous quality improvement project to improve the immunization rates of children under 3 years of age at two urban family medicine residency clinics in Salt Lake City, Utah, as well as a break-even cost analysis to the clinics for the intervention.MethodsImmunization records were distributed to provider-medical assistant teamlets daily for each pediatric patient scheduled in clinic to decrease missed opportunities. An outreach intervention by letter, followed by telephone call reminders, was conducted to reach children under 3 years of age who were behind on recommended immunizations for age (total n=457; those behind on immunizations n=101). Immunization rates were monitored at 3 months following start of intervention. A break-even analysis to the clinics for the outreach intervention was performed.ResultsImmunizations were improved from a baseline of 75.1% (n=133) and 79.6% (n=223) at the two clinics to 92.1% (n=163) and 89.6% (n=251), respectively, at 3 months following the start of intervention (P<0.01). The average revenue per immunization given was $81.57. The financial break-even point required 36 immunizations to be administered.ConclusionSignificant improvement in the immunization rate of patients under 3 years of age at two family medicine residency training clinics was achieved through decreasing missed opportunities for immunization in clinic, and with outreach through letters and follow-up phone calls. The intervention showed positive revenue to both clinics.     

Barriers to providing diabetes care in community health centers

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.     

Adult immunizations: recommendations for practice

Each year in the United States, 50,000 to 90,000 adults die of pneumococcal disease, influenza, and hepatitis infections. These figures vastly exceed mortality due to vaccine-preventable diseases in children. In addition, adult immunizations are cost-effective and lifesaving measures. Nonetheless, surveys reveal that both physicians and patients underuse adult immunizations as an effective means of disease prevention. The goal of achieving higher adult immunization rates is critically dependent on improving the attitudes and practices of health-care providers. In this article, we review several vaccines routinely used in the practice of adult medicine.     

Records--the Achilles' heel of school nursing: answers to bothersome questions.

This article addresses practice issues related to school health records and school nursing documentation. Because the issues have been posed by practicing school nurses, the article is in Question and Answer (Q and A) format. Specifically, the questions addressed concern the following: ownership and storage location of student health records when the school nurse is contracted from a community health agency rather than employed by the school district; documentation of sensitive health information on students' health records including pregnancy, drug and alcohol abuse, mental illness, history of suicide attempt, and HIV status; inclusion of medical diagnoses and current medications on a student's Individual Educational Program (IEP); and Health Insurance Portability and Accountability Act (HIPAA)-permitted communications between school nurses and health care providers related to students' immunization status, regarding a student's treatment needs in school, and via facsimile (e.g., records of immunizations, completed physical examination forms, and medical orders). HIPAA, the Family Educational Records and Privacy Act (FERPA), and other laws are addressed as appropriate, and resources for obtaining further information are included.     

Indicators of Differences in Immunization Rates of Mexican American and White Non-Hispanic Infants in a Medicaid Managed Care System

Abstract Immunization levels of Mexican American and white non-Hispanic infants enrolled in Arizona's Medicaid managed care demonstration project, a prototype of the model proposed for a reformed health care system, were compared and the influence of sociodemographic characteristics, acculturation levels, health beliefs of the mothers, and infant health status on immunization levels were assessed. The study used data collected from office records, birth certificates, and household interviews. The random sample included 292 white non-Hispanic and 274 Mexican American infants. White non-Hispanic infants received more immunizations by age 1 than the Mexican American infants. However, after controlling for a full set of explanatory variables in a multiple regression analysis, ethnicity was no longer a significant predictor of immunization levels. Significant predictors of a higher number of immunizations included fewer siblings, older maternal age, and higher maternal education. Health insurance and enrollment in a managed care plan were not sufficient to ensure adequate immunization of these Medicaid enrolled infants. Results are discussed in terms of previous research and the essential functions of public health as outlined in the Institute of Medicine's Report on the Future of Public Health.