Victoria A. Freeman

Parental knowledge, attitudes, and demand regarding a vaccine to prevent varicella

BACKGROUND Maintenance of high immunization rates is challenged by frequent changes to the recommended immunization schedule. This study assessed parent-reported knowledge of, attitudes about, and demand for a new vaccine against varicella. METHODS Six months following licensure of the varicella vaccine, a cross-sectional study was conducted by mailed survey among a sample of parents of 23- to 35-month-old children. Effective response rate was 65%. RESULTS Three quarters of parents had heard about the vaccine to prevent varicella. The lay media was the most frequently mentioned source of information. Thirteen percent of parents had already obtained the vaccine for their child, another quarter planned to get it, and one half were undecided. The most frequently cited factor influencing parents who had obtained or intended to obtain the vaccine was their doctors recommendation. For those undecided or not inclined to get the vaccine, insufficient information about the vaccine was the most frequently listed factor. CONCLUSION Publicizing a new vaccine through the media may be effective in raising public awareness, but detailed information about the vaccine and the recommendation of providers is still important in a parents decision about the vaccine for their child.

Adopting Immunization Recommendations: A New Dissemination Model

Objective: This paper presents a new approach for understanding factors related to physician adoption of clinical guidelines, using childrens vaccine recommendations as a case study. Methods: The model traces sequential steps, from awareness to agreement to adoption and, finally, adherence to the guideline. Movement through these stages can be catalyzed or retarded by many influences, grouped into two major categories: environmental characteristics of the physicians practice, and information characteristics of the guideline. Environmental characteristics include sociocultural factors, professional characteristics, and practice organization factors. Information characteristics include the guidelines relative advantage, complexity, and compatibility with existing guidelines and protocols, as well as mechanisms of guideline dissemination. Implications: This model can be used to identify characteristics that will likely impede or facilitate guideline adoption, and to focus dissemination efforts on key issues.

The role of state policies and programs in buffering the effects of poverty on children's immunization receipt.

OBJECTIVES This study assessed the influence of public policies on the immunization status of 2-year old children in the United States. METHODS Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up. RESULTS Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states. CONCLUSIONS While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.

Recruitment and retention in rural and urban EMS: results from a national survey of local EMS directors.

Maintaining an adequate staff is a challenge for rural emergency medical services (EMS) providers. This national survey of local EMS directors finds that rural EMS are more likely to be freestanding, that is, not affiliated with other public services, to employ only emergency medical technician-basics (EMT-Bs), and to be all volunteer. Rural EMS directors are more likely than urban ones to report that they are not currently fully staffed. The most common barriers to recruitment of EMTs in both urban and rural areas include unwillingness of community members to volunteer and lack of certified EMTs in the area. In rural areas, barriers to EMT training were noted more often than in urban areas as was the lack of employer support for employee volunteers. Similar rural training barriers affected retention of staff. Rural respondents reported that they lose staff to burnout and to difficulty in meeting continuing education requirements. Among rural respondents, those who direct all-volunteer EMS were the most likely to report recruitment and retention problems. The results suggest areas for further study including how volunteer EMS agencies can transition to paid agencies, how to bring EMS education to rural areas, and how EMS can work with other agencies to ensure EMS viability.

Designated Medical Directors for Emergency Medical Services: Recruitment and Roles.

CONTEXT Emergency medical services (EMS) agencies rely on medical oversight to support Emergency Medical Technicians (EMTs) in the provision of prehospital care. Most states require EMS agencies to have a designated medical director (DMD), who typically is responsible for the many activities of medical oversight. PURPOSE To assess rural-urban differences in obtaining a DMD and in their responsibilities. METHODS A national survey of 1,425 local EMS directors, conducted in 2007. FINDINGS Rural EMS directors were more likely than urban ones to report DMD recruitment problems, but recruitment barriers were similar, with the most commonly reported barrier being an unwillingness of local physicians to serve. Rural EMS directors reported that their DMDs were less likely to be trained in Emergency Medicine, and were less likely to provide educational support functions such as continuing education. Rural agencies were more likely to get on-line medical direction from their DMD, but were less likely to always get the on-line support they needed. Common barriers to on-line support were typical of rural communication barriers. CONCLUSIONS Existing recommendations for DMD qualifications may be difficult to attain in rural communities. To develop programs that will support medical direction for rural EMS agencies, it is important to learn what physicians identify as the barriers to serving as DMDs, and whether there are alternative and innovative ways to provide an optimal level of medical oversight. Solutions will likely be multi-faceted, as EMS activities and organizational structures are diverse and the responsibilities of the DMD are broad.

Costs of developing childhood immunization registries: case studies from four All Kids Count projects.

We conducted case studies using structured interviews at four sites to understand the financial resources needed to implement childhood immunization registries. The total cost of planning and implementing a central registry ranged from

Enforcement of age-appropriate immunization laws.

2.4 million to almost

Prospects for childhood immunization registries in public health assessment and assurance: initial observations from the All Kids Count initiative projects.

7 million over the first five years. In addition, substantial investment by individual or group providers often was required. Registries are large information systems that require considerable investment of developmental resources, regardless of the number of children eventually entered into the system. Given the substantial investment that a registry represents, the realistic anticipation of such resource needs is important to successful planning and implementation.

The Awareness-to-Adherence Model of the Steps to Clinical Guideline Compliance: The Case of Pediatric Vaccine Recommendations

BACKGROUND The state of North Carolina has statutes that require age-appropriate immunization as recommended by the U.S. Public Health Service. Provisions of this statute allow for criminal misdemeanor charges and injunctions to be brought against parents who do not have their children immunized on time. The decision to invoke the age-appropriate immunization statute rests with the health director of each county. This study was performed to determine if the county health directors were aware of this statute and whether they had ever utilized it to enforce age-appropriate immunization. METHODS All health department directors in the state of North Carolina (N = 86) received letters inviting them to complete a 20-minute structured phone interview at a time of their convenience. Specific questions addressed their knowledge of the statutes and the specific penalties available. Additional questions addressed their attitudes and beliefs about the law and what they believed the state government could do to assist in enforcing the law. RESULTS Interviews were completed for 75 of the 86 (87%) county health departments or districts. All respondents reported they were aware, prior to receiving the materials informing them of the study, that the state required children to be immunized on time. Over 95% reported they knew the law required age-appropriate immunization and 100% were aware of school/licensed day-care requirements. The vast majority (83%) of county health directors believe that criminal misdemeanor charges and injunctions should be brought against parents for failing to have their child age-appropriately immunized. However, only 5% (n = 4) of health directors reported that their county had ever brought criminal misdemeanor charges, and none had filed an injunction against a parent whose child was not immunized on time. CONCLUSIONS Despite the presence of legal statutes, there have been only rare efforts to compel age-appropriate immunization through enactment and enforcement of criminal penalties on parents. Much of the hesitancy for such efforts likely comes from the fear of the confusing, hard-to-understand legal procedures and from the potential negative impact on public opinion that these tactics may create. Although such actions should be taken only as a last resort, they may be necessary on some occasions.

The Challenge and Potential of Childhood Immunization Registries

This article offers an overview of selected evaluation findings from the initial implementation year of the Robert Wood Johnson Foundations All Kids Count childhood immunization initiative in which demonstration projects were funded to develop community-based immunization registry and follow-up systems in 14 sites throughout the United States. The basic components of these systems, the process through which these registries were developed, efforts to secure the participation of private sector providers, the prospects for system success at the community level, and the potential for these immunization programs to influence other aspects of primary health care for children are addressed.