Disparities in Children's Health Care:
Getting to Solutions
Reducing Immunization Disparities Study (RIDS):
A Project of PROS and NMAPedsNet
Pediatric Practice-based
Research Networks
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NMAPedsNet
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Paul Darden, MD
Medical University of South Carolina
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Pediatric Research in Office Settings
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25 June 2006
Pediatric Section of the NMA practicebased research network
Minority providers
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AAP Practice-based research network
Voluntary
~1,800 clinicians in ~600 practices
PIDS: Race and
Underimmunization
AA
Non-AA
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PIDS – Polio Immunization
Delivery Study
PROS & NMAPedsNet
68.4%
81.5%
Maternal
Education
P<.00001
RR for underimmunization (adjusting for maternal
education): 1.56 (95% CI 1.45,1.69)
Immunization
Rate AfricanAmerican
Immunization
Rate all others
OR (95% CI)
< high school
graduate
60.8%
72.5%
1.70 (1.28, 2.26)
High school
graduate
64.1%
77.6%
1.94 (1.56, 2.42)
Some college
72.6%
81.3%
1.63 (1.18, 2.27)
College graduate
77.6%
85.3%
1.68 (1.15, 2.43)
The National
Immunization Survey
1997-1999
PIDS Racial Disparity Conclusions
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Immunization Rate
In this group of children, cared for by primary care
pediatricians in US, AA patients significantly at risk for
underimmunization
Maternal
Education
Underimmunization not readily explained by: lack of access
to physician, SES, differences in race of provider and
patient, residence in inner city, parental perception of
barriers to obtaining vaccines, or parental preferences for
receiving needed immunizations at illness visit
Further research needed so that immunization needs of AA
children can be better met by health care delivery system
African-American
White
Hispanic
< high school
graduate
66.6%
72.1%
72.3%
High school
graduate
73.1%
77.7%
74.6%
Some college
74.4%
81.1%
75.3%
College graduate
78.3%
85.5%
79.2%
Bold, italic – different from White, P<.05
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Why should there be differences by race/ethnicity?
– from IOM Unequal Treatment
Office Systems
Provider prompts
Patient reminder and recall
Subject to ambiguity and
misunderstanding
Social Economic and
Cultural Influences
Financial Incentives
Institutional Design
Legal Environment
Cultural Influences
Patient Input
Medical History, Patient
Preferences
Interpretation
Subjectivity of
perception
Multiple diagnostic
alternatives
Intervention
Uncertainty with
respect to efficacy
Multiple treatment
alternatives
Racially disparate
clinical decisions
Data
Physical Exam,
Diagnostic Tests
Medical Records
Main Study Objective
Stereotyping
Prejudice
Conscious and unconscious
Conscious and unconscious
RIDS – Study Outline
Hypothesis generation
To determine if practice level interventions
can eliminate racial disparity in immunization
rates between African American (AA)
children and all other children
Intervention design
Piloting the interventions
To increase the likelihood that these
interventions will be both effective and
acceptable; parents, office staff and providers
will collaborate in their design.
Hypothesis Generation:
Focus Groups
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The objective of RIDS is to:
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Methods
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design and test interventions … that reduce the
disparity in immunization rates between AA
children and all other racial/ethnic groups.
The objective of the focus groups:
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Testing the interventions
To understand AA parent and pediatric office
staff perspectives of barriers to immunization
for AA children.
Facilitated discussion with providers
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PROS Coordinators
NMAPedsNet Steering Committee
Development of discussion guide
Focus groups
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4 practices, diverse geographically and SES
2
Provider Themes
Facilitated Discussion with
PROS and NMA PedsNet
Practitioners
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PROS
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NMAPedsNet
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Focus Groups - Subjects
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Parent mistrust of physicians & medical system
Decreased interest in preventive care (well child visits and
immunizations)
Practice limitations to provide flexible appointments and
reminders
Distrust of health care system
Concern about vaccine safety
Concern about pain and number of shots
Personal control of immunization
Extended family members (grandmother)
discouraging/controlling immunization
RIDS – Focus Groups
4 practices
Practice recruited subjects
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Parents
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African American
Children between 1 and 3 years
Mixed SES
Vocal
Prefer not completely immunized
Staff
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All staff invited to participate.
If too large a group, representative of nursing,
scheduling and administration.
Parent focus group – Household
income
Staff focus group – numbers
10
70%
60%
8
Staff
6
Nurse Asst
4
Nurse
2
< 20
50%
20-40
40%
41-75
30%
> 75
20%
don't know
10%
0
In 1,000s
0%
CA
FL
GA
MD
CA
FL
GA
MD
3
Parents
Providers
Distrust of the medical system but parents
trust their pediatrician
Distrust of health care system
RIDS
Intervention Design Meeting
Shots frequently delayed for minor illnesses Shots frequently delayed for minor illnesses
- Clinician suggested
- Parent suggested
Mothers make the decisions and direct
health care
Extended family members
discouraging/controlling immunization
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Illnesses prevented by vaccines are trivial
Baltimore, MD
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Young mothers don’t value prevention
including immunizations
Decreased interest in preventive care
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school & daycare immunization
requirements drive immunization
school & daycare immunization
requirements drive immunization
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Reminders are appreciated
Practice limitations to provide flexible
appointments and reminders
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Concern about vaccine safety
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Parents
Office staff
Nurses
Providers
Study staff
Concern about pain and number of shots
Personal control of immunization
RIDS – Pilot study
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6 practices
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Evaluate intervention materials
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4 PROS and 2 NMAPedsNet
Physicians
Office staff
Parents/patient
“The Cow Pock – or – the Wonderful Effects of the New Inoculation!”
J. Gillray, 1802
Pilot – Parent questionnaire
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How useful was the information on the poster to
you?
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Not useful
Somewhat useful
Very useful
Overall, what effect do you think that this poster
would have on parents in deciding whether or not to
immunize their children?
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No effect
Make parents less likely to immunize their children
Make parents more likely to immunize their children
RIDS Phase III
Outline of main study and issues: Initial
Immunization survey
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Data collected prior to any intervention
Consecutive survey of 60 children
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3-18 months old
seen by 1 practitioner in each office
Front office staff gets oral consent from
parent
Parental Study Questionnaire completed
4
Data collection
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Parental Study Form
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Race/ethnicity, maternal education, family income
Level of agreement with 6 statements about
immunizations
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Abstracted from practice medical record
Data entered by practices onto study web site or
photocopied and sent to PROS central
Interventions
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Dates of immunizations of study patients
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Outcomes
Based on themes developed during focus
groups
Designed for parents or practices
Pilot study conducted to assess
parental/practitioner response to content
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Delay in receiving immunizations based
on age at enrollment
Parental agreement with immunization
statements
Compare outcomes in African American
children to those of other
races/ethnicities
Intervention: Increase trust in
vaccines
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Poster for waiting/exam rooms
Parental responses stratified AA and non-AA
Interventions modified based on feedback
"LIKE ALL PARENTS, I WANTED TO MAKE SURE THAT
THE VACCINES THAT MY CHILDREN RECEIVED WERE
SAFE, PURE AND EFFECTIVE."
Intervention: Increasing immunization
administration during minor illnesses
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Of course, I had questions, so I asked our children’s doctor:
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"Do the vaccines really prevent disease, or are they still in
the testing phase?"
Office meeting to reinforce recommendation
that mild illness not a contraindication
Office policy
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Our doctor assured me that all of the recommended vaccines have been fully tested and have
been proven to prevent disease.
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"Are the vaccines pure?"
The doctor said that the vaccines used for all children in the United States are thoroughly
tested to make sure that there are no germs in them or other ingredients that might hurt my
children.
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Parents told to keep vaccination visits despite
minor illness
Not to cancel vaccination visits for mild illness
Handout for practitioner to give parents
"There seem to be a lot more vaccines than when I was a child. If I didn’t get the
vaccine why should my children?"
Our doctor told me that although I never had any serious problems with childhood diseases,
many children did back when I was young. By giving my children these new vaccines I will
protect them from getting hepatitis, spinal meningitis, and even chickenpox. Even though I
don’t like to see them cry when they get a shot, it is worth it to prevent these diseases.
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Handout for parents
Intervention: Improving
communication with parents
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Intervention: Promoting
benefits of vaccination
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3 posters for waiting/exam rooms
describing benefits of specific
immunizations in “story form.”
“Medical Miracle” brochure
Educational sheet for practitioners on
effective communication strategies for
discussing immunizations with parents
of African American children
Includes specific issues raised in focus
groups
WHY SHOULD YOUR CHILD GET THE CHICKENPOX VACCINE?
VACCINATED
NOT VACCINATED
Joshua’s mother dropped him off at school this
morning on her way to work. He got the
chickenpox vaccine when he was just one year old
and is now immune against chickenpox. His mother
is relieved since some children in his class have
missed as much as a week of school from the
chickenpox that is going around their town.
Ashley is in bed with the chickenpox. She has a fever
of 101 degrees, feels bad, and really wants to scratch
her rash. This is the third straight day of school she
has missed because of the chickenpox. Ashley’s
mother is worried; she wishes her daughter felt
better and has missed work for 3 straight days. The
work is piling up, and her boss is frustrated. When she
was a toddler, Ashley’s pediatrician recommended the
chickenpox vaccine, but Ashley’s mother didn’t think it
was worth it. Now she does.
Vaccines are one of the best things that you can do for your child to make sure that he or she is healthy.
If you have any questions about any vaccine or immunization, talk it over with your child’s doctor.
Intervention: Increasing the
priority for immunizations
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Reminder/recall postcard
Prenatal handout
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For obstetricians, prenatal classes, prenatal
visits to pediatrician
Describes vaccines and diseases presented
6
Assessment of health beliefs
regarding immunization
I worry that some of the vaccines that my
child receives are not 100% pure.
(pure)
completely agree
agree somewhat agree
Somewhat disagree disagree completely disagree
Transformed to ordinal scale for analysis: 6= highly
favorable for immunizations, 1= highly unfavorable
Other health belief statements
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The main reason that I have my child
immunized is so that he/she can attend
daycare or school (attend school)
Other health belief statements
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I am confident that the vaccines that
my child receives have been thoroughly
tested and have been shown to prevent
disease. (prevent disease)
Other health belief statements
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I don’t think that my child should
receive vaccines when he/she has a
cold or ear infection. (minor illness)
Other health belief statements
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Getting all the recommended
immunizations is one of the most
important things that I can do to make
sure my child is healthy. (important)
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RIDS Intervention
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Practice-level intervention
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Clinician
Office staff
Parents
All office staff, clinicians,
patients/parents receive the
intervention
Implementation of
Interventions
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Interventions implemented in 20
participating practices
4 “control” practices randomly selected
Practices implement interventions for
period of 9 months to 1 year
After intervention period conduct
second immunization survey in all
practices
Initial Assessment - 53% of patients black
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