This study was conducted in four inner-city, primary care centers in Pittsburgh, Pennsylvania that were representative of settings where children of low-income households in urban areas receive their primary care: the Primary Care Clinic at Children’s Hospital of Pittsburgh- a medical center affiliated with the University of Pittsburgh which offers primary health care to a large Medicaid-insured population; the East Liberty Family Health Care Center, an inner-city, neighborhood health center serving any who need care in the community regardless of income or insurance status; the Matilda H. Theiss Health Center, located in a large, public housing project adjacent to the University of Pittsburgh which serves a predominately Medicaid-insured population; and, the Allegheny County Health Department’s Northside Child Health Clinic. These four clinics were chosen because they were known to serve predominately children with Medicaid insurance.


Medicaid billing records at three of the four clinics were used to identify children who were born between January 1,1991, and May 31,1995, and who were currently receiving primary care at the clinic. The age range of the children was 12 months to 5.5 years (mean age was 3.5 years; median age 3.6 years) and was chosen in order to capture the parents’ (or guardians’) knowledge, attitudes, beliefs and immunization behavior with regard to their preschool children. In instances where two or more age-eligible children had the same address and telephone number, the youngest child was selected for inclusion in the study. At the fourth site, clinic personnel had concerns about confidentiality and preferred to identify the sample (utilizing the same criteria) and mail the introductory letters themselves. Approval for this study was received from the Institutional Review Board for the Health Sciences, University of Pittsburgh.

Introductory letters, including an endorsement from the respective clinic director, were sent to parents of all eligible children. Parents were asked if they would participate in a 30 minute telephone survey and provide permission for researchers to review their youngest child’s immunization record by signing and returning an enclosed consent form. Parents were offered a payment of $25 for participation. The letters were mailed in a series of eight waves of 100 to 200 each, over the course of the survey period from June to October 1996. Follow-up calls to non-responding parents were initiated two weeks after the mailings. Telephone interviews were not conducted until a signed consent form was returned. Interviews were conducted by trained staff using a computer assisted telephone interviewing (CATI) system.

After the telephone survey was completed with the parent, a medical record review was completed for each child to determine dates of immunization for 4 (DTP), 3 polio virus containing and 1 (MMR) vaccine doses. Records were abstracted from each immunization provider reported by the parent and synthesized to produce the most complete immunization record possible. Chart review data was collected between October of 1996 and January 1997. order levitra


In order to understand parents’ conceptualization of childhood disease and prevention, the following process was followed. First, a panel of eight experts in several disciplines including pediatric infectious disease, public health and decision theory was consulted regarding what they believed parents needed to know in order to make an informed decision regarding com­pleting a core set of immunizations for their preschool children. Based on the responses from the expert panel, the major determinants of decision making behavior were identified. Next, a set of open-ended, face-to-face interviews were conducted with 25 African-American parents of children less than two years of age who were late for one or more of the basic series of childhood immunizations. The purpose of the open-ended interviews was to develop the structured, closed-ended telephone survey instrument that addressed the major determinants of decision making behavior, and develop the response categories for the survey items from the perspective of the target population of parents.

The second step of this process involved the pilot testing and administration of the telephone survey instrument. Variables chosen for inclusion in the survey included items generated by the expert panel as well as key constructs from the Precaution Adoption Process Model – a stage-based, theoretical model of health behavior adoption. This model provided the theoretical framework for the instrument design because it allows one to examine both cognitive and non-cognitive aspects of immunization behavior. The model assumes a linear approach to health behavior adoption and postulates that before one adopts a new health behavior, they progress through a series of stages. They must first have an awareness of childhood diseases followed by an acknowledgment of their susceptibility to the disease. Next, they must decide to take a precaution to avoid or lessen the consequences of the disease. And, finally, the person takes the preventive action– i.e. gets the vaccine for their child. canadian cialis online

The telephone survey instrument consisted of 51 questions – 12 of which had subparts – for a total of 138 data points. The instrument contained questions based on the following constructs: childhood disease recognition, parental experience with childhood diseases, parental beliefs regarding the likelihood of children getting whooping cough (the term whooping cough is used interchangeably in this manuscript with pertussis) and measles, parental beliefs about their child’s susceptibility as well as childhood disease transmission and prevention, judgments about the severity and consequences of getting childhood dis­eases, knowledge of and beliefs about immunization effectiveness, judgments regarding likelihood of side effects, beliefs about barriers to immunizations and, demographics-age, race, education, income, employment status and number of children. Information regarding the sex of the respondent was not collected in this study because this information was not available to the investigators at the time that recruitment letters were mailed. Once parents mailed in a consent form agreeing to be interviewed by telephone, it was felt that it would be awkward to ask the parent during the telephone interview if they were male or female. Therefore, this information was not collected.