Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Factors influencing parental compliance with the preschool children’s immunization schedule Symonds, Barbara Dianne 1979

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1979_A5_7 S94.pdf [ 3.84MB ]
Metadata
JSON: 831-1.0094610.json
JSON-LD: 831-1.0094610-ld.json
RDF/XML (Pretty): 831-1.0094610-rdf.xml
RDF/JSON: 831-1.0094610-rdf.json
Turtle: 831-1.0094610-turtle.txt
N-Triples: 831-1.0094610-rdf-ntriples.txt
Original Record: 831-1.0094610-source.json
Full Text
831-1.0094610-fulltext.txt
Citation
831-1.0094610.ris

Full Text

FACTORS INFLUENCING PARENTAL COMPLIANCE WITH THE PRESCHOOL CHILDREN'S IMMUNIZATION SCHEDULE by BARBARA DIANNE SYMONDS B.S.N., Univers ity of B r i t i s h Columbia, 1978 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept th i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1978 ^ Barbara Dianne Symonds, 1979 In presenting th i s thesis in par t i a l fu l f i lment of the requirements for an advanced degree at the Univers ity of B r i t i s h Columbia, I agree that the Library shal l make i t f ree ly avai lable for reference and study. I further agree that permission for extensive copying of th i s thesis for scholar ly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publ icat ion of th i s thesis for f inanc ia l gain shal l not be allowed without my written permission.. Department of The Univers ity of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 D E - 6 B P 7 5 - S 1 I E ABSTRACT j FACTORS INFLUENCING PARENTAL; COMPLIANCE WITH THE PRESCHOOL CHILDREN'S IMMUNIZATION SCHEDULE The control of communicable diseases in chi ldren i s an important public health ro le . With the a v a i l a b i l i t y of e f fec t i ve vaccines, the conquest of many childhood diseases i s possible. However, the success of the present immunization programs rests u l t imately with the parents, who are responsible for ensuring that t he i r ch i ld ren ' s immunization status i s complete. Many factors can influence th i s parental compliance. The parents of kindergarten students in two suburban communities completed a questionnaire on immunizations and family cha rac te r i s t i c s . The questionnaire was constructed using items submitted from a panel of public health nurses and from the l i t e r a t u r e . A pretest was conducted.. The t o t a l ' number of questionnaires returned by the deadline was 376. Data on pre-school ch i ld ren ' s immunization status were also co l lected from health unit records. Analyses of the data included frequency d i s t r i bu t i on s , contingency table analyses, factor analys i s , and discriminant analys i s . The major f indings of the study were: 1. There was a difference between preschool ch i ld ren ' s recorded immunization status according to health unit s t a t i s t i c s and the national standard. 2. There was a discrepancy between preschool ch i l d ren ' s immunization status as reported by parents and as recorded in health unit s t a t i s t i c s . 3. There was not a s i gn i f i c an t re lat ionsh ip between parental education l e v e l , family mobi l i ty , family socio-economic l e v e l , family composition, or parental knowledge of immunizations and preschool ch i ld ren ' s reported immunization status. 4. There was a s i gn i f i c an t re lat ionsh ip between a pos i t ive parental att i tude toward immunization and completed preschool ch i ld ren ' s reported immunization status. 5. There.was a s i gn i f i can t re lat ionship amongst the var iables. High family mobi l i ty , a low educational level for the father, an incomplete parental immunization status, and a fee l ing of lack of knowledge about immunizations were discriminatory for a reported incomplete immunization status. As well mob i l i t y , education-income, family composition and att i tude best accounted for the re lat ionsh ip amongst the variables on factor analysis Implications for nursing pract ise are discussed and recommendations for further research are suggested. TABLE OF CONTENTS CHAPTER PAGE I. INTRODUCTION OF THE STUDY 1 Introduction 1 The Problem 3 Statement of the problem 3 S ignif icance of the problem. 3 Assumptions of the Study 5 Def init ions of Terms Used 5 Limitations of the Study 8 Hypotheses Tested 8 Overview of the Remainder of the Study 9 II. REVIEW OF THE LITERATURE 10 Compliance with Medical Regimens 10 Factors Influencing Compliance 13 Education of the parents 14 Socio-economic level of the family 16 Knowledge and att itudes 18 Family Composition ., 20 Family mobi l i ty 21 Immunization Status 23 Immunization Standards 26 Summary 26 i v CHAPTER PAGE II I. THE DESIGN AND METHODOLOGY 27 The Design of the Study 27 Exploratory design 27 The sett ing 28 The subjects 28 Methodology of the Study 29 Measurement procedures 29 Overview of the Data Analysis 31 Summary 32 IV. ANALYSIS OF THE DATA 33 Analysis Related to the Questions 34 Analysis related to Question I 34 Analysis related to Question II 35 Analysis related to Question III 36 Analysis related to Hypothesis I 36 Analysis related to Hypothesis II 39 Analysis related to Hypothesis III 44 Analysis related to Hypothesis IV 45 Analysis related to Hypothesis V 47 Analysis related to Hypothesis VI 53 Analysis related to Hypothesis VII 54 Additional Data 57 Summary 59 v CHAPTER PAGE V. SUMMARY, DISCUSSION OF THE FINDINGS, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY 60 Summary 60 Discussion of the Findings 62 Reported and recorded immunization status 62 Selected internal and external factors 64 Sources of error 67 Conclusions 69 Implications for Nursing Pract ice 70 Recommendations for Further Study 70 BIBLIOGRAPHY 72 APPENDICES 78 A. The Questionnaire U t i l i z e d for the Study 79 B. Covering Letter to the Parents 85 C. B r i t i s h Columbia Department of Health Infant Immunization Schedule 87 v i LIST OF TABLES TABLE PAGE I. Immunization Status of School Enterers 1972-1975 23 II. Rate of Measles, Mumps and Rubella 1972-1975 24 I I I. Questions and Hypothses With Appropriate Source of Data . . . 30 IV. Chi ldren ' s Recorded Immunization Status Compared To National Standard 34 V. Disease Spec i f i c Recorded Versus Reported Immunization Status 35 VI. Frequency D i s t r ibut ion for Chi ldren 's Reported Immunization Status 36 VII. Frequency D i s t r ibut ion for Mothers' Educational Level . . . . 37 VIII. Frequency D i s t r ibut ion for Fathers' Educational Level . . . . 38 IX. Analysis of Mothers' Educational Level By Chi ldren 's Reported Immunization Status 38 X. Analysis of Fathers' Educational Level By Chi ldren 's Reported Immunization Status 39 XI. Frequency D i s t r ibut ion of Years of Residence At Present Address 40 XII. Frequency D i s t r ibut ion For Number of Times Moved in Last 5 Years 41 XIII. Frequency D i s t r ibut ion for Farthest Move In Last Two Years 41 XIV. Frequency D i s t r ibut ion For Mobi l i ty Index 42 XV. Crosstabulation of Mobi l i ty Index By Reported Immunization Status of Chi ld 43 XVI. Analysis of the Number of Children in the Family By Chi ldren 's Reported Immunization Status 44 XVII. Family Income 45 v i i TABLE PAGE XVIII. Analysis of Family Income By Chi ldren ' s Reported Immunization Status 46 XIX. Frequency D i s t r ibut ion for Parental Immunization Status 47 XX. Frequency D i s t r ibut ion For Parent 's Dread Of Immunization as a Chi ld 48 XXI. Frequency D i s t r ibut ion for Ch i ld ' s Dread Of Immunization 48 XXII. Frequency D i s t r ibut ion for Responsibi l i ty For Immunization 49 XXIII. Analysis of Parental Att i tude Score By Chi ldren ' s Reported Immunization Status 50 XXIV. Crosstabulation of Own Immunization Status By Reported Immunization Status of Chi ld . . . 51 XXV. Crosstabulation of Responsib i l i ty for Immunization By Reported Immunization Status of Chi ld. . . . . 51 XXVI. Crosstabulation of Ch i ld ' s Dread of Immunization By Reported Immunization Status of Chi ld 52 XXVII. Analysis of Knowledge Score By Chi ldren ' s Reported Immunization Status 53 XXVIII. Terminal Factor Analysis - Varimax, Orthognal Rotation 55 XXIX. C l a s s i f i c a t i on Function For Stepwise Discriminant Analysis 56 XXX. Analysis of Deciding Person By Chi ldren ' s Reported Immunization Status 57 XXXI. Analysis of Feelings of Adequacy of Knowledge By Chi ldren ' s Reported Immunization Status 58 v i i i ACKNOWLEDGEMENTS I would l i k e to extend my sincere thanks to the many people whose generous support and encouragement made th i s study possible. In pa r t i cu l a r , I am indebted to Helen E l f e r t , my advisor, for her continued assistance and patience. I am grateful to the other members of my committee, the s t a f f of the Boundary Health Unit, and my t yp i s t , Dianne Thicke, for the i r cooperation and understanding. I also wish to thank Jack Yensen and the s t a f f at the computing centre for the i r patient introduction to the world of computers, and the many parents who con-sc ient ious ly completed and returned the questionnaire. F i na l l y , I wish to thank a l l those members of my family who so generously gave of the i r time to care for my ch i ld ren, and provide me with the love and encouragement needed to complete th i s task. i x 1 CHAPTER I INTRODUCTION TO THE STUDY INTRODUCTION At present, i t i s possible to immunize against and prevent many common childhood diseases. Despite t h i s , many chi ldren have an incomplete immunization status. They are, then, at r i sk f o r , or suffer from diseases which are preventable. Morbidity and mortal i ty from vaccine-preventable diseases continue. Interest in ch i ld ren ' s immunizations peaked during the United States po l iomyel i t i s vaccination t r i a l s in the mid 1950 1s. The over-whelming success of these t r i a l s , as well as the occasional f a i l u r e , was widely examined and publ ic ized.^ Following t h i s , despite the a v a i l a b i l i t y of other e f fect i ve immunizations, public and medical interest appeared to wane. The conquest of many childhood diseases was thought to be imminent. When the predicted eradication of these diseases did not occur, medical interest was rekindled; however, publ ic in teres t in many areas remained dormant. Unfortunately "advances in the technology of vaccine del ivery systems have lagged far behind the technology of developing new vaccines". Monroe Sirken, "National Par t i c ipat ion Trends 1955-61 in the Pol iomyel i t i s Vaccination Program", Publ ic Health Reports, Vol. 77, No. 8 (August, 1962) 661. 2 Herbert Schreier "On the Fai lure to Eradicate Measles" New  England Journal of Medicine Vol. 290, No. 14, ( A p r i l , 1974) 803. J . Witte, "Recent Advances in Publ ic Health", American Journal of Publ ic Health, Vol. 64 (1974) 939. 2 As a r e su l t , the development of improved del ivery systems i s needed -4 especia l ly for the young. Immunizations are provided for the preschool ch i l d in the Province of B r i t i s h Columbia at both private physicians ' o f f i ces and community health centres at no d i rect cost to the family. The schedule of immunizations i s prescribed by the B r i t i s h Columbia Government, Department of Health. Records are kept by the physician or health centre s t a f f as each immunization i s given. There i s , however, no central ized system for insuring that each preschool c h i l d ' s immunizations are kept up to date. That re spons ib i l i t y l i e s with the parents. They must ac t i ve ly comply with the prescribed immunization schedule in order to ensure maximum protection from disease for the i r c h i l d . Studies have demonstrated that a number of factors can influence th i s compliance. These include internal factors such as educational l e v e l , socio-economic status, knowledge, and att itudes as well as external factors such as family composi-5 t ion and mobi l i ty . When a ch i l d enters the school system, the publ ic health nurse examines each medical record and immunizes as necessary to complete the schedule. During the school years, immunizations are normally continued 4 Robert Markland and Douglas Durand, "An Investigation of Socio-Psychological Factors Af fect ing Infant Immunization" American Journal of  Public Health, Vol. 66, No. 2, (Feb, 1976) 168. 5 Carol D'Onofrio, Reaching Our Hard to Reach, State of Ca l i f o r n i a , Department of Public Health, (1966) 11-15. 3 by the nurse in the school. A growing concern has been expressed by publ ic health nurses regarding the incomplete immunization status of chi ldren entering school. THE PROBLEM Statement of the Problem This study was designed to discover the status of ch i ldren ' s immunizations and to determine the influence of selected factors on that status. The spec i f i c questions investigated in th i s study were: I. Are the recorded levels of preschool ch i ld ren ' s immunizations comparible to the national standard? II. Is there a difference between ch i ld ren ' s immunization status as reported by parents and as recorded in health unit s t a t i s t i c s ? I I I. Is there a re lat ionship between one or more of the selected internal or external factors and preschool ch i ld ren ' s reported immunization status? S ignif icance of the Problem The control of communicable diseases was the or ig ina l mandate for the creation of publ ic health services. Although today this scope has broadened great ly, the control of the spread of diseases i s s t i l l of primary concern. Therefore, as the numbers of chi ldren at r i sk r i se above acceptable l eve l s , the control of disease, the respons ib i l i t y of, and a major j u s t i f i c a t i o n for publ ic health serv ices, i s threatened. 4 Community health nurses, by v i r tu re of the i r role and number, are responsible for the implementation of the immunization program for those children who are not immunized by the i r pr ivate physician. Often pre-school immunization provides the only regular contact for young famil ies with the community health centre. During a v i s i t for immunizations the community health nurse may also provide developmental screening examinations for the ch i l d and problem-solving opportunit ies, ant ic ipatory guidance, and health teaching for the parent. In th is way immunizations are integrated with the ent i re preventative health program and provide an opportunity for regular nurse-parent interchange. Fai lure to seek immunization may jeopardize th i s opportunity. Despite the many advantages of seeking regular immunizations for the i r ch i ld ren, many parents do not. In th i s study, the factors inf luencing this compliance were examined. The results can then be used to develop health education programs to increase the ch i ld ren ' s level of immunization in the community. The i den t i f i c a t i on of famil ies at r i sk may help to define the emphasis and d i rect ion of these education programs, thereby ass i s t ing in the more e f f i c i e n t a l l ocat ion of nursing resources. For society as a whole, morbidity and mortal i ty from communicable disease has the great s ign i f icance of unnecessary loss of l i f e and increased medical costs. For the ind iv idual chi ldren and family, prevention of these diseases reduces the r i sk of needless suf fer ing, 5 disability, or death. In an ostensibly preventative health service, one of the major areas where primary prevention is essential, is that of assuring the optimal health of our children. ASSUMPTIONS OF THE STUDY 1. Properly given at the specified age and time intervals, immunizations are effective against the specific diseases for which they have been developed. 2. The standard set for the minimum level of immunization in a population that is necessary to control each childhood disease is effective. DEFINITIONS OF TERMS USED Attitude. An individual's organization of psychological processes, as representative of previous experience. In this study attitude toward immunizations is operationally defined as a composite score derived in response to items 22 to 27 on the questionnaire. Community Health Center. Center responsible for the administration of preventative health services in the community. Of primary concern to its multidisci piinary staff is the control of the spread of communicable disease. Also called the public health unit. Compliance. The act of following a medical prescription. For the purpose of this study the medical prescription is the British Columbia Government Infant Immunization Schedule. 6 Entry to the School System. Children usually aged 5 or 6 who are registered to begin Grade I for the f i r s t time at the commencement of the school year. Epidemic. The occurrence in a community of a disease in excess of normal expectancy, derived from a common source. Factors. Variables which influence an i nd i v i dua l ' s behaviour. For th is study, education, income, knowledge, and att i tude are considered internal and family composition and mobi l i ty are considered external. Family Composition. The number of chi ldren in the family and the re la t i ve pos it ion of the ch i l d in the study. Family Mobi l i ty Index. A composite score derived from the number of times a family has moved in the past f i ve years, the length of time at the present address, and the distances involved in each move. Immunization Status. The completeness of the prescribed immunization status for the age of the c h i l d . For th is study, immunization status is considered complete,if up-to-date for age, or incomplete i f not. Kindergarten. An optional class fo r young chi ldren the year before they begin Grade I. In the municipal ity studied kindergarten classes are offered as a part of the public school system. Knowledge. An indiv idual ' s range of information, awareness, or understanding of facts . In this study knowledge of immunizations i s operational ly defined as a composite score derived in response to items 13 to 20 on the questionnaire. 7 Preschool Ch i ld . A ch i l d between the ages of 15 months, when the i n i t i a l childhood immunization program should be completed, and entry to the school system (age 5 - 6 ) . Prescribed Immunizations Schedule. B.C. Government, Department of Health Immunization Schedule. It i s presented in Appendix C. Recorded Immunization Status. Immunizations received according to health unit records. Reported Immunization Status. The immunizations a ch i l d has received according to parental report. Vaccine-Preventable Diseases. The communicable diseases for which the Government of B r i t i s h Columbia offers routine immunization to chi ldren. They are Rubella, Rubeola, Po l i o , Diphtheria, Pertuss i s , and Tetanus. 8 LIMITATIONS OF THE STUDY 1. The study was l imi ted to a sample of kindergarten pre-schoolers and the i r parents in the munic ipa l i t ies of Surrey and White Rock, B r i t i s h Columbia. 2. The kindergartens chosen randomly for the study, were l imited by approval from the p r inc ipa l s . Of the 24 classes chosen, pr inc ipa l s of four schools refused permission. 3. Accuracy and completeness of the questionnaires were dependent upon parental cooperation and r e c a l l . 4. Recorded immunization status was l imi ted to those chi ldren who were immunized by the community health nurse. HYPOTHESES TESTED In re la t ion to Question I I I , the seven nul l hypotheses tested were: I There i s no re lat ionship between the reported immunization status of chi ldren and parental education. II There i s no relat ionship between the reported immunization status of chi ldren and family mobi l i ty. III There i s no re lat ionship between the reported immunization status of chi ldren and family composition. IV There i s no relat ionship between the reported immunization status of chi ldren and family socio-economic status. V There is no relat ionship between the reported immunization status of chi ldren and parental at t i tude toward immunization. 9 VI There i s no re lat ionship between the reported immunization status of children and parental knowledge of immunizations. VII There i s no relat ionship between the reported immunization status of chi ldren and two or more of the selected internal and external factors. OVERVIEW OF THE REMAINDER OF THE STUDY Chapter II contains a review of the l i t e r a t u r e under the fol lowing headings: Compliance with Medical Regimens, Factors I n f l u -encing Compliance, Immunization Status, and Immunization Standards. Chapter III deta i l s the design and methodology used in the study. Chapter IV contains an analysis of the data obtained in the study. Chapter V i s a summary of the findings of the study; the con-clusions arr ived at ; impl icat ions; and recommendations for further research. 10 CHAPTER II REVIEW OF THE LITERATURE The l i t e r a t u r e reviewed is presented under the fol lowing subject headings: 1. Compliance with Medical Regimens 2. Factors Influencing Compliance with Immunization Schedules A. Education of the Parents B. Socio-Economic Level of the Family C. Knowledge and Attitudes about Immunizations and the Communicable Diseases D. Family Composition E. Family Mobi l i ty 3. Immunization Status 4. Immunization Standards During the i n i t i a l search for relevant l i t e r a t u r e , the Medlar II Computer Service was u t i l i z e d . T i t l e s were retr ieved under the headings "Immunization and Quality of Health Care" and "Education on Immunization". COMPLIANCE WITH MEDICAL REGIMENS During the past century modern technology has evolved highly e f f e c t i v e , e f f i c i e n t medical regimens for the treatment and prevention of disease. Increasingly, the re spons ib i l i t y for seeking and maintaining these regimens rests with the publ ic. I t i s with some concern that health care workers have studied how well the publ ic have accepted th i s respon-s i b i l i t y by monitoring the i r compliance with medical recommendations and prescr ipt ions. 11 Few researchers have attempted to define a theoret ical frame-work to explain compliant behaviour with preventative health prescr ip-t ions. However, in 1967, Davis examined compliance with reference to the dissonance theory. He hypothesized that a medical prescr ipt ion exposes a person to information which may d i f f e r from ex i s t ing patterns of da i ly l i v i n g , tastes, and desires. This establishes a dissonant condi-t ion and a decision to comply (or not) resu l t s . In making this decision the patient attempts to establ ish an internal harmony, consistency, or congruity among his act ions, att itudes and values. This i s referred to as a drive toward consonance among cogn i t i on sJ In a l a te r study, Davis established a set of assumptions upon which he based his compliance research. These included: a) that indiv iduals d i f f e r more or less in the i r personal character i s t ic s as they seek medical care; b) that these personal character i s t ic s are taken into account by the health care worker; c) that discussion and assessment of the prescr ipt ion occurs with other i n f l uen t i a l persons; d) that these influences interact with the personal character i s t ics and the nature of the prescr ipt ion, to produce patterns of compliance.2 ^Milton Davis, "Predict ing Non-Compliant Behaviour", Journal of  Health and Social Behaviour, Vol. 8, (Dec, 1967), 265. 2 Milton Davis, "Variat ions in Pat ients ' Compliance with Doctor's Advice: An Emperical Analysis of Patterns of Communication", American Journal of Public Health, Vol. 58, No. 2, (Feb, 1968), 274. 12 Davis and many others have used a wide range of methods to measure and co l l e c t the i r data. Marston, in her review of the current l i t e r a tu re on compliance, summarized the f i ve major methods that have been used to measure compliance, including drug excretion tes t s , p i l l counts, d i rec t observation, remaining under medical supervis ion, and fol low through of re fe r ra l s . She noted that the research sett ings for most of these studies were outpatient hospital c l i n i c s or physicians ' o f f i ce s . "Nearly a l l the research to date has been conducted by physicians or behavioural s c i en t i s t s . Problems of motivating es sent ia l l y well people to u t i l i z e preventa-t ive health measures and early diagnostic serv ices , . . . are appropriately of concern to nursing."3 The research has also revealed variat ions in the rate of com-p l i an t behaviour. Davis reported that the l i t e r a t u r e disclosed a non-compliancy range varying from 15 to 93 percent. "This wide range i s not surpr is ing when the var iety of populations, the various methods of data c o l l e c t i o n , and the d i f fe rent medical problems investigated are considered... Regardless of the d i f ferences, at least a th i rd of the patients in most studies f a i l e d to comply with doctor 's orders."4 The variables studied by each researcher also varied widely. Marston concluded from the l i t e r a t u r e that a c lear picture did not emerge concerning the determinant factors of compliance. She recommends that 3Mary-Vesta Marston, "Compliance with Medical Regimens" A Review of the L i t e r a tu re " , Nursing Research, Vol. 19, No. 4, 312. 4 Davis , op. c i t . (1968) 274. 13 future studies investigate the role of mult ip le variables simultaneously. "A better understanding of the roles of these variables i s needed in order 5 to know how best to a s s i s t patients in caring for t he i r own heal th. " FACTORS INFLUENCING COMPLIANCE A number of studies have focused on the patient character i s t i c s associated with compliance. Investigated were demographic, phys ica l , and psychological f a c t o r s . 6 ' 7 ' 8 ' 9 ' 1 0 ' ^ Both Mars ton and Davis, in the i r review, reported that much of the l i t e r a t u r e revealed incon-s i s tent resu l t s . "Therefore, i t i s only possible to cu l l some impressions 12 about which patient character i s t i c s influence non-complaint behaviour." 5 Marston, op. c i t . , 321. ^Mary-Vesta Marston, op. c i t . , 3 1 3 . 7 Mi l ton S. Davis, op. c i t . , 274. Milton S. Davis, "Predict ing Non Compliant Behaviour", Journal  of Health and Social Behaviour, Vol. 8, (Dec, 1967), 265. Martha C. Hardy, "Psychological Aspects of Ped i a t r i c s " , Journal  of Ped ia t r i c s , Vol. 48, (Jan, 1956), 104. ^°Caro1 D'Onofrio, Reaching Our Hard to Reach, State of C a l i f o r n i a , Department of Public Health, 1966. ^ W i l l i a m G. Mather et a l . , "Social and Economic Factors Related to Correction of School-Discovered Medical and Dental Defects", The  Pennsylvania Medical Journal , (Oct, 1974), 983. 1 2 Dav i s , op. c i t . , (1967), 275. 14 However, both reviewers were pr imar i ly concerned with research examining treatment oriented compliance. The major f indings exploring preventative-oriented compliance (espec ia l ly immunization) are presented in the fol lowing sections including education, socio-economic l e v e l , knowledge, a t t i tudes , family composition, and mobi l i ty . A. Education of the Parents The educational level attained by the parents, measured by the number of years of completed schooling, was a factor examined in many studies. Mather et a l . , in a project to determine factors inf luencing correct ive action fol lowing school health examinations, found education ranked second in s ign i f icance for medical problems and fourth for dental 13 problems. In contrast, Davis, in a study of l i f e s t y l e modification among farm-based cardiac pat ients, reported that tests of the s ign i f icance of the point correlat ions between f i f t een variables ( including education) and compliance showed that not a s ingle factor was s i g n i f i c an t l y 14 correlated with compliance. Marston's l i t e r a tu re review c i ted ten a r t i c l e s showing education having l i t t l e association with compliance, four a r t i c l e s demonstrating a s i gn i f i can t association and f i ve a r t i c l e s 15 re la t ing increased education to non-compliant behaviour. However, in Mather et a l . , op. c i t . , 983. 4 Dav i s , op. c i t . (1967), 275. 5 Marston, op. c i t . , 313. 15 the i r research related d i r e c t l y to immunization programs, Clausen, Me r r i l l et a l . , and D'Onofrio reported that educational level generally bears a d i rect re lat ionsh ip to immunization status. 1 6 J 7 J 8 A study done in Ca l i f o rn i a in 1956 determined that the mother's education was the single most important factor related to the immunization 19 status of her ch i ldren. However, in an e a r l i e r study Winkelstein et a l . found that in New York when parental education was correlated with socio-economic l e v e l , the education factor disappeared in the lower hal f 20 of the economic scale. "These var iat ions in the association of educa-t ion and vaccine acceptance, along with the observation of Clausen et a l . that marked differences in educational levels were associated with many differences in be l i e f and a t t i tude, indicate the need to look deeper into 21 the dynamics involved." ^ 6John A. Clausen et a l . , "Parent Attitudes Toward Par t i c ipa t ion of Their Children in Pol io Vaccine T r i a l s " , American Journal of Publ ic  Health, Vo l . 44, (Dec, 1954), 1526. ^Malcolm H. M e r r i l l , "Att itudes of Cal i fornians Toward Po l iomel i t i s Vaccinat ion", American Journal of Publ ic Health, Vol. 48, No. 2, (Feb, 1958), 146. 1 o D'Onofrio, op. c i t . , 12. 19 A.C. H o l l i s t e r et a l . , Ca l i f o rn ia Health Survey, Part I, State of Ca l i f o r n i a , Department of Publ ic Health, Berkley, Ca l i f o rn i a (1958). 20 Francis A. Ianni, "Age, Soc i a l , and Demographic Factors in Acceptance of Pol io Vaccinat ion", Publ ic Health Reports, Vol . 75, No. 6, (June, 1960), 545. ?1 D'Onofrio, op. c i t . , 12. 16 B. Socio-Economic Level of the Family The l i t e r a t u r e describing the influence of socio-economic status on compliance was equivocal. Marston's l i t e r a t u r e review stated "For the most part, socio-economic status has not been.found to be 22 related to compliance" (17 studies showed no re lat ionship and 8 studies showed a pos i t ive re lat ionsh ip ) . However, Davis c i ted seven studies 23 re lat ing a lower socio-economic status and non-compliance. Mather et a l . in a school based study found family income was ranked seventh 24 in importance for medical problems and f i r s t for dental problems. The l i t e r a t u r e concerned s p e c i f i c a l l y with immunization and socio-economic status i s more conclusive. Most studies demonstrated 22 Marston, op. c i t . , 317. 2 3 Dav i s , op. c i t . , (1968) 275. 2 4 Mather, op. c i t . , 983. 17 a consistent re lat ionship between socio-economic status and low immunization l e v e l s . 2 5 ' 2 6 ' 2 7 ' 2 8 , 2 9 ' 3 0 In the Ca l i f o rn i a study, H o l l i s t e r et a l . presented evidence that persons of lower socio-economic status had lower levels of immunization for po l i o , d iphther ia, pertuss i s , 31 and tetanus. D'Onofrio noted that: "Patterns of po l iomyel i t i s outbreaks before and af ter the advent of the pol io vaccines also dramatize socio-economic differences in immunization leve l s . P r io r to 1956, cases of pol io were scattered throughout a l l socio-economic areas, but a f te r th i s time, they were concentrated in the lower socio-economic areas, ind icat ing that the unimmunized i . e . susceptible populations were located there."32 2 5 M e r r i l l , op. c i t . , 146. Warren Winkelstein and Saxon Graham, "Factors in Par t i c ipat ion in the 1954 Po l iomyel i t i s Vaccine F ie ld T r i a l s , Erie County, New York" American Journal of Publ ic Health, Vol. 49, No. 11, 1454. Francis Ianni, et a l . , "Age, Soc i a l , and Demographic Factors in Acceptance of Pol io Vaccinat ion", Publ ic Health Reports, Vol . 75, No. 6, 545. Thomas Francis, "Symposium on Controlled Vaccine F ie ld T r i a l s Po l i omye l i t i s " , American Journal of Publ ic Health, Vo l . 47, (March 1957), 283. OO Robert Serf ! ing et a l . , "The CDC Quota Sampling Technic With Results of 1959 Po l iomyel i t i s Vaccination Surveys", American Journal of  Publ ic Health, Vol. 50, No. 11, 1847. Of ) R.E. Markland and D.E. Durand, "Appl icat ions and Implementation, Socio-Psychological Determinants of Infant Immunization", Decision Sciences, Vol. 6 (1957), 284. 31 H o l l i s t e r , op. c i t . 3 2 D ' 0 n o f r i o , op. c i t . , 1 1 . 18 C. Knowledge and Attitudes About Immunizations and Communicable Diseases Certain spec i f i c knowledge and att i tudes must be present for a person to seek immunization. According to Rosenstock: "He must perceive that he personally i s susceptible to the disease, that the i l l n e s s , i f contacted would be serious, and that the vaccine i s safe and e f fec t i ve 33 in reducing s u s cep t i b i l i t y and seriousness." D'Onofrio notes that knowledge about immunization does not insure that the indiv idual w i l l believe that the r i s k i s a personal one. However, she states that: "...we can s t i l l assume that the information he possesses on these points i s related to his att i tudes and be l ie f s about them, not only because what he knows helps shape his a t t i tudes , but also because his ex i s t ing att itudes influence what information f i l t e r s ~» through his perception and becomes 'knowledge' to him." The extent of th is perceived s u s cep t i b i l i t y to a disease was also described by Rosenstock. He noted that "...72 percent of the young adult sample believed that po l iomyel i t i s had been nearly brought under 35 con t ro l . " He hypothesized that these kinds of be l ie f s could reduce the pub l i c ' s fee l ing of s u s cep t i b i l i t y and create a l a i s s e z - f a i r e att i tude toward immunization. I.M. Rosenstock, "Why Pople Fa i l to Seek Polio Vaccinat ion", Public Health Reports, Vol . 74, No. 2, (Feb, 1959), 98. 0 D'Onofrio, op. c i t . , 20. 35 Rosenstock, op. c i t . 19 Other factors which may influence perceived s u s cep t i b i l i t y have been studied. These include incorrect knowledge of the immunization procedure e.g. mult iple versus s ingle i n jec t i ons , as well as the necessity oc of periodic boosters. Information about the seriousness of communicable diseases has been demonstrated to a f fect immunization behaviour. In 1954, Clausen, Sudenfeld, and Deasy, in a study of mothers of Grade 2 ch i ld ren , noted that more than f ou r - f i f t h s agreed that "more people worry about pol io than about 37 any other disease that s t r ikes ch i l d ren . " D'Onofrio suggested that th is accent on pol io may have served to de-emphasize the other communicable diseases. She also notes that the public att i tude toward the so-cal led childhood diseases as "something a l l kids get" and "nothing to worry about", combined with the lack of knowledge of the potential seriousness of these op diseases may adversely a f fect immunization behaviour. Att itudes toward immunization have been a recurring theme in the l i t e r a t u r e . The Ca l i f o rn i a Health Study determined that over 90 percent of the respondents had a favourable att i tude toward the immunization 39 of ch i ldren. D'Onofrio noted that most of the mothers studied agreed 3 6 D ' 0 n o f r i o , op. c i t . , 22. 37 Clausen et a l . , op. c i t . , 1526. 3 8 D ' 0 n o f r i o , op. c i t . , 24. OQ H o l l i s t e r , op. c i t . 20 that the i r chi ldren should receive immunization, but few could name 40 the diseases involved. Me r r i l l et a l . found that 81 percent of mothers questioned in Ca l i f o rn ia were in favour of pol io vaccines for the i r 41 ch i ldren. S imi lar results are recorded by Glasser in a nationwide 42 study. D. Family Composition The family frequently has an influence on the immunization status of i t s indiv idual members, according to the l i t e r a t u r e . Guthrie found that f i r s t born are more often immunized than are successive 43 ch i ldren. The Ca l i f o rn ia Health Survey concluded that fami l ies with . two chi ldren from 0 - 1 4 years of age were most often protected against po l io . Those households with larger numbers of chi ldren were less l i k e l y 44 to have been vaccinated. Markland and Durand found that parental age was also a factor , older age levels being associated with adequate immunization 40 D'Onofrio, op. c i t . , 25. 4 1 M e r r i l l , op. c i t . , 147. 42 Melvin Glasser, "A Study of the Public s Acceptance of the Salk Vaccine Program", American Journal of Public Health, (Feb, 1958) 144. 43 N. Guthrie, "Immunization Status of Two-Year-Old Infants in Memphis and Shelby County, Tennessee", Public Health Reports, Vo l . 98, No. 5, (May, 1963), 443. 44 H o l l i s t e r , op. c i t . 21 45 and younger age levels with inadequate immunization. This was in d i rect contrast to the findings of Guthrie who found the reverse to be t r u e . 4 6 The parent who makes the decision about taking a ch i l d for immunizations also i s reported to have an e f f ec t . Schonfield et a l . found that when the father i s involved in the decision i t i s more often 47 against immunization than when the mother alone decides. E. Family Mobi l i ty There i s l i t t l e mention of the e f fect of mobi l i ty on immuniza-t ion in the l i t e r a t u r e . However, a study done in 1973 which looked at Health Unit u t i l i z a t i o n in the Boundary area, indicated that 20.2 percent of the residents sampled had l i ved in the i r present home less than one year. 45 Markland, op. c i t . 46 Guthrie, op. c i t . , 446. 47 Jacob Schonfield et a l . , "Medical Att itudes and Practices of Parents Toward a Mass Tuberculin-Testing Program", American Journal  of Public Health, Vol . 53, No..5, (May, 1963), 772. When the years of residence were compared to the use of health unit 48 services the fol lowing was observed: USE OF HEALTH UNIT SERVICES ( in to ta l ) BY YEARS OF RESIDENCE Number of Times Used Percent Non Users Years of Residence Total Ni l Once Twice Three or More Times 1 . . . . 239 100 25 37 77 41.8 2 . . . . . 149 24 18 30 77 16.1 3 . . . . 130 17 18 20 75 13.1 4 . . . . 129 10 13 15 91 7.8 5 . . . . 123 8 20 8 87 6.5 6 . . . . 88 4 20 4 60 4.5 7 . . . . 313 17 52 26 218 5.4 9 . . . . 2 - 1 - 1 -Total 1,173 180 167 140 686 15.3 D'Onofrio discussed the e f fect of a high proportion of mobile famil ies in a community on immunization behaviour "...when an indiv idual changes his environment, he must pass through a process of physical and soc ia l adjustment to his new surroundings. The crux of th i s adjustment i s the integrat ion of the i n d i v i d -ual into a new social system... The greater the changes due to mobi l i ty and the more rapid and important the sh i f t s in socia l o r ienta t ion , the more d i f f i c u l t i t becomes for indiv iduals to know what to expect in t he i r new environment."49 Boundary Health Unit, U t i l i z a t i o n Survey, Special Report No. 141. Div is ion of V i t a l S t a t i s t i c s , Department of Health, Province of B r i t i s h Columbia, (1975). D'Onofrio, op. c i t . , 147. 23 According to D'Onofrio, th is socia l d i sor ientat ion resulted in sporadic or reduced contact with local health author i t ies and therefore reduced immunization leve l s . IMMUNIZATION STATUS The incidence of the common childhood communicable diseases i s a recorded s t a t i s t i c in most provinces and states. Best noted that in 1975, despite an immunization rate of 71.1 percent for the chi ldren entering school, there were 3,626 reported cases of measles in Ontario. As these figures represent only the number of cases reported b y physicians, Best states they represent ju s t the " t i p of the iceberg!" He notes that in 1974 the estimated cost of providing care for those hospita l ized in Ontario with acute measles was $227,576.00. In the same study the recorded immunization status of school enterers from 1972-75 for measles, 50 mumps and rubel la was as fo l lows: TABLE I IMMUNIZATION STATUS OF SCHOOL ENTERERS 1972-1975 YEAR Health Units Reporting MEASLES % of Total School Enterers MUMPS % of Total School Enterers RUBELLA % of Total School Enterers 1972 37 58.6 _ 19.8 1973 34 62.2 - 32.3 1974 37 65.9 - 41.6 1975 35 71.1 23.7 55.8 E.W. Best, "Measles, Mumps, and Rubella: Epidemiologic Considerations", Ontario Ministry of Health, 1976, 10. 24 The reported cases and rates of the same three diseases from 1972-75 51 were recorded as fol lows: TABLE II RATE OF MEASLES, MUMPS AND RUBELLA 1972-75 MEASLES MUMPS RUBELLA YEAR Cases Rate per Cases Rate per Cases Rate per 100,000 100,000 100,000 1972 899 12 3,035 39 675 9 1973 2,829 36 10,456 132 604 8 1974 4,333 54 12,526 155 2,600 32 1975 3,626 44 5,352 65 3,459 42 In Ottawa in 1972, Furesz assayed antibody levels in blood samples of school chi ldren aged s ix to nine. F i f t y - f i v e percent of the chi ldren studied had received l i v e virus vaccine for rubeola and 27 percent had received mumps vaccinations. S im i l a r l y , seventy-four percent were 52 susceptible to rube l la . Other Canadian studies have reported s im i la r resu l t s . ' Witte, of the Center for Disease Control , A t lanta , noted 55 that s im i la r trends are occurring in the United States. 5 1 i b i d C O J . Furesz "An Antibody Survey of Children in an Ottawa Public School" Canadian Journal of Publ ic Health, Vol. 64, (July/Aug, 1973), 401. C O A. Chagnon et a l . , "Rubella Antibody Studies in the Inhabitants of Montreal" Canadian Journal of Publ ic Health, Vol. 60, (Oct, 1969), 395. 54 Lee Bertram "The Percentage of School Enterers Having Received Immunization in the Borough of Etobicoke in 1972", Canadian Journal of Public Health, Vol. 65, (Jan/Feb, 1974), 41. 5 5 John Witte, "Current Status of Vaccine-Preventable Diseases," Postgraduate Medicine, Vol. 56, No. 4, (Oct, 1974), 55. 25 Reports of loca l i zed epidemics also occurred in the l i t e r a t u r e . 56 57 Measles outbreaks in Calgary in 1970 and in Winnipeg in 1973 are among those c i t ed . Most recently 23 chi ldren in Terrace, B.C. were found to be CO carr ie r s of d iphther ia. "In 1967, at the American Publ ic Health Association meeting in San Francisco, a paper was presented that announced the p o s s i b i l i t y of complete eradicat ion of measles by the end of that year. Six years l a te r and some 10 years a f te r the highly e f fec t i ve l i v e measles-virus vaccines were l icensed in the United States, we are s t i l l faced with a measles problem of epidemic proportions. There i s almost uniform agreement ' that measles i s s t i l l a problem because of a f a i l u r e to vaccinate chi ldren against the disease."69 6^ Agnes O-'Neil, "The Measles Epidemic in Calgary 1969-1970; the Protective Effect of a Vaccination for the Individual and the Community", Canadian Medical Association Journal, Vol. 105 (Oct 23, 1971), 819. 57 Percy Barsky, "Measles: Winnipeg, 1973", Canadian Medical  Association Journal, Vol . 110, (Apr i l 20, 1974), 931. 58 Der Hoi-Yin, "23 Terrace Chi ldren, Teacher Found Carr iers of Diphther ia", Vancouver Sun, Vol . 92, No. 17, (1978), A l . " He rbe r t Schreier, "On the Fa i lure to Eradicate Measles", The New. England Journal of Medicine, Vol . 290, No. 14, (Apr 4, 1974), 803. 26 IMMUNIZATION STANDARDS To control against epidemics of disease in a community, the United States Government Center for Disease Control reports an 85 per-60 cent immunization level in the population i s needed. The Canadian government advises s i m i l a r l y . SUMMARY The l i t e r a t u r e review included an invest igat ion of the major factors inf luencing compliance with immunization schedules and the current status of immunizations in Canada and the United States. The discrepancies between those factors which influence general medical compliance and those which influence preventative oriented compliance were noted. Controversy also ex i s t s concerning which factors d i r e c t l y influence immunizations. However, education, socio-economic l e v e l , a t t i tude , knowledge, family composition and mobi l i ty are c i ted most cons i stent ly. The l i t e r a t u r e revealed a tendency towards decreasing levels of immunization for a l l childhood diseases in both Canada and the United States. Several instances of l oca l i zed epidemics were noted. Chapter III contains the design and methodology of the study. Markland, op. c i t . , 284. 27 CHAPTER III DESIGN AND METHODOLOGY This chapter describes two major areas: the design of the study, including the set t ing and sample; and the methodology, including the measurement procedures, pretest, data c o l l e c t i o n , and an overview of the data analys is. THE DESIGN OF THE STUDY Exploratory Design There were three objectives for the study. The f i r s t was to compare ch i ld ren ' s immunization status with the national standards. The second was to compare the ch i ld ren ' s recorded immunization status with the i r reported immunization status. The l a s t was to discover the re lat ionsh ip between ch i ld ren ' s immunization status and selected internal and external factors. The design employed for the research was an exploratory one. A survey questionnaire was designed to determine i f a re lat ionsh ip existed amongst the variables inf luencing ch i ld ren ' s immunization status and to quantify parental knowledge of the i r ch i ld ren ' s immunizations. Information concerning the recorded status of ch i ld ren ' s immunizations was obtained using health unit records. 28 The Setting The sett ing was one health unit area whose boundaries included two munic ipa l i t ies adjacent to a large c i t y . These munic ipa l i t ies contained two school d i s t r i c t s . The population of th i s area in 1971 was 108 ,950J The socio-economic range was broad, including representation from a wide 2 range of ethnic groups and re l i g ions . The Subjects A sampling of the 5 to 6 year old preschool population was obtained using kindergarten classes in the area. Of the 49 classes (2,262 students), 24 classes were chosen to be studied using a table of random 3 numbers. However, in four cases, pr inc ipa l s refused permission to d i s t r i bu te the questionnaire. Twenty classes (537 students) part ic ipated in the study. The questionnaire was given to each ch i l d in the sample to be taken home, completed by a parent, and returned. The tota l number of subjects returning completed questionnaires by the deadline, was 376 (60.6 percent). Kindergarten students were chosen because of the ease of d i s t r i b u -t ion of the questionnaires in the classroom sett ing. The study was con-ducted in the spring, with the students entering Grade I the fol lowing September. As w e l l , by sampling kindergarten students, chi ldren who had been at r i sk for disease throughout the ent i re preschool age span were i den t i f i ed . Vancouver Census Tract Bu l l e t i n - 1971, S t a t i s t i c s Canada Series A and B (August, 1975). 2 I b i d . boundary Health Unit, Kindergarten Enrolment S t a t i s t i c s , 1976. 29 METHODOLOGY OF THE STUDY Measurement Procedures 4 The major source of data for the study was the questionnaire. This format was chosen because of the nature of the data to be co l lected and the large sample s i ze . Approximately nine minutes were needed to complete the questionnaire. Conf ident ia l i t y was assured in a covering 5 l e t t e r which also encouraged cooperation and noted health unit approval. Permission was granted by the d i s t r i c t superintendent of schools to approach the pr inc ipa l s of the chosen classes seeking approval fo r d i s t r i bu t i on of the questionnaire. Twenty of the twenty-four school pr inc ipa l s agreed to have the i r kindergarten teachers d i s t r ibute the questionnaires to each ch i l d . During the construction of the questionnaire, publ ic health nurses were asked to examine and ed i t items relevant to the hypotheses concerning knowledge and att itudes toward immunization. These items had been obtained from the l i t e r a t u r e . The nurses were then asked to submit o r ig ina l items to complete these sections. Of the four nurses s o l i c i t e d , three contributed items for inc lus ion. Other items were inferred from the l i t e r a t u r e , or evolved d i r ec t l y from a question or hypothesis. Each item was then assigned to match the question or hypothesis i t was designed to test . Table III presents the questions and hypotheses with the appropriate source of data. See Appendix A. See Appendix B. 30 TABLE III QUESTIONS AND HYPOTHESES WITH APPROPRIATE SOURCE OF DATA Question Number I II III Hypothesis I Hypothesis Topic Comparison to National Standards Source of Data Health Unit Records Recorded versus Reported Health Unit Records Status Questionnaire Item 21 II III IV V VI VII Family Educational Level Family Mobi l i ty Family Composition Family Socio-Economic Level Att i tude Toward Immuni zation Knowledge of Immunization Mult ip le Factors Questionnaire Items 10 and 11 Questionnaire Items •4, 5 and 6 Questionnaire Items 7 and 8 Questionnaire Item 12 Questionnaire Items 22, 23, 24, 25, 26, 27 and 28 Questionnaire Items 13, 14, 15, 16, 17, 18, 19, and 20 Questionnaire Items A l l of the above except Item 21 The questionnaire was constructed using a mult ip le choice format which i s appropriate for computer analysis. Where poss ib le, "I don ' t know" or "undecided" choices were given to l i m i t guessing. Those items which tested att i tudes were designed as three choices (agree, disagree, or undecided) rather than f i ve ( including the extras, strongly agree and strongly disagree) because of the d i f f i c u l t y in determining the exclusiveness of the extra choices. 31 Upon completion of the questionnaire, a panel of publ ic health nurses was asked to evaluate whether each item was appropriate and inc lus ive in re lat ion to i t s matched question or hypothesis. A pretest was also conducted on eight parents of preschool ch i ldren. These were a l l mothers who attended the health unit c l i n i c fo r immunization of the i r preschool chi ldren. The time taken to complete the questionnaire was noted. At the completion of the pretest each mother was interviewed by the researcher to determine the c l a r i t y of each item and to discuss any comments the mothers wished to make. The results of these interviews were used to reconstruct several of the test items. Health unit records were also used as a source of data. During the year, the health unit c le rk s , using the kindergarten class l i s t s , prepared a record of each c h i l d ' s immunization status from the health unit charts. These records would be used by the public health nurses to complete the ch i ld ren ' s immunizations during the summer and ensuing Grade I year. Overview of the Data Analysis The data analysis centered on the questions investigated and the hypotheses. The questionnaire was designed for analysis by computer using the S t a t i s t i c a l Package for the Social Sciences (SPSS) 6 and Stepwise Discriminant Analysis (UBC BMD07M).7 Frequency d i s t r ibut ions and cross-tabulations with immunization status, were performed for each of the Norman Nie et a l . , S t a t i s t i c a l Package for the Social Sciences, (McGraw H i l l Book Company, New York, (1975). 7Jason Halm, Stepwise Discriminant Analys is, Univers ity of B r i t i s h Columbia Computing Centre (UBC BMD07M), (1976). 32 selected factors: socio-economic l e v e l ; parental educational l e v e l ; knowledge of and att i tude toward immunization; family composition; and family mobi l i ty. A factor analysis was then performed to determine i f an underlying pattern of re lat ionship existed amongst the var iables. F ina l l y a discriminant analysis was performed to determine the s t a t i s t i c a l d ist inct iveness of a group of subjects with complete, versus incomplete, immunization. SUMMARY The parents of kindergarten students from 20 randomly selected classes completed a questionnaire on preschool immunizations. The questionnaire had been constructed using items submitted from a panel of publ ic health nurses and obtained from the l i t e r a t u r e . A pretest was conducted. Analysis of the test items included frequency d i s t r i bu t i on s , crosstabulations, factor analys i s , and discriminant analys is. Detai ls of the data analysis are contained in Chapter IV. 33 CHAPTER IV ANALYSIS OF THE DATA The analysis of the data was f a c i l i t a t e d by the use of a computer. Two programs were used; the S t a t i s t i c a l Package for the Social Sciences (SPSS) 1 and Stepwise Discriminant Analysis (UBC BMD07M).2 I n i t i a l l y , the basic d i s t r i bu t iona l character i s t i c s of each 3 variable were analyzed using the subprogram FREQUENCIES. This provided the researcher with a basic computer reference f i l e and a v a l i d i t y check to ensure that subsequent analysis was based on accurate input information. Relationships amongst the variables were then examined using 4 a contingency table analysis with subprogram CROSSTABS. Each var iable was tabulated as a function of the ch i ld ren ' s reported immunization status. A level of confidence of 0.01 was used to establ i sh s t a t i s t i c a l s ign i f icance. Following t h i s , a factor analysis was done to determine i f there was an underlying pattern of relat ionships amongst the var iables. Sub-program FACTOR was used to reduce the number of s i gn i f i c an t var iables. 1 Nie et a l . , op. c i t . ? Halm, op. c i t . 3 Nie et a l . , op. c i t . , 181. 4 I b i d , 218. 5 I b i d , 468. 34 Last ly a stepwise discriminant ana l y s i s 6 was used to s t a t i s t i -c a l l y d i st inguish between the two groups; those i n which ch i ld ren ' s immunization were complete and those in which they were not. Results of the data analysis are presented below, focusing on the s pec i f i c questions invest igated, with a discussion of addit ional data fol lowing. ANALYSIS RELATED TO THE SPECIFIC QUESTIONS INVESTIGATED Analysis Related to Question I Question I examined the level of preschool ch i ld ren ' s immunizations using data obtained from the health unit records. Table IV shows the recorded immunization status of a l l of the preschool chi ldren registered in kindergarten, compared to the national standard. The mean for the three immunizations was 48.9 percent complete. When compared to the national standard the mean difference for the three immunizations was 36 percent. TABLE IV CHILDREN'S RECORDED IMMUNIZATION STATUS COMPARED TO NATIONAL STANDARD N = 2262 Immunization Percent Immunized National Standard (Percent) Percent Difference D.P.T. 50.0 85 35 Po l i o , oral 49.8 85 35 Rubeola 46.9 85 38 Mean 48.9 85 36 Halm, op. c i t . , 1. 35 Data Analysis Related to Question II Question II examined the difference between the recorded and reported ch i ld ren ' s immunization status. Data for the reported immunization status were co l lected in two modes. F i r s t l y , respondents were asked to report whether the i r c h i l d ' s immunizations were complete, incomplete, or unknown. This i s referred to in the remainder of the study as the ch i ld ren ' s reported immunization status. Secondly, respondents were asked to i dent i f y those diseases for which the i r ch i l d needed immunization. This i s referred to as the d isease-speci f ic reported immunization status. Data for the recorded immunization status were obtained from health unit records of a l l kindergarten students. When the d i sease-spec i f ic reported immunization status was compared to the recorded status from health unit records, there was a mean percent difference of 39.7 as shown in Table V. Rubeola, the least complete immunization according to the records (46.9 percent), was reported by the respondents as the most complete (89.9 percent). Rubeola, therefore had the largest percent difference (43.0 percent). Only 18 respondents reported immunizations lacking for a l l four diseases. T A B L E v DISEASE-SPECIFIC RECORDED VERSUS REPORTED IMMUNIZATION STATUS Immunization Recorded Completeness of Immunization N = 2262* Number Percent Reported Completeness of Immunization N = 376 Number Percent Percent Difference D.P.T. 1132 50.0 332 88.5 38.5 Pol io 1126 49.8 329 87.5 37.7 Rubeola 1061 46.9 338 89.9 43.0 Mean 1106 48.9 333 88.6 39.7 *Note: The recorded immunization status sample includes a l l the kindergarten chi ldren on health unit record. The reported immunization status i s a sample drawn from a l l kindergarten students including those immunized by the i r family physicians. 36 Table VI, a frequency d i s t r i bu t i on for ch i ld ren ' s reported immunization status, shows that 70.5 percent of the respondents sampled, believed the i r ch i ld ren ' s immunizations to be up-to-date. As w e l l , 21.0 percent of the mothers responded that the i r ch i ld ren ' s immunizations were incomplete. TABLE VI FREQUENCY DISTRIBUTION FOR CHILDREN'S REPORTED IMMUNIZATION STATUS Category Label Absolute Frequency Relative Frequency (Percent) Complete 265 70.5 Incomplete 79 21.0 Unknown 24 6.4 Missing Data 8 2.1 Total 376 100.0 Data Analysis Related to Question III Question III sought to determine i f a re lat ionsh ip existed between one or more of the selected internal and external factors and preschool ch i ld ren ' s immunization status. The results are presented focusing on acceptance or reject ion of the seven hypotheses related to th i s question. Data Analysis Related to Hypothesis I Hypothesis I stated that there i s no re lat ionsh ip between the reported immunization status of chi ldren and parental education. Tables VII and VIII show frequency d i s t r ibut ions for mothers' and fathers ' educational leve l s . TABLE VII FREQUENCY DISTRIBUTION FOR MOTHERS' EDUCATIONAL LEVEL Category Label Absolute Frequency Relative Frequency (Percent) Grade 10 or Less 89 23.7 Grade Twelve 155 41.2 Tech or Voc 71 18.9 Some Univers ity 29 7.7 College Grad 21 5.6 Missing Data 11 2.9 Total 376 100.0 TABLE VIII FREQUENCY FATHERS' DISTRIBUTION FOR EDUCATIONAL LEVEL Category Label Absolute Frequency Relative Frequency (Percent) Grade 10 or Less 98 26.1 Grade Twelve 101 26.9 Tech or Voc 94 25.0 Some Univers ity 37 9.8 College Grad 29 7.7 Missing Data 17 4.5 Total 376 100.0 38 The mothers' and fathers ' educational levels were compared to reported immunization status. The results are presented as a contingency table analysis in Tables IX and X respect ively. A chi-square test of s t a t i s t i c a l s i gn i f i cance, to determine whether a systematic re lat ionship existed between mothers' education and ch i ld ren ' s reported immunization status, y ie lded a raw chi-square of 13.89151 with 8 degrees of freedom and a s ign i f icance of 0.0846. The same s t a t i s t i c a l procedures applied to the fathers ' educational l e v e l , resulted in a raw chi-square of 19.34769 with 8 degrees of freedom and a s ign i f icance of 0.0131. TABLE IX ANALYSIS OF MOTHERS' EDUCATIONAL LEVEL BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 360 Immunization Status Mothers' Educational Level Complete Incomplete Unknown Raw Total (Percent) Grade 10 or less 57 20 11 88 (24.4%) Grade 12 112 31 10 153 (42.5%) Tech or Vocational School 49 19 1 69 (19.2%) Some Univers ity 23 6 0 29 (8.1%) Univers ity Graduate 18 2 1 21 (5.8%) Column Total (Percent) 259 (71.9%) 78 (21.7%) 23 (6.4%) 360 (100%) Raw Chi-Square = 13.89151 with 8 degrees of freedom. Signif icance = 0.0846 39 TABLE X ANALYSIS OF FATHERS' EDUCATIONAL LEVEL BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 354 Immunization Status Fathers' Educational Level Complete Incomplete Unknown Row Total (Percent) Grade 10 or Less 69 17 12 98 (27.7%) Grade 12 68 28 5 101 (28.5%) Tech or Vocational School 63 23 4 90 (25.4%) Some Univers ity 29 7 0 36 (10.2%) University Graduate 27 1 1 29 (8.2%) Column Total (Percent) 256 (72.3%) 76 (21.5%) 22 (6.2%) 354 (100.0%) Raw Chi-Square = 19.34769 with 8 degrees of freedom. S ignif icance - 0.0131 On the basis of these f indings, the nu l l hypothesis was accepted. Data Analysis Related to Hypothesis II Hypothesis II stated that there i s no re lat ionsh ip between ch i ld ren ' s reported immunization status and family mobi l i ty . The questionnaire items concerning family mobi l i ty s o l i c i t e d informa-t ion about the number of years the family had resided at the i r present address (Table XI), the number of times the family had moved in the past f i ve years (Table XI I ) , and the farthest move (Table XI I I ). A mobi l i ty index 40 composite was formed by amalgamation of these three items. The choices for each item were ranked from 1 to 5, according to increasing mobi l i ty . These rankings are included on the questionnaire in Appendix A. A tota l score was computed ranging from 3 (did not move) to 15. Scores from 3 to 7 were c l a s s i f i e d as low mob i l i t y ; 8 to 11, medium mob i l i t y ; and 12 to 15, high mobi l i ty . The frequency d i s t r i bu t i on of th i s composite i s presented in TABLE XIV. TABLE XI FREQUENCY DISTRIBUTION OF YEARS OF RESIDENCE AT PRESENT ADDRESS Category Label Absolute Frequency Relative Frequency (Percent) Less than 1 Year Between 1 - 2 Years Between 2 - 3 Years Between 3 - 4 Years More Than 4 Years Missing Data Total 77 61 55 45 134 4 376 20.5 16.2 14.6 12.0 35.6 1.1 100.0 TABLE XII FREQUENCY DISTRIBUTION FOR NUMBER OF TIMES MOVED IN LAST 5 YEARS Category Label Absolute Frequency Relative Frequency (Percent) Once 98 26.1 Twi ce 69 18.4 Three Times 47 12.5 4 or More Times 42 11.2 Never 114 30.3 Missing Data 6 1.6 Total 376 100.0 TABLE XIII FREQUENCY DISTRIBUTION FOR FARTHEST MOVE IN LAST TWO YEARS Category Label Absolute Frequency Relative Frequency (Percent) From Lower Mainland 150 39.9 From Elsewhere in B.C. 14 3.7 From Another Province 29 7.7 From Outside Canada 9 2.4 Have Not Moved 160 42.6 Missing Data 14 3.7 Total 376 100.0 42 TABLE XIV FREQUENCY DISTRIBUTION FOR MOBILITY INDEX Category Label Absolute Frequency Relative Frequency (Percent) Low 139 37.0 Medium 152 40.4 High 77 20.5 Missing Data 8 2.1 Total 376 100.0 S l i gh t l y more than one-half (51.3 percent) of the fami l ies had l i ved in the i r present homes less than three years, while 20.7 percent had resided there less than one year. When questioned about the number of times the family had moved in the past f i ve years, 42.1 percent reported moving two or more times. In the previous two years, 55.8 percent of the fami l ies had moved, 41.4 percent from the lower mainland and 13.8 percent from elsewhere. When a contingency table analysis between the mobi l i ty index and ch i ld ren ' s reported immunization status was performed, the raw chi-square was 3.25306 with 4 degrees of freedom and a s ign i f icance of 0.5164 (Table XV). Analysis of the three component items of the mobi l i ty index by reported immunization status y ielded s im i l a r levels of s i gn i f i c ance . 7 On the basis of these f indings, the nul l hypothesis was accepted. TABLE XV CROSSTABULATION OF MOBILITY INDEX BY REPORTED IMMUNIZATION STATUS OF CHILD Immunization Status Mobi l i ty Index Complete Incomplete Unknown Row Total (Percent) Low 104 26 8 138 (38.1) Medi urn 111 31 9 151 (41.7) High 47 19 7 73 (20.2) Column Total (Percent) 262 (72.4%) 76 (21.0%) 24 (6.6%) 362 (100.0%) Raw Chi-Square = 3.25306 with 4 degrees of freedom. Signif icance = 0.5164 (a) Years at Present Address by Reported Immunization Status. Chi-Square - 5.24998, 8 degrees of freedom and s ign i f icance of 0.7306 (b) Farthest Move By Reported Immunization Status. Chi-Square-4.49941, 8 degrees of freedom, and s ign i f icance of 0.8095 (c) Number of Times Moved by Reported Immunization Status. Chi-Square - 11.39023 with 8 degrees of freedom and s ign i f icance of 0.1806. 44 Data Analysis Related to Hypothesis III Hypothesis III states that there i s no re lat ionsh ip between the reported immunization status of chi ldren and family composition. The family composition was studied under two items on the question-naire; the number of chi ldren in the family, and the pos it ion in the family of the ch i l d studied. The mean number of chi ldren in these fami l ies was 2.469 with a standard deviation of 0.878. The questionnaire was brought home by the eldest ch i l d in 46.0 percent of the fami l i e s . Table XVI presenfe the results of a crosstabulation of the number of chi ldren in the family by reported immunization status. TABLE XVI ANALYSIS OF THE NUMBER OF CHILDREN ..IN THE FAMILY BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 367 Immunization Status Number of Children Complete Incomplete Unknown Row Total (Percent) 1 x 17 8 2 27 (7.4%) 2 145 41 11 197 (53.7%) 3 82 17 4 103 (28.1%) 4 14 8 5 27 (7.4%) 5 or more 7 4 2 13 (3.5%) Column Total (Percent) 265 (72.2%) 78 (21.3%) 24 (6.5%) 367 (100.0%) Raw Chi-Square = 15.65569 with 8 degrees of freedom. S ignif icance = 0.0476 45 When a contingency table analysis was performed on the pos i t ion in the family of the ch i l d in the study by reported immunization status the s ign i f icance of the chi-square was 0.4511. On the basis of the s ign i f icance establ ished, the nul l hypothesis was accepted. Data Analysis Related to Hypothesis IV Hypothesis IV states that there i s no re lat ionsh ip between the immunization status of chi ldren and family socio-economic status. Table XVII shows the income level of the fami l ies sampled. TABLE XVII FAMILY INCOME Category Label Absolute Frequency Relative Frequency (Percent) Less Than $5,000 8 2.1 $5,000 To $10,000 33 8.8 $10,000 To $15,000 88 23.4 $15,000 To $20,000 122 32.4 More Than $20,000 69 18.4 Missing Data 56 14.9 Total 376 100.0 46 The average income of the famil ies sampled was in the $10,000 to $15,000 category. According to the Canada Census b u l l e t i n , in 1971 the g average income for a l l fami l ies in the area was $9,323. Just over 10 percent (10.9) of the famil ies sampled reported incomes of less than $10,000. Of the 376 famil ies who returned the questionnaire, 56 or 14.9 percent did not respond to the item concerning income. Table XVIII shows the results of a crosstabulation of family income by ch i ld ren ' s reported immunization status. The raw chi-square i s 14.15424 with 8 degrees of freedom and a s ign i f icance of 0.0778. TABLE XVIII ANALYSIS OF FAMILY INCOME BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 315 Family Income Immunization Status Complete Incomplete Unknown Row Total (Percent) Less than $5,000 3 3 . 2 8 (2.5%) $5,001 to $10,000 22 7 3 32 (10.2%) $10,001 to $15,000 64 21 3 88 (27.9%) $15,001 to $20,000 90 26 4 120 (38.1%) More Than $20,001 47 12 8 67 (21.3%) Column Total (Percent) 226 (71.7%) 69 (21.9%) 20 (6.3%) 315 (100.0%) Raw Chi-Square = 14.15424 with 8 degrees of freedom. S ignif icance = 0.0778 Vancouver Census Tract B u l l e t i n , S t a t i s t i c s Canada Series B (1971), 49. 47 Based on the f indings, the nul l hypothesis was accepted. Data Analysis Related to Hypothesis V Hypothesis V stated that there i s no re lat ionsh ip between the reported immunization status of chi ldren and parental at t i tude toward immunization. An at t i tude score was compiled using data from s ix items on the questionnaire. These items included; parental immunization status, recognized importance of immunization, preference of disease to immuni-za t ion , parental dread of immunization, c h i l d ' s dread of immunization, and acceptance of re spons ib i l i t y for immunization. Two of these items had pos i t ive att i tude response frequencies close to 90 percent (importance of immunizations - 88.6 percent and prefer disease to immunization - 89.6 percent). Tables XIX, XX, XXI and XXII present the frequencies for the other four items. TABLE XIX FREQUENCY DISTRIBUTION FOR PARENTAL IMMUNIZATION STATUS Immunization Status Absolute Frequency Relative Frequency (Percent) Complete 139 37.0 Incomplete 141 37.5 Unknown 86 22.9 Missing Data 10 2.7 376 100.0 48 A tota l of 60.4 percent of the respondents reported an incomplete or unknown immunization status. TABLE XX FREQUENCY DISTRIBUTION FOR PARENT'S DREAD OF IMMUNIZATION AS A CHILD Dreaded Immunization Absolute Relative Frequency Frequency (Percent) Agree 135 35.9 Disagree 196 52.1 Undecided 33 8.8 Missing Data 12 3.2 Total 376 100.0 Of the parents responding, 35.9 percent expressed a dread of receiving immunizations as a c h i l d . TABLE XXI FREQUENCY DISTRIBUTION FOR CHILD'S DREAD OF IMMUNIZATION Dreads Immunization Absolute Frequency Relative Frequency (Percent) Agree Disagree Undecided Missing Data Total 85 230 45 16 376 22.6 61.2 12.0 4.3 100.0 49 When questioned about the i r ch i ld ren, 22.6 percent of the parents thought the i r chi ldren dreaded getting immunizations. TABLE XXII FREOUENCY DISTRIBUTION FOR RESPONSIBILITY FOR IMMUNIZATION Nurse and School Responsible Absolute Frequency Relative Frequency (Percent) Agree 114 30.3 Disagree 201 53.5 Undecided 53 14.1 Missing Data 8 2.1 Total 376 100.0 S l i g h t l y less than half (44.4 percent) of the parents were undecided or f e l t that the school and public health nurse should be responsible for the i r ch i ld ren ' s immunizations. A composite att i tude score was tabulated as a function of the number of items in which the parent chose the response ind icat i ve of a pos i t ive att i tude toward immunization. Two points were assigned for each pos i t ive response, one point for each undecided response, and zero points for each negative response. For the s ix items, scores ranged from zero to twelve. Because two of the items were answered pos i t i ve l y by an overwhelming majority (approximately 90 percent) of respondents, the att i tude score was adjusted s l i g h t l y to accommodate this s lant. As a re su l t , at t i tude scores from 0 to 4 were c la s s i fed low; 5 to 8, medium; and 9 to 12, high. 50 A contingency table analysis of att i tude score by reported immunization status i s presented in Table XXIII. A raw chi-square of 26.15884 with 4 degrees of freedom, and a s ign i f icance of 0.0000 were establ ished. Therefore, a more pos i t ive parental att i tude score i s associated with parental reports of a more complete immunization status. TABLE XXIII ANALYSIS OF PARENTAL ATTITUDE SCORE BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 368 Att i tude Score Complete Immunization Status Incomplete Unknown Row Total (Percent) Low 35 5 10 50 (13.6%) Medi urn 126 51 11 188 (51.1%) High 104 23 3 130 (35.3%) Column Total (Percent) 265 (72.0%) 79 (21.5%) 24 (6.5%) 368 (100.0%) Raw Chi-Square = 26.15884 with 4 degrees of freedom. S ignif icance = 0.0000. Two of the s ix variables which made up the composite att i tude score, were highly associated with ch i ld ren ' s reported immunization status. Raw c h i -squares were s i gn i f i c an t for parental immunization status, at a level of 0.0000, and for re spons ib i l i t y for immunization status, at a level of 0.0046. The chi-square of the c h i l d ' s fear of immunization by reported immunization status, was s i gn i f i can t at a level of 0.0341. Detai ls are presented in Tables XXIV, XXV, and XXVI. 51 TABLE XXIV CROSSTABULATION OF OWN IMMUNIZATION STATUS BY REPORTED IMMUNIZATION STATUS OF CHILD Chi ldren ' s Immunization Status Own Immunization Complete Incomplete Unknown Row Total (Percent) Complete 114 20 3 137 (37.6%) Incomplete 100 35 6 141 (38.7%) Unknown 48 24 14 86 (23.6%) Column Total (Percent) 262 (72.0%) 79 (21.7%) 23 (6.3%) 364 (100.0%) Raw Chi-Square S ignif icance = = 29.03819 with 4 degrees of freedom. 0.0000 TABLE XXV CROSSTABULATION OF RESPONSIBILITY FOR IMMUNIZATION BY REPORTED IMMUNIZATION STATUS OF CHILD Immunization Status Responsib i l i ty Complete Incomplete Unknown Row Total (Percent) Agree 77 20 14 111 (30.6%) Disagree 149 47 4 200 (55.1%) Undecided 36 11 5 52 (14.3%) Column Total (Percent) 262 (72.2%) 78 (21.5%) 23 (6.3%) 363 (100.0%) Raw Chi-Square = 15.05357 with 4 degrees of freedom. Signif icance = 0.0046 52 TABLE XXVI CROSSTABULATION OF CHILD'S DREAD OF IMMUNIZATION BY REPORTED IMMUNIZATION STATUS OF CHILD - Immunization Status Ch i ld ' s Dread Of Immunization Complete Incomplete Unknown Row Total (Percent) Agree 61 18 6 85 (23.9%) Disagree 169 49 10 228 (64.0%) Undecided 24 12 7 43 (12.1%) Column Total (Percent) 254 (71.3%) 79 (22.2%) 23 (6.5%) 356 (100.0%) Raw Chi-Square = 10.40747 with 4 degrees of freedom. S ignif icance = 0.0341 Therefore, a completed parental immunization status and parental acceptance of the re spons ib i l i t y for the i r ch i ld ren ' s immunizations are associated with reports of a more complete immunization status in the ch i l d . Based on these findings the nul l hypothesis was rejected. 53 Data Analysis Related To Hypothesis VI Hypothesis VI stated that there i s no re lat ionsh ip between the reported immunization status of chi ldren and parental knowledge of immuni zat ion. The composite knowledge score was tabulated using eight items from the questionnaire (13 through 20). One mark was assigned for each incorrect response. A composite score category of low, medium or high was formed as the inverse of the tota l of incorrect responses. Therefore, those respondents with the fewest errors scored a high knowledge score. There were 126 respondents coded high; 166 respondents coded medium; and 84 respondents coded low for knowledge score. Table XXVII presents a contingency table analysis of knowledge score by ch i ld ren ' s reported immunization status. The chi-square i s calculated to be 4.16580 with 4 degrees of freedom and s ign i f icance i s 0.3840. TABLE XXVII ANALYSIS OF KNOWLEDGE SCORE BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 368 Knowledge Score Immunization Status Complete Incomplete Unknown Row Total (Percent) High 92 28 5 125 (34.0%) Medium 117 35 10 162 (44.0%) Low 56 16 9 81 (22.0%) Column Total (Percent) 265 (72.0%) 79 (21.5%) 24 (6.5%) 368 (100.0%) Raw Chi-Square = 4.16580 with 4 degrees of freedom. S ignif icance = 0.3840 54 Based on these f ind ings, the nul l hypothesis was accepted. Data Analysis Related to Hypothesis VII Hypothesis VII stated that there i s no re lat ionsh ip between the reported immunization status of chi ldren and two or more of the factors of parental education, family mob i l i t y , family composition, family socio-economic status, parental att i tude and parental knowledge of immunization. A factor analysis was performed to determine i f an underlying pattern of relat ionships existed amongst the var iables. For th i s purpose a l l the var iab les , including the composite var iables, transiency index, att i tude score, and knowledge score, were entered to form the corre lat ion matrix. I n i t i a l l y a factor matrix using pr inc ipa l factor with i te rat ions (replacement of main diagonal elements with communalty estimates) to determine eigenvalues was done. Eigenvalues represent the amount of tota l variance accounted for by the var iable. The number of factor s , four, chosen for rotat ion was determined by the r e l a t i ve sizes of the eigenvalues. The f i n a l analysis was accomplished using a varimax ( s imp l i f i ca t i on of the columns of the matr ix) , orthogonal ( r ight angle) rotat ion to terminal factors. In the unrotated so lu t ion , every var iable i s accounted fo r by two s i gn i f i c an t common factors. However, the rotated solutions are conceptually simpler because they are accounted for by a s ingle s i gn i f i can t common factor. This terminal rotated solut ion i s presented in Table XXVIII. 55 TABLE XXVIII TERMINAL FACTOR ANALYSIS -VARIMAX, ORTHOGNAL ROTATION FACTOR I - MOBILITY Variables Mobi l i ty Index Composite Years at Present Address Farthest Move FACTOR II - EDUCATION - INCOME Variables Father 's Education Mother's Education Income FACTOR III - FAMILY COMPOSITION Variables Number of Children Pos it ion in Family FACTOR IV - ATTITUDE Variables Feel Have Adequate Knowledge Own Immunization Status Att i tude Score (Composite) Loadings 0.94959 0.87960 0.73410 Loadings 0.71728 0.65390 0.35204 Loadings 0.68209 0.62820 Loadings 0.62927 0.24329 0.14319 The factor analysis indicated that a re lat ionship existed amongst the var iables. The extracted factors of mob i l i t y , education - income, family composition, and at t i tude best accounted for the re lat ionsh ip amongst a l l the var iables. As w e l l , a discriminant analysis was used to determine the variables which contributed most to the d i f f e ren t i a t i on between incomplete and complete ch i ld ren ' s reported immunization status. The mathematical objective of the 56 discriminant analysis was to weigh and l i nea r l y combine the variables studied so that the groups with complete and incomplete immunization status were as s t a t i s t i c a l l y d i s t i n c t as possible. The stepwise procedure was used to detect those variables which, in combination, best accounted for the d i st inct iveness of each group. Table XXIX presents the results of the discriminant analys is. TABLE XXIX CLASSIFICATION FUNCTION FOR STEPWISE DISCRIMINANT ANALYSIS N = 228 Variable Immunization Status Complete Incomplete or Unknown Times Moved 2. 7547 2. 4603 Father 's Education 2. 0084 1. 7748 Own Immunization Status 2. 8040 3. 3914 Feel Have Adequate Knowledge 2. 2323 2. 5894 Constant -12. 527 -12. 700 Discriminant analysis i s a predict ive t oo l . The information gained in Table XXIX indicates that a c h i l d ' s immunization status i s more l i k e l y to be incomplete as reported by the parents when there i s : 1) high family mobi l i ty 2) a low educational leve l fo r the father 3) an incomplete parental immunization status 4) a fee l ing of lack of knowledge, in the parent, about immunizations. 57 As w e l l , ch i ld ren ' s immunization status i s more l i k e l y to be reported as complete when there i s : 1) low family mobi l i ty 2) a high level of education for the father 3) a completed parental immunization status 4) confidence of knowledge of immunizations by parent. On the basis of these f ind ings, the nul l hypothesis was rejected. ADDITIONAL DATA Two of the items on the questionnaire e l i c i t e d information which was not d i r e c t l y related to a hypothesis. The f i r s t of these determined who made the decision for the c h i l d to be taken for immunizations (item 9). The respondents reported the mother made the decision in 84.3 percent of the cases. Table XXX shows a contingency table analysis for the deciding person by ch i ld ren ' s reported immunization status. The raw chi-square was 10.04901 with 4 degrees of freedom and a s ign i f icance of 0.0396. TABLE XXX ANALYSIS OF DECIDING PERSON BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 366 Deciding Person(s) Immunization Status Complete Incomplete Unknown Row Total (Percent) Mother 226 66 19 311 (85.0%) Father 9 3 4 16 (4.4%) Mother and Father 29 9 1 39 (10.7%) Column Total (Percent) 264 (72.1%) 78 (21.3%) 24 (6.6%) 366 (100.0%) Raw Chi-Square = 10.04901 with 4 degrees of freedom. S ignif icance = 0.0396 58 The second item concerned the respondents' fee l ing about the adequacy of personal knowledge of immunizations (item 28). In responding, 53.7 percent f e l t t he i r knowledge was adequate, 21.8 percent f e l t i t was inadequate, and 21.8 percent were undecided. Contingency table analysis of feel ings of adequate knowledge by reported immunization status presented in Table XXXI, revealed a chi-square of 31.91490 with 4 degrees of freedom and a s ign i f icance of 0.0000. Therefore, a fee l ing of inadequate knowledge of immunizations i s associated with a more incomplete ch i ld ren ' s immunization status as reported by parents. TABLE XXXI ANALYSIS OF FEELINGS OF ADEQUACY OF KNOWLEDGE BY CHILDREN'S REPORTED IMMUNIZATION STATUS N = 361 Feel Adequate Knowledge? Complete Immunization Incomplete Status Unknown Row Total (Percent) Agree 163 34 3 200 (55.4%) Disagree 43 27 12 82 (22.7%) Undecided 53 18 8 79 (21.9%) Column Total (Percent) 259 (71.7%) 79 (21.9%) 23 (6.4%) 361 (100.0%) Raw chi-square = 31.91490 with 4 degrees of freedom. Signif icance = 0.0000. 59 SUMMARY Analysis of the data related to Question I revealed that there was a difference between the ch i ld ren ' s recorded immunization status and the national standards. When the data re la t ing to Question II was analyzed, a discrepancy was noted between the ch i ld ren ' s reported and the recorded immunization status. For Question I I I , analysis of the data re la t ing to Hypothesis I, I I , I I I , IV, and VI, demonstrated that there was not a s i gn i f i c an t re lat ionship between, parental educational l e v e l , family mobi l i ty , family socio-economic l e v e l , family composition, and parental knowledge of immunizations, and ch i ld ren ' s reported immunization status. Accordingly, these nul l hypotheses were accepted. The data re la t ing to Hypothesis V demonstrated a s i gn i f i can t re lat ionship between parental att i tude toward immunizations and ch i ld ren ' s reported immunization status. In accordance, the nu l l hypothesis was rejected. Analysis of the data re la t ing to Hypothesis VII indicated that a re lat ionship existed amongst two or more of the variables and reported immunization status. As a resu l t of these f ind ings, the nul l hypothesis was rejected. Analysis of the addit ional data indicated that no re lat ionsh ip existed between the deciding person and reported immunization status. However, a corre lat ion between parental feel ings of adequacy of knowledge of immunizations and reported immunization status was establ ished. A discussion and implications of these findings w i l l be presented in Chapter V. 6G CHAPTER V SUMMARY, DISCUSSION OF THE FINDINGS, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER RESEARCH SUMMARY This exploratory study was designed to determine the status of ch i ld ren ' s immunizations and to discover the influence of the selected internal and external factors on that status. The spec i f i c questions asked for the study were: I. Are the recorded levels of preschool ch i ld ren ' s immunizations comparible to the national standard? II. Is there a di f ference between ch i ld ren ' s immunization status as reported by parents and as recorded in health unit s t a t i s t i c s ? I I I . Is there a re lat ionsh ip between one or more of the selected internal or external factors and preschool ch i ld ren ' s immunization status? The fol lowing hypotheses were tested in re la t ion to Question I I I: I. There i s no re lat ionsh ip between the reported immunization status of preschool chi ldren and parental education. I I. There i s no re lat ionsh ip between the reported immunization status of preschool chi ldren and family mobi l i ty . I I I. There i s no re lat ionsh ip between the reported immunization status of preschool chi ldren and family composition. IV. There i s no re lat ionship between the reported immunization status of preschool chi ldren and family socio-economic status. 61 V. There i s no re lat ionsh ip between the reported immunization status of preschool chi ldren and parental att i tude towards immunization. VI. There i s no re lat ionsh ip between the reported immunization status of preschool chi ldren and parental knowledge towards immunization. VII. There i s no re lat ionsh ip between the reported immunization status of preschool chi ldren and two or more of the selected internal and external factors. The l i t e r a t u r e review included an invest igat ion of the major variables inf luencing compliance with immunization status and the current status of immunizations in Canada and the United States. The study was conducted in one suburban health un i t . The parents of kindergarten students from twenty classes completed a questionnaire on ch i ld ren ' s immunizations. The questionnaire had been constructed using items submitted from publ ic health nurses or inferred from the l i t e r a t u r e . A to ta l of 376 questionnaires was returned. The data were analyzed as fol lows: 1. The basic d i s t r i bu t i ona l character i s t i c s of each of the chosen variables were analyzed. 2. Each variable was tabulated as a function of the ch i ld ren ' s immunization status using a contingency table analysis. 3. A factor analysis was done to determine i f there was an underlying pattern of relat ionships amongst the var iables. 4. A discriminant analysis was used to s t a t i s t i c a l l y d ist inguish between those groups of chi ldren whose immunizations were reported to be complete and those whose were not. 62 The major findings of the study were: 1. There was a difference between preschool ch i ld ren ' s recorded immunization status, according to health unit s t a t i s t i c s , and the national standard. 2. There was a discrepancy between preschool ch i ld ren ' s immunization status as reported by parents and as recorded in health unit s t a t i s t i c s . 3. There was not a s i gn i f i can t re lat ionship between parental education leve l . fami ly mobi l i ty , family socio-economic l e v e l , family composition, or parental knowledge of immunizations and preschool ch i ld ren ' s reported immunization status. 4. There was a s i gn i f i c an t re lat ionsh ip between a pos i t i ve parental att i tude toward immunization and completed preschool ch i ld ren ' s reported immunization status. 5. There was a s i gn i f i can t re lat ionsh ip amongst the var iables. High family mobi l i ty , a low educational level for the father, an incomplete parental immunization status, and a fee l ing of lack of knowledge about immunizations were discriminatory for a reported incomplete immunization status. As well mob i l i ty , education-income, family composition and att i tude best accounted for the relat ionship amongst the variables on factor analys is. DISCUSSION OF THE FINDINGS The findings are discussed under the fol lowing headings: A. Recorded and Reported Immunization Status. B. Selected Internal and External Factors. C. Sources of Error. A. Reported and Recorded Immunization Status The data analysis revealed a mean difference of 36 percent between recorded levels of immunization and the national standards. This suggests not only that large numbers of chi ldren are at r i s k for preventable diseases, but also that health unit ch i l d health c l i n i c s are not being u t i l i z e d as f u l l y as possible. Results of the data analysis on the d i sease-spec i f ic reported immunization status indicated that most of the chi ldren were incomplete for one or two of the immunizations. This p a r t i a l l y complete status indicates the chi ldren and the i r parents have been in contact with the health unit (or doctor ' s o f f i ce ) on at least one occasion. When parents were asked to respond to the item on the immunization status of the i r ch i ld ren, a discrepancy occurred. A to ta l of 70.5 percent of parents responded that t he i r ch i ld ren ' s immunizations were complete (21 percent reported them as incomplete). However, when asked to i dent i f y those spec i f i c diseases for which the i r ch i ld ren ' s immunizations were incomplete, only 11.4 percent reported the missing immunizations. This discrepancy may have ar i sen, in part, from a f a i l u r e to understand the item. It should be noted that items with a contingency phrase ( i . e . i f the answer to " a " i s no, then please answer "b") are often misinterpreted. However, the discrepancy may also indicate that parents cannot r eca l l those spec i f i c diseases for which the i r ch i ld ren ' s immunizations are incomplete. In support o f . th i s argument, the results of items 13 and 14 indicate that only 21.3 percent of the respondents could cor rect ly ident i f y the diseases for which immunization i s offered in B.C. and those for which a s ingle immunization offers l i f e l ong protect ion. These items h ighl ight a general lack of knowledge about the spec i f i c diseases for which immunization is offered. This confusion may influence a parent 's a b i l i t y to r eca l l the d i sease-speci f ic immunization status of his or her ch i ldren. 64 There are a number of other reasons which might explain why parents cannot reca l l the status of the i r ch i ld ren ' s immunizations. Some of these include: 1. a lack of understanding of the immunization schedule 2. a f a i l u r e of nurses to communicate the appropriate immunization information to the parent 3. a time lapse problem i . e . the c h i l d ' s immunization status i s forgotten over the preschool years. Further research might provide more ins ight into th i s dimension of the study. B. The Selected Internal and External Factors Although both mother's and fa ther ' s educational level were not s i g n i f i c an t l y related to reported immuniation status, i t i s in terest ing that the discriminant analysis determined that the father ' s education contributed to the s t a t i s t i c a l d i s t inct iveness of the two groups (immunization complete or incomplete). Perhaps th i s i s a r e f l e c t i on of the male dominance of our North American fami l i e s . Further research i s indicated. Family mobi l i ty i s another var iable which, on contingency table analys i s , f a i l e d to reveal a s i gn i f i can t re lat ionship with reported immunization status. However, in the factor analys i s , Factor I, which accounts for the highest corre lat ion amongst the var iables, was mobi l i ty . 65 As w e l l , the discriminant analysis determined mobi l i ty was s i g n i f i c an t . Therefore, when the variables are examined in re la t ion to each other, mobi l i ty emerges as an important contr ibuting var iable although in i s o l a t i on i t i s not s i g n i f i c an t l y related to the ch i ld ren ' s reported immunization status. The reason that mobi l i ty i s a dominating influence was not examined in th i s study. However, i t may be that the process of adjustment and integrat ion into a new community causes a reor ientat ion period during which f am i l i e s ' p r i o r i t i e s become reorganized. Accordingly, many of the variables such as educational l e v e l , family s i ze , or att i tude toward immunization would be influenced. Further research i s indicated in th i s area. The high family mobi l i ty determined by the study may indicate the necessity for a re-examination of t rad i t i ona l methods of health education in our immunization program. Perhaps more emphasis on parental re spons ib i l i t y for t he i r ch i ld ren ' s immunizations i s necessary. Perhaps central computer records and not i f i ca t i on s systems would encourage more parents to keep the i r ch i ld ren ' s immunization up-to-date. Ef fort s should be made to create a del ivery system for ch i ld ren ' s immunizations which i s more responsive to the mobile factor in our society. . Family composition occurred as a s i gn i f i c an t var iable only in the factor analys is. This indicates that, although not i nd i v idua l l y related to reported immunization status, i t i s to some extent responsible for inf luencing the 66 other var iables. This is in d i rect contrast to the findings of the Ca l i fo rn ia Health Survey 1, in 1958, which reported a d i rect re lat ionship between family s ize and completed immunization status. Part of th i s discrepancy may be accounted for by the smaller mean family s ize (2.469 reported in th i s study) of today. Although there was no d i rect re lat ionship between income and reported immunization status, the sample may have been biased. Two of the four pr inc ipals who refused consent to d i s t r ibute the questionnaire, were from areas that reported the lowest incomes in the Canada Census of 1971. The average income of the fami l ies studied was,accordingly, higher than that reported in the census. There was a s i gn i f i cant re lat ionship between parental att i tude and reported immunization status. As w e l l , att i tude loaded highly on Factor IV in the factor analys i s , and one of the items from the composite att i tude score, was s i gn i f i can t in the discriminant analys is . These results indicate that att i tude i s an important component of the study of immunizations. The design of future health education campaigns should be directed toward att i tude change. The component of the composite att i tude score, which was s i gn i f i can t in the discriminant analysis was the parental immunization status. Perhaps parents who keep the i r own immunizations up-to-date are more l i k e l y to have a pos it ive att i tude toward immunization and, therefore, keep the i r ch i ld ren ' s immunizations up^to-date. H o l l i s t e r , op. c i t . 67 Parental knowledge was not s i gn i f i can t in any of the s t a t i s t i c a l analyses performed. However, when parents were asked to rate the adequacy of the i r knowledge of immunizations, only s l i g h t l y more than one-half f e l t the i r knowledge level was adequate. Furthermore, when th i s fee l ing of adequacy was compared to the reported immunization status i n the contingency table analys i s , in the factor ana lys i s , and in the discriminant analys i s , the results were s i gn i f i can t . These f indings ind icate that the actual knowledge score obtained by the parent does not influence ch i ld ren ' s reported immunization status. However, the feel ings the parents have about the state of the i r knowledge i s re lated. Perhaps the focus of our health education programs should be aimed not only d i r e c t l y at the del ivery of factual knowledge but also at increasing parental feel ings about the adequacy of t he i r knowledge. C. Sources of Error Kindergarten classes were used in th i s study to se lect a random sample of preschool students. The kindergarten reg i s t ra t ion in the spring of the study was 2,262 students. The fol lowing September, 2,270 students registered for Grade I. I t would appear that almost a l l preschool chi ldren attend kindergarten. Accordingly, sample representativeness was considered adequate for the study. The accuracy of the health unit records was not examined in th i s study. Since many of the immunizations were given 4 or 5 years ago, accuracy i s d i f f i c u l t to estab l i sh. However, accuracy could be established by blood antibody t i t r e l e ve l s , or by extrapolat ion, involv ing a study of accuracy in present record keeping systems. S im i l a r l y , the accuracy of the parental immunization status was not determined. Both of these inaccuracies represent possible sources of error. 68 Another factor may influence the accuracy of the recorded immunization status s t a t i s t i c . This concerns the a b i l i t y of the health unit record to accurately r e f l e c t the immunization status of those chi ldren who are immunized by the i r family physician or another health un i t . Although the health unit attempts to determine the status of the chi ldren immunized elsewhere, communications may not be consistently accurate or complete. R e l i a b i l i t y and v a l i d i t y are important considerations in the design of a study, in par t i cu la r with reference to a questionnaire. Because of the exploratory nature of the material and the fact that th i s questionnaire was designed for the project, i t i s d i f f i c u l t to assess i t s r e l i a b i l i t y . However, comparison with the Canada Census on income, education, and family s ize indicates the questionnaire was answered accurately by the respondents on these items. The internal consistency of the two part item on the status of the ch i ld ren ' s immunizations (item 21) i s a possible source of error. Further test ing i s needed to determine i f the discrepancy between reported immunization status and reported d isease-speci f ic immunization status results from the design of the item or i s an accurate re f l ec t i on of parental r e c a l l . The evidence from item 13 and 14 regarding knowledge of immunizations would support the l a t t e r . The questionnaire was designed with items from two sources. Public health nurses were asked to submit items to measure knowledge and a t t i tude . Other items were inferred d i r e c t l y from the l i t e r a t u r e . Following the pretest, another panel of two public health nurses was asked to assess each item. Further refinement of the questionnaire, using the results of 69 the item analysis from this study, might ensure v a l i d i t y . As w e l l , the a b i l i t y of the variables which emerged on discriminant analysis to predict immunization behaviour was not tested. Further study i s needed to assess the i r predict ive v a l i d i t y . Another possible source of error concerns the lack of the researcher 's control over the test ing s i tuat ion . Questionnaires were sent home to be completed. Directions did not indicate who should complete the questionnaire. Inaccuracies may have evolved i f the parent usually responsible for the c h i l d ' s immunization, did not complete the form. CONCLUSIONS The conclusions drawn as a resu l t of the study are: 1. The immunization status of preschool chi ldren as recorded in health unit records i s not s u f f i c i e n t l y complete to control the vaccine preventable c h i l d -hood diseases. 2. Preschool ch i ld ren ' s reported immunization status when not complete, i s usually only p a r t i a l l y incomplete. 3. Parental report of the i r preschool ch i ld ren ' s immunization status d i f f e r s from health unit records. 4. Parental educational l e v e l , family mobi l i ty , family composition, family socio-economic l e v e l , and parental knowledge of immunizations are not s i g n i f i c an t l y related to preschool ch i ld ren ' s reported immunization status. 5. Parental at t i tude toward immunization i s s i g n i f i c a n t l y related to preschool ch i ld ren ' s reported immunization status. 6. Parental immunization status i s s i g n i f i c an t l y related to preschool ch i ld ren ' s reported immunization status. 7. Parental feel ings of the adequacy of the i r knowledge of immunizations is s i g n i f i c an t l y related to preschool ch i ld ren ' s reported immunization status. 70 IMPLICATIONS FOR NURSING PRACTICE The immunization status of the preschool chi ldren as recorded in health unit records studied was not s u f f i c i e n t l y complete to control epidemics of the vaccine, preventable childhood diseases. The health un i t , through the community health nurses i s largely responsible for the administration of the immunization program. Therefore, the f indings of th i s study have the fol lowing implications for nursing pract ice: 1. Su f f i c i en t p r i o r i t y should be accorded to the infant immunization program to ensure that the immunization levels in the population approach the national standards. The present vaccine del ivery system i s f a i l i n g to ensure that our chi ldren are protected from the morbidity and mortal i ty of childhood diseases. 2. For the majority of ch i ld ren, t he i r immunization status i s only p a r t i a l l y incomplete. This means that the parents have been in contact with a health care worker about t he i r ch i ld ren ' s immunizations on at least one occasion. At th i s time nurses should ensure that parents know the i r ch i ld ren ' s immunization status and when succeeding immunizations are due. 3. Health education programs should be designed to emphasize the formation of a pos i t ive att i tude toward infant immunizations. 4. Families who are "at r i s k " for incomplete immunizations in the i r preschool chi ldren should be i den t i f i e d . Health education tac t i c s could then be directed towards these fami l ie s . 5. Ef forts should be made to ensure the accuracy and completeness of the health unit immunization records. RECOMMENDATIONS FOR FURTHER STUDY The recommendations for future study can be grouped into three sequences. The f i r s t involves expanding the results of the present study. This exploratory study examined the reported status of ch i ld ren ' s immunizations 71 and examined some of the variables inf luencing that status. A detai led analysis of the components of each of the var iab les , which was s i g n i f i c a n t l y related to immunization, should fol low. As w e l l , the predict ive a b i l i t y of the factors which emerged on discriminant analys i s , the cost of the morbidity and mortal i ty of the vaccine preventable diseases, or the extension of th is study to include older ch i ld ren, could be examined. The second sequence involves the creation and evaluation of relevant health education materials for immunizations. Using the results of th is study, media campaigns and other health education techniques could be evolved to influence the immunization practices of preschool ch i ld ren ' s parents. The effects of these health education campaigns could then be evaluated. The th i rd sequence of studies might involve the use of centra l ized computer services in the immunization program to improve the recorded s t a t i s t i c s and to develop a no t i f i c a t i on system. For example, the effectiveness of enclosing a computerized reminder for immunizations due with the family allowance cheque could be invest igated. BIBLIOGRAPHY A. BOOKS Kerl inger, F.N. Foundations of Behavioral Research. New York: Holt, Rinehart and Winston, Inc., 1964. Nie, N.H., Jenkins, J .G. , H u l l , C.H., Steinbrenner, K., and Bent, D.H. S t a t i s t i c a l Package for the Social Sciences. New York: McGraw H i l l Book Company, 1975. Treece, E.W. and Treece, J.W. Elements of Research in Nursing. Saint Louis: The C.V. Mosby Company, 1977. 73 B. PERIODICALS Annonymous, "V ictory over Smallpox." Nursing Mirror. (Apr i l 3, 1975) 39-41. Barsky, P. "Measles: Winnipeg, 1973" Canadian Medical Association Journal. Vol. 110 (Apr i l 20, 1974) 931-934. Bertram, L.I. "The Percentage of School Enterers Having Received Immunization in the Borough of Etobicoke.in 1972." Canadian Journal  of Publ ic Health. Vol. 65 (Jan/Feb 1974) 41-44. Breslow, L. and Somers, A.R. "The Lifetime Health Monitoring Program." The New England Journal of Medicine. Vo l . 296, No. 11, (March 17, 77) 601-606. Choynon, A., Davignon, L. and Pav i lon i s , V. "Rubella Antibody Studies in the Inhabitants of Montreal". Canadian Journal of Publ ic Health. Vol. 60. (Oct. 1969) 395-399. Clausen, J.A., Sudenfeld, M.A., and Deasy, L.C. "Parent Att itudes Toward,. Par t i c ipat ion of Their Children on Pol io Vaccine T r i a l s . American  Journal of Publ ic Health, Vol . 44 (Dec, 1954). 1526-1536. Cranston, L. "Communicable Diseases and Immunization." The Canadian Nurse. (Jan, 1976) 34-40. Daniels, A. "Don't Condem Your Chi ldren, Make Sure They're Immunized." The Vancouver Sun. (March 8, 1978). D2. Davis, M.S. "Var iat ions in Patients Compliance with Doctors' Advice: An Empirical Analysis of Patterns of Communication." American Journal of  Publ ic Health. Vol . 58, No. 2, (Feb, 1968) 274-285. Davis, M.S. "Predict ing Non-Compliant Behavior". Journal of Health and  Social Behavior. Vol . 8 (Dec 1967) 265-271. Fe inste in, A.R., Harrison, F.W., Epstein, J.A., Taranta, A., Simpson, R. and Tursky, E. "A Control led Study of Three Methods of Prophylaxis Against Streptococcal Infection in a Population of Rheumatic Chi ldren. " The New England Journal of Medicine. Vol . 260 #14 (Apr i l 2, 1959) 697-701. Francis, T:., "Symposium on Controlled Vaccine F ie ld T r i a l s " Po l i omye l i t i s " . American Journal of Publ ic Health. Vol. 47 (March 1957) 283-387. Furesz, J . "An Antibody Survey of Children in an Ottawa Publ ic School". Canadian Journal of Publ ic Health. Vol. 64 (July/August, 1973) 398-402. 74 Gee, L. and Sowell, R.F. "A School Immunization Law i s Successful in Texas". Public Health Reports. Vol . 90 No. 1, (January-February 1975) 21-24. Glasser, M.A. "A Study of the Pub l i c ' s Acceptance.of the Salk Vaccine Program." American Journal of Publ ic Health. Vo l . 48, No. 2 (Feb. 1958) 141-146. Granoff, D.M., Page. J.L. and Drachman, R.H."A Measles Outbreak and the Fa i lure to Obtain Immunization". Hopkins Medical Journal. Vol. 131 (October 1972) 281-286. Gutherie, N. "Immunization Status of Two-Year Old Infants in Memphis and Shelby County, Tennessee". Publ ic Health Reports. Vol . 98, No. 5, (May, 1963) 443-447. Guyer, B., Glondel ia, J.W., Bisno, A.L., Schoffner, W., Ray, R.B., Rendtorff, R.C., and Hutheson, R.H. "The Memphis State Univers ity Rubella Outbreak" Journal of American Medical Associat ion. Vol . 227, No. 11 (March 18, 1974) 1298-1300. Hardy, M.C."Psychologic Aspects of Ped iat r i c s " The Journal of Ped iat r i c s . Vol . 48 (Jan 1956) 104-114. Hastings, J.T. "Evaluation in Health Education". The Journal of School  Health. (Dec. 1970), 519-522. Hoekelmon, R.A. "What Constitutes Adequate Well-Baby Care?" Ped iat r ic s . Vol. 55. No. 3. (March 1975) 313-326. Hoi-Yin, D. "23 Terrace Chi ldren, Teacher Found Carr iers of Diphtheria". The Vancouver Sun. Vol . 92, No. 17 (1973) A l . Ianni, F.A., Albrecht, R.M., Bock, W.E. and Polon, A.K. "Age, Soc i a l , and Demographic Factors in Acceptance of Pol io Vaccinat ion". Publ ic Health Reports. Vol. 75. No. 6. (June 1960). 545-556. Kot ler, P. and Zaltman, G. "Social Marketing: An Approach to Planned Social Change." Journal of Marketing. Vol . 35 (Ju ly , 1971), 3-12. Lepow, M.L., Steele, F.M., Ross, M.R., and Randolf, M.F. "Measles Immunization Status in 1972 Among F i r s t and Second-Grade School Children i n Danbury, Connecticut". Ped iat r i c s . Vol. 55, No. 3, (March, 1975) 348-353. Levanthal, "Fear Appeals and Persuasion". The D i f fe rent ia t ion of a Motivational Construct". American Journal of Publ ic Health. Vol . 61 No. 6 (June 1971) 1208-1224. 75 Lovejoy, G.S., Giondel ia, J.W. and Hicks, M. "Successful Enforcement of an Immunization Law". Publ ic Health Reports. Vol. 89,No. 5 (Sept-Oct 1974) 456-458. Mackenzie, V.P. "Evaluating Family Planning Programs In a Canadian Context". Canadian Journal of Publ ic Health. Vol. 63 (May-June 1972) 228-236. Markland, R.E. and Durand, D.E., "Appl icat ions and Implementation" Decision  Sciences. Vol . 6 (1975) 284-297 r Markland, R.E., and Durand, D.E. "An Investigation of Socio-Psychological Factors Affect ing Infant Immunization" American Journal of Publ ic Health Vol. 66 No. 2 (February 1976) 168-170. Marston, M. "Compliance With Medical Regimens. A Review of the L i te ra tu re " . Nursing Research. Vol. 19, No. 4. (July-August 1970) 312-323. Mather, W.G., Whitman, L.B., Samson, A.D., and Ayers, M.E. "Social and Economic Factors Related to Correction of School-Discovered Medical and Dental Defects". The Pennsylvania Medical Journal. (Oct. 1954) 983-989. M e r r i l l , M.H., H o l l i s t e r , A.C., Gibbens, S.F., and Haynes, A.W. "Att itudes of Cal i fornians Toward Po l iomyel i t i s Vaccination". American Journal of  Publ ic Health. Vol. 48, No. 2. (Feb, 1958), 146-152. Nelson, K.E., K a l l i c k , C.A., Resnick, L., K a l l i c k , S., Gotoff, S.P., and Levin, S. "Current Strategy for Urban Measles Contro l " . Journal of  the American Medical Association. Vol. 227, No. 7 (Feb 18, 1974) 780-783. Nielsen, G.H. "A Project in Parent Education". Canadian Journal of Publ ic  Health. Vo l . 61 (May/June, 1970) 210-214. 0 ' N e i l , A.E. "The Measles Epidemic in Calgary 1969-70; The Protective Effect of Vaccination for the Individual and the Community". Canadian Medical  Association Journal. Vol. 105 (October 23, 1971) 819-825. Polk, L.D, "Less Measles - Really Down This Time?" C l i n i c a l Ped ia t r i c s . Vol. 14 No. 4 (Apr i l 1975) 321-322. Rosenstock, I.M. "Why People Fa i l to Seek Pol io Vaccinat ion". Publ ic Health Vol. 74, No. 2 (Feb, 1959) 98-102. 76 Sch i f f , G.M., Tinnemann, C.C., Shea, L., Witte, J . J . , Ackerman, J .H . , Stapleton, L., E l s i a , W.R., and Agna, M. " S i ro log i ca l Survey for Rubella and Measles Antibodies Among F i r s t Graders". Journal of the  American Medical Associat ion. Vol. 227, No. 1 (Jan 7, 1974) 49-52. Schonfield, J . , Schmidt, W.M., and S t e rn f i e l d , L. "Medical Att itudes and Practices of Parents Toward a Mass Tuberculin-Testing Program". American Journal of Publ ic Health. Vol. 53, No. 5, (May, 1963) 772-781. Schreier, H.A., "On the Fa i lure to Eradicate Measles". The New England  Journal of Medicine. Vol . 290, No. 14, (Apr i l 4, 1974) 803-804. Se r f l i n g , R.E., Corne l l , R.G. and Sherman I.L. "The COC Quota-Sampling Technic With Results of 1959 Poliomyelites Vaccination Surveys". American Journal of Publ ic Health. Vol. 50, No. 12 (December 1960) 1847-1857. Sirken, M.S. "National Pa r t i c ipat ion Trends 1955-61 in the Po l iomye l i t i s Program". Publ ic Health Reports. Vol. 77, No. 8 (August, 1962) 661-665. "Vancouver, Census Tract Bu l l e t i n - 1971, Series A". S t a t i s t i c s Canada. (May, 1973). "Vancouver, Census Tract Bu l l e t i n - 1971, Series B".. S t a t i s t i c s Canada. (August, 1974). Vernon, T.M., Conner, J .S. , Shaw, B.S., Lompe, J.M. and Doster, M.E. "An Evaluation of Three Techniques For Improving Immunization Levels i n Elementary Schools". American Journal of Publ ic Health. Vol. 66, No. 5 (May 1976) 457-460. Watts, D.D. "Factors Related to the Acceptance of Modern Medicine". American Journal of Publ ic Health. Vo l . 56, No. 8 (August 1966) 1205-1212. Winkelstein, W., and Graham, S. "Factors in Pa r t i c ipa t ion in the 1954 Po l iomyel i t i s Vaccine F ie ld T r i a l s , Er ic County, New York". American  Journal of Publ ic Health. Vol . 49, No. 11 (November, 1959) 1454-1466. Witte, J . J . "Current Status of Vaccine-Preventable Diseases". Postgraduate  Medicine. Vol. 56, No. 4 (Oct, 1974) 55-59. Ya rne l l , J . "Evaluation of Health Education: The Use of a Model of Preventive Health Behavior". Social Science and Medicine. Vo l . 10 393-398. 77 C. UNPUBLISHED WORKS Best, E.W.R., "Measles, Mumps, and Rubella: Epidemiologic Considerations". Unpublished Work. Ontario Min ist ry of Health (1975), (Mimeographed). "Boundary Health Unit U t i l i z a t i o n Survey, 1973". D iv i s ion of V i t a l S t a t i s t i c s . Dept. of Health, Province of B r i t i s h Columbia, 1975. (Mimeographed). Halm, J . Stepwise Discriminant Analys is. Univers ity of B r i t i s h Columbia Computing Centre (UBC BMD07M), 1976. H o l l i s t e r , A.C., Longshore W.A., Gibbens, S.F., Leslaw V., and Hausknecht. Ca l i f o rn i a Health Survey, 1956, Part I. State of C a l i f o r n i a , Department of Publ ic Health, Berkeley, Ca l i f o rn i a (1958). 78 APPENDICES APPENDIX A THE QUESTIONNAIRE WITH PERCENT FREQUENCY FOR EACH RESPONSE AND RANKINGS FOR ITEMS 4, 5 AND 6 INCLUDED 80 QUESTIONNAIRE 1. Ch i l d ' s Name 2. Father 's Name (Or Guardian)_ (Last Name) (Last Name) ( F i r s t Name) ( F i r s t Name) 3. Address Please place a • in the box beside the response which most c losely answers the question. 4. How long have you l i ved at your present address? 20.5 ( ) 1 year or less 16.2 ( ) between 1 - 2 years 14.6 ( ) between 2 - 3 years 12.0 ( ) between 3 - 4 years 35.6 ( ) more than 4 years 5. How many times have you moved in the past f i ve years? 26.1 ( ) once 18.4( ) twice 12.5 ( ) three times 11.2( ) four or more times 30.3 ( ) never 6. In the l a s t two years, which statement(s) best describes your move(s)? (One for each move). 39.9 ( ) moved here from somewhere else in the lower mainland 3.7 ( ) moved here from elsewhere in B.C. 7.7 ( ) moved here from another province 2.4 ( ) moved here from outside Canada 42.6 ( ) did not move 7. How many chi ldren are there in the family? 7.2 ( ) one 53.2 ( ) two 27.7 ( ) three 7.4 ( ) four 3.7 ( ) f i ve or more FOR OFFICE USE ONLY Rank 5 4 3 2 1 Rank 2 3 4 5 1 Rank 3 4 5 1 Was th i s questionnaire brought home by the eldest chi ld? 45.5 ( ) Yes 53.5 ( ) No 9. Who usually makes the decision to take th i s ch i l d for his or her immunization (shot)? 84.3 ( ) mother 4.3 ( ) father 0.0 ( ) babysitter 0.5 ( ) r e l a t i ve mother and 10.4 ( ) other (please specify) father 0.5 Doctor  10. What is the education of the mother of th i s family? 23.7 ( ) Grade 10 or less 41.2 ( ) Completed High School 18.9 ( ) Further education i f yes: 7.7 ( ) Technical School or Vocational School 5.6 ( ) University or College Graduated ( ) 11. What i s the education of the father of th is chi ld? 26.1 ( ) Grade 10 or less 26.9 ( ) Completed High School 25.0 ( ) Further education i f yes: 9.8 ( ) Technical School or Vocational School 7.7 ( ) Univers ity of College Graduated ( ) 12. Which category contains the 1976 net family income from a l l sources (wages, social assistance, unemployment insurance, etc.) 2.1 ( ) less than $5,000 8.8 ( ) $5,001 - $10,000 23.4 ( ) $10,001 - $15,000 32.4 ( ) $15,001 - $20,000 18.4 ( ) more than $20,000 13. Place a s / i n the box beside those diseases for which immunization i s offered in B r i t i s h Columbia. Item 13 & 14 ( ) Whooping Cough Total Number of Errors ( ) German Measles ( ) Diphtheria 0 - 21.3 percent 1 - 11.7 percent 2 - 2 1 . 0 percent 3 - 18.1 percent ( ) Tetanus ( ) Pol io ( ) Scar let Fever ( ) Smallpox ( ) Chickenpox ( ) Red Measles 14. Place a i n the box beside those diseases for which one in ject ion (shot) offers a l i f e l ong protect ion. 4 - 10.6 percent 5 or more - 15.7 percent missing 1.6 percent tota l 100 percent ( ) Whooping Cough ( ) German Measles ( ) Diphtheria ( ) Tetanus ( ) Pol io ( ) Scar let Fever ( ) Smallpox ( ) Chickenpox ( ) Red Measles 15. Pol io immunization i s given by mouth. 89.9 ( ) True 6.1 ( ) False 16. A ch i l d usually receives his or her f i r s t immunizations at the age of s i x months. 31.9 ( ) True 63.3 ( ) False 17. A Chi ld should be immunized while he i s not fee l ing well? 9.0 ( ) True 87.5 ( ) False 18. Immunizations given at the health unit are free. 92.8 ( ) True 4.0 ( ) False 19. For every 1,000 reported cases of measles there i s one measles death. 38.8( ) True 37.0( ) False 20. How many cases of measles were there in Canada l a s t year? 2.1( ) 2,000 or less 2.7( ) more than 2,000 but less than 5,000 5.9( ) more than 5,000 but less than 12,000 7.7( ) more than 12,000 74.5( ) I don ' t know 21. My c h i l d ' s immunizations are up to date. 70.5( ) Yes 21.0( ) No 6.4( ) I don ' t know I f the answer i s no, place a V beside any of the fo l lowing diseases f o r which your c h i l d needs immunization. 9.8( ) Red Measles 11.7( ) D iphther ia 13.6( ) German Measles 12.5( ) Po l io 22. My own immunizations are up to date. 37.0( ) Yes 37.5( ) No 22.9( ) I don ' t know 23. Immunization is one of the most important aspects of your c h i l d ' s health care. 88.6( ) Agree 1.9( ) Disagree 6.9( ) Undecided 24. I would rather my c h i l d take a chance on get t ing measles than be immunized. 3.2 ( ) Agree 89.6 ( ) Disagree 4.0 ( ) Undecided 25. I dreaded gett ing "shots" as a c h i l d . 35.9 ( ) Agree 52.1 ( ) Disagree 8.8 ( ) Undecided 26. My c h i l d dreads gett ing " shots " . 22.6 ( ) Agree 61.2 ( ) Disagree 12.0 ( ) Undecided 27. The Publ ic Health Nurse and the school should be responsib le fo r keeping school c h i l d r e n ' s immunizations up to date. 30.3 ( ) Agree 53.5 ( ) Disagree 14.1 ( ) Undecided 28. I f ee l I have adequate knowledge about immunizations. 53.7 ( ) Agree 21.8 ( ) Disagree 21.8 ( ) Undecided APPENDIX B THE COVERING LETTER APPENDIX C GOVERNMENT OF BRITISH COLUMBIA, DEPARTMENT OF HEALTH INFANT IMMUNIZATION SCHEDULE The immunization schedule for chi ldren as provided by the Province of B r i t i s h Columbia Health Department i$ as fo l lows: 3 months Pertuss i s , Diphtheria and Tetanus, combined. Oral Pol io (Sabin) 4 months Pertuss is , Diphtheria and Tetanus, combined. 5 months Pertuss i s , Diphtheria and Tetanus, combined. Oral Pol io (Sabin) 12 months Measles Vaccination 14 months Pertussis (whooping cough), Diphtheria and Tetanus, combined. Oral Pol io (Sabin) 15 months Rubella Vaccination 5 to 6 years Pertuss i s , Diphtheria and Tetanus or Diphtheria and Tetanus combined. Oral Pol io Gr. 5 - about 10 years Diphtheria, Tetanus, combined. Oral Pol io (Sabin) Gr. 10 - about 15 years Diphtheria, Tetanus, combined. Oral Pol io (Sabin) Adults - every Diphtheria, Tetanus, combined. Oral Pol io 5 years (Sabin) 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0094610/manifest

Comment

Related Items