Parental Hesitation as a Factor in Delayed Childhood Immunization

IntroductionOne reason for lower immunization rates is that some parents hesitate to have their children immunized. A hesitancy questionnaire was developed to identify reasons parents hesitate in having their children immunized.MethodsThe hesitancy questionnaire was distributed from local pediatric and family practice offices and from the area's county health department. To be eligible, participants needed to be present in the clinic with a child needing a minimum of one immunization that was at least 6 months overdue.ResultsWhen questioned why their child was overdue for immunizations, the most common response was that participants were confused about the immunization schedule and not sure when to return. Of the participants who reported having concerns regarding immunizations, the child's pain/crying/anxiety was the most commonly occurring answer. When asked where they receive the majority of childhood immunization information, participants frequently identified their health care provider as the main source of information.DiscussionHealth care providers may be missing opportunities to educate hesitant parents about immunizations. Parents may not have ample opportunities to discuss their immunization concerns in detail with their health care provider during regularly scheduled clinic visits. It is important for health care providers to suggest ways parents can cope with their child's pain/crying/anxiety when receiving immunizations.     

Delayed transition of care: a national study of visits to pediatricians by young adults

ObjectiveDespite numerous policy statements and an increased focus on transition of care, little is known about young adults who experience delayed transition to adult providers.MethodsWe used cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between 1998 and 2008 to examine delayed transition among young adults ages 22 to 30. We defined delayed transition as continuing to visit a pediatrician after the age of 21 years.ResultsOverall, we found that 1.3% (95% confidence interval [CI] 1.1–1.7) of visits by young adults to primary care physicians were seen by pediatricians, approximately 445,000 visits per year. We did not find a significant change in delayed transition during the past decade (β = ?.01; P = .77). Among young adults, visits to pediatricians were more likely than visits to adult-focused providers to be for a chronic disease (25.7% vs 12.6%; P = .002) and more likely to be billed to public health insurance (23.5% vs 14.1%; P = .01). In adjusted models, visits by young adults to pediatric healthcare providers were more likely associated with chronic disease (adjusted relative risk [ARR] 2.2; 95% CI 1.5–3.4), with public health insurance (ARR 1.9; 95% CI 1.3–2.9), or with no health insurance (ARR 1.9; 95% CI 1.1–3.4).ConclusionsAlthough most young adult visits were to adult providers, a considerable number of visits were to pediatricians, indicating delayed transition of care. There has been no substantial change in delayed transition during the past decade. Visits by young adults with chronic disease, public health insurance, or no health insurance were more likely to experience delayed transition of care.     

Measles outbreak among unvaccinated preschool-aged children: opportunities missed by health care providers to administer measles vaccine

A measles outbreak in an inner-city area primarily involved preschool-aged children younger than 5 years of age. The reasons why 31 unvaccinated preschool children with measles disease had not been vaccinated were investigated. For some patients, health care providers missed opportunities to vaccinate eligible patients against measles. Of the 26 patients whose full immunization status was known, ten (38%) were vaccinated with diphtheria and tetanus toxoids and pertussis vaccine and/or oral poliovirus vaccine at a time when they could have received measles vaccine simultaneously, according to recommendations of the Immunization Practices Advisory Committee and the American Academy of Pediatrics. In addition, five of ten health care providers interviewed missed at least one opportunity to administer measles vaccine because of a minor illness that was not a contraindication to vaccination. Unvaccinated patients were more likely to receive health care in the public sector, have single mothers, and have parents who had no knowledge of existing vaccines; they were less likely to be age-appropriately immunized with other antigens. If measles immunization levels among preschool children in the United States are to be increased, education of both health care providers and parents, coupled with innovative strategies targeted to preschool children, particularly of low socioeconomic groups in inner cities, are needed.     

Tetanus immunization among adolescent girls in Rural Haryana

This survey was undertaken to estimate tetanus immunization coverage of adolescent girls in a selected rural community of Haryana and to ascertain the knowledge of these girls and their mothers about tetanus. The study period was between April 1996–March 1997. A 30-cluster immunization coverage house to house survey was carried out by a female social worker. The total population covered was 30448. Twelve roadside villages were selectively chosen. Eleven year and 17 year old girls (210 in each group) were surveyed for coverage evaluation. For K.A.P. survey 114 grils (aged 17 years) and 98 mothers (of 11 year old girls) were interviewed. Chi square, percentage and 95% confidence interval were used for statistical analysis. Coverage for tetanus immunization was 44.3% among 17 year old girls and 26.7% among 11 year old girls. The coverage was better (35%) among school going girls as compared to non-school going girls (13%). Correct immunization schedule of pregnant women was told by 16 (7.5%) respondents. None of them told the correct immunization schedule for children. Death was told as the main danger from tetanus by 172 (81%) respondents. Most (98%) were aware of the role of clean-stump (umbilical cord) at the time of delivery in the etiology of tetanus neonatorum. Tetanus immunization coverage needs to be improved among adolescents. They also need to be educated on various aspects of tetanus.     

Provider Attitudes Toward Public-Private Collaboration to Improve Immunization Reminder/Recall: A Mixed-Methods Study

ObjectiveTo assess primary care providers' current reminder/recall practices, preferences for collaboration with health departments in reminder/recall efforts, attitudes toward practice-based and population-based reminder/recall, and experiences with a population-based reminder/recall intervention.MethodsProviders responsible for making decisions about immunization delivery at all primary care practices that participate in the Colorado Immunization Information System were surveyed. Data collection was preceded by an intervention in which half of 14 counties received a population-based reminder/recall intervention conducted by the health department. Practice staff involved in immunization activities were then selected for semistructured telephone interviews that were based on the location of their practice within specified strata, including whether they were in the intervention counties, urban/rural location, and practice type.ResultsA total of 282 (73.6%) of 383 of providers responded to the survey, and 253 who administered vaccines to children 19 to 35 months were retained; 82 staff members at 36 practices were interviewed. Providers' preferences for who should conduct reminder/recall were almost evenly split, with slightly more indicating that it should be conducted by the health department. Cost and feasibility issues were perceived barriers to conducting practice-based recall, particularly among urban practices. Support for population-based reminder/recall was highest among rural practices. Concern about perceived inaccuracies in immunization registry data was the major barrier to conducting population-based reminder/recall. The population-based intervention did not create an undue burden on practices.ConclusionsA collaborative approach to reminder/recall involving both providers and health departments is preferable for many providers and may be a viable solution to the barriers of practice-based reminder/recall.     

A community based approach to improve health care seeking for newborn danger signs in rural wardha, India

Objective  To find out the effect of community mobilization and health education effort on health care seeking behavior of families with sick newborns, and to explore the rationale behind the changed health care seeking behaviors of mothers in a rural Indian community. Methods  In the present community based participatory intervention, a triangulated research design of quantitative (survey) and qualitative (Focus group discussions, FGDs) method was undertaken for needs assessment in year 2004. In community mobilization, women’s self help groups; Kishori Panchayat (KP, forum of adolescent girls), Kisan Vikas Manch (Farmers’ club) and Village Coordination Committees (VCC) were formed in the study area. The trained social worker facilitated VCCs to develop village health plans to act upon their priority maternal and child health issues. The pregnant women and group members were given health education. The Lot Quality Assurance Sampling (LQAS) technique was used to monitor awareness regarding newborn danger signs among pregnant women. In year 2007, a triangulation of quantitative survey and a qualitative study (free list and pile sort exercise) was undertaken to find out changes in health care seeking behaviors of mothers. Results  There was significant improvement in mothers’ knowledge regarding newborn danger signs. About half of the mothers got information from CLICS doot (female community health worker). The monitoring over three years period showed encouraging trend in level of awareness among pregnant women. After three years, the proportion of mothers giving no treatment/home remedy for newborn danger signs declined significantly. However, there was significant improvement in mothers’ health care seeking from private health care providers for sick newborns. Conclusion  The present approach improved mothers’ knowledge regarding newborn danger signs and improved their health care seeking behavior for newborn danger signs at community level. Due to lack of faith in government health services, women preferred to seek care from private providers.     

A Mixed Methods Analysis of Care Coordination Needs and Desirable Features of an M-Health Application to Support Caregivers of Children With Down Syndrome

IntroductionCare coordination is critical for the management of health care needs of children with Down syndrome by encompassing management of health information and linking of providers. This study was designed to identify caregiver and health care provider experiences of care coordination to inform the development of an m-health application.MethodIn this mixed methods study, caregivers completed survey materials addressing the child's health care needs, m-health use, and care coordination experiences. A sample of caregivers and health care providers were interviewed to further understanding.ResultsMost caregivers reported having a primary health care provider but wanted increased communication and help with care coordination. Interview data identified themes related to care coordination challenges, including information management, information sharing, use of health care guidelines, tracking health data, resources, technology use, previous application use, and coordination of schedules.DiscussionQualitative themes were linked to desired features of an m-health application to aid in development.     

Societal impact of combination vaccines: experiences of physicians, nurses, and parents

Crowded immunization schedules can result in missed or delayed dosing. Combination vaccines help immunize children on time, limit the required number of injections, and allow new vaccines to be added to the schedule. In the United States, a pentavalent vaccine combining diphtheria, tetanus toxoids, and acellular pertussis (DTaP), recombinant hepatitis B (HepB), and inactivated poliovirus vaccine (IPV) is available. Here, we describe the findings of informal surveys among providers, nurse managers, business managers, and parents on their attitudes toward and experiences with the DTaP-HepB-IPV vaccine. Combination vaccine use is expected to increase as more become available and awareness of their benefits grows.     

An exploratory survey on the state of training in adolescent medicine and health in 36 European countries

The development of adolescent health and medicine as a medical discipline lags behind in Europe compared with other regions of the world. This study aims to evaluate the structure and content of adolescent medicine and health training curricula for medical students, paediatricians, and other primary care physicians in the European region. A questionnaire survey was sent by e-mail to experts in the field from 36 European countries, addressing the content of adolescent health issues. Data was obtained from all 36 countries. At the undergraduate level, seven countries reported some mandatory stand-alone teaching (sessions dealing specifically with adolescents), while seven countries reported optional stand-alone teaching. In only 7 out of 36 countries were issues critical to adolescents covered as stand-alone sessions. At the postgraduate level, 15 countries delivered stand-alone mandatory training sessions to primary, secondary, or tertiary care paediatricians, covering most of the five critical areas listed in the questionnaire. In another 13 countries, such sessions were not mandatory and were inexistent in eight of them. The coverage among school physicians was similar but was much lower among general practitioners.

Conclusion: Paediatric associations and academic institutions should advocate for a better coverage of adolescent health and medicine in the training curricula of health care providers.

Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project

IntroductionThe American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child care visits by pediatric health care providers. The evidence shows a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults. The purpose of this Quality Improvement (QI) project was to increase pediatric providers’ awareness on ACEs through education and increase the utilization of an ACE screening tool.MethodThis QI project used a pre-post test to evaluate the effectiveness of the educational model and the utilization of the screening tool within an urban pediatric primary care clinic.ResultsThis project demonstrated an increase in provider awareness as well as a marked increase in the utilization of the screening tool.DiscussionFour hundred eighty ACE screening tools were collected over a 12-week period. By introducing the ACE screening tool as the standard of care in the primary care office, providers can provide early interventions to mitigate the potential untoward outcomes. This QI project also demonstrated that there was a statistical and clinical significance (p value < 0.001) in the provider's knowledge pre-post the educational intervention.     

Health care providers’ and parents’ attitudes toward administration of new infant vaccines—a multinational survey

The New Vaccinations of Infants in Practice online survey in seven countries evaluated vaccination-related attitudes and concerns of parents of infants and health care providers (HCPs) who provide pediatric medical care. The survey showed that HCPs and parents were open to adding new vaccines to the immunization schedule, even if it requires co-administration with current vaccines or introduction of new office visits. Parental disease awareness campaigns would be helpful to achieve widespread acceptance of changes to vaccination schedules. In addition, HCPs would ideally provide disease education to parents to accompany recommendations for a new vaccine.     

Control of neonatal tetanus

It is estimated from community-based surveys in 1981–1982 in India that between 230,000 and 250,000 children die each year from neonatal tetanus. Hospital data from India reveal that more than 90 per cent of neonatal tetanus cases and deaths occur in the first two weeks of life. They also show that the male to female ratio of cases ranges from 1·3 to more than 10 and these cases peak in August and September. In controlling this disease, two approaches should be emphasized: (i) increasing the immunization coverage of women of childbearing age, especially pregnant women, with tetanus toxoid; and (ii) improving maternity care, especially increasing the proportion of deliveries attended by a trained person. The incidence of neonatal tetanus should serve as an index of the quality and the degree of utilization of the maternal health services, of the impact of immunization programmes and of the progress being made in developing primary health care.     

Parental Limited English Proficiency and Health Outcomes for Children With Special Health Care Needs: A Systematic Review

BackgroundOne in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.ObjectiveTo conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.Data SourcesPubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.Eligibility CriteriaUS studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.MethodsThree trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.ResultsFrom 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Conclusions and ImplicationsParental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.     

Antibody response to vaccination after haematopoietic cell transplantation in children using a reduced dose schedule—A retrospective cohort study

Children receiving HCT loose protective immunity to vaccines received pre‐HCT. Therefore, revaccination post‐HCT is of major importance. In Denmark, a vaccination schedule with fewer doses post‐HCT has been used, including two doses for diphtheria, tetanus, polio, measles, mumps, and rubella, and one dose only for Haemophilus influenzae type B. The background for this was the presumption that post‐HCT immunization constituted booster vaccination of donor immunity. Our objective was to evaluate the proportion of children protected after the scheduled vaccination programme. A nationwide retrospective cohort study of all children who have received an HCT in Denmark during 1994‐2012. Antibody levels were analysed in blood samples drawn before and after vaccination, and the probability of achieving protection after the scheduled immunization programme was estimated. A total of 198 children were included. The protection post‐immunization was as follows: diphtheria 75.3%, tetanus 89.1%, polio 97.7%, and Haemophilus influenzae type B 94.8%. For diphtheria and tetanus, the probability of achieving protection increased to 93.8% and 97.3%, respectively, after a third dose. For measles, mumps, and rubella, the probability of achieving protection was 89.4%, 80.9%, and 94.2%, respectively. In conclusion, our findings support a more extensive vaccination schedule including three doses for diphtheria and tetanus which are in line with current international guidelines.     

What constitutes adequate well-baby care?

Two hundred forty-six full-term, first-born well infants were randomly assigned to receive well-baby care during their first year in one of four ways: six visits by a physician; three visits by a physician; six visits by a pediatric nurse practitioner (PNP); or three visits by a PNP. One hundred sixteen of the study babies received care in a clinic setting and 130 in a private-practice setting. The adequacy of care rendered was assessed by measurement of gain in maternal knowledge important for competence in child-rearing, level of maternal satisfaction, degree of maternal compliance, and attainment of the health supervision planned. These endpoints were subjected to two-way and three-way analyses of variance to determine if there were differences across the setting, provider, or schedule variables. Essentially no differences were observed in the endpoints measured within settings between providers of care, between visit schedules, or between any of the provider and visit schedule combinations. These results indicate that well-baby care during the first year delivered by PNPs is as adequate as that delivered by physicians and the use of abbreviated visit schedules by either professional does not reduce the adequacy of care.     

Parental Factors Affecting Pediatric Medication Management in Underserved Communities

BackgroundMedication errors and adverse drug events are common in the pediatric population. Limited English proficiency and low health literacy have been associated with decreased medication adherence, increased medication errors, and worse health outcomes. This study explores parental factors affecting medication management in underserved communities.MethodsUsing qualitative methods, we identified factors believed to affect medication management among parents. We conducted focus group discussions between December 2019 and September 2020. We recruited parents and health care professionals from local community partners and a tertiary care children's hospital. Sessions were recorded and transcribed. Three investigators created the coding scheme. Two investigators independently coded each focus group and organized results into themes using thematic analysis.ResultsEleven focus groups were held (n = 45): 4 English-speaking parent groups (n = 18), 3 Spanish-speaking parent groups (n = 11), and 4 health care professional groups (n = 16). We identified 4 main factors that could impact medication delivery: 1) limited health literacy among parents and feeling inadequate at medication administration (knowledge/skill gap), 2) poor communication between caregivers (regarding medication delivery, dosage, frequency, and purpose) and between providers (regarding what has been prescribed), 3) lack of pediatric medication education resources, and 4) personal attitudes and beliefs that influence one's medication-related decisions.ConclusionsThe compounding effect of these factors – knowledge, communication, resource, and personal belief – may put families living in underserved communities at greater risk for medication errors and suboptimal health outcomes. These findings can be used to guide future interventions and may help optimize medication delivery for pediatric patients.