We found that among Medicaid children in a managed care program, who were assigned to a primary care case manager physician, up-to-date immunization rates at 18 months were still low. Age appropriate immunization rates were even lower. The temporal patterns of immunizations indicated that compliance with the immunization schedule faltered after the second month of life (See Figure 1). By 18 months of age AAI status declined from 37% to 6%. UTD status declined from 37% to 19% at 15 months and then increased to 28% at 18 months and to 46% by 2 years of age. Other studies of low-income urban populations have found similar rates.

Children who were African-American and those with young mothers were less likely to be up-to-date at 18 months. Although some studies have found little effect of race on immunization status our results are consistent with those that found racial disparities in immunization rates. Our finding that children of mothers under 20 were less likely than children of older mothers to achieve full immunization for their children by 18 months, although not extensively reported previously, confirms another recent study. It is likely that younger mothers had fewer resources and less knowledge and experience of the need to help their children achieve full immunization status.Our findings that low-income children served by public health departments or community health centers were more likely to have received complete immunizations by 18 months of age parallels results of other studies, even though in studies of a general population (not studied here), private providers have higher rates. It may be that patient compliance was easier due to the traditional reliance on health departments by these patients for immunizations. Also, the traditional emphasis of public health providers on preventive care may have been an important component of assuring compliance with immunization recommendations.
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In the model predicting AAI status among UTD children, we found rural residence was the only significant predictor of not being immunized at appropriate age intervals. A potential area for further research is whether the long travel time to care in rural areas may affect access to timely follow-up; immunization at exact age-appropriate intervals may therefore be difficult. A catch-up strategy of achieving multiple vaccinations at the same visit on the part of both mothers and providers could have been utilized as a more expedient, convenient option.

Age-appropriate rates were considerably lower than UTD rates and variables that predicted UTD status did not predict AAI status. Immunization at the appropriate age is important for conferring immunity and is a public health goal. Numerous children are incompletely protected during a period when they are most susceptible to preventable childhood diseases. This trend is particularly alarming as the recommended schedule of immunizations has expanded. Studies demonstrate that the techniques and interventions with patients and providers that are important to achieve UTD status may not be similarly effective to achieve AAI status. Opportunities for proactive prevention may differ depending on the desired immunization level. Further research on these criteria with a nationally representative sample is needed.

As HMOs exit the Medicaid market, states are reverting to primary care case management programs. Our results raise concerns about the effectiveness of primary care case management as a mechanism to promote timely immunization to these patients. A recent survey has shown that physician attitudes in great measure determine whether immunizations are given. The already-stressed, safety-net provider pool caring for vulnerable populations in managed care may be stressed beyond their resources to promote adherence. This population, despite Medicaid coverage, may have limited psychosocial resources to aid compliance with recommendations for preventive care. Fostering adherence for resource-poor populations requires more intensity than for other groups. Safety-net providers may not have the resources to implement such programs. Additionally, parents may not act assertively in obtaining immunization for their child. Although outbreaks have occurred, and children may be increasingly susceptible to certain childhood diseases, the danger from childhood diseases may be incorrectly perceived by parents as minimal.
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Thus, we believe our results imply that community advocates and providers must work together to design improved systems of health care delivery that do not impede, but rather foster, successful immunization programs. A number of proactive strategies have proven effective, including outreach to families, both in-person and by telephone. Scheduled home visits would ensure that mothers, especially young mothers, are aware of the importance of immunizations. More effective tracking systems, such as assessment and feedback of coverage levels to providers and immunization registries, could be useful in assisting parents to obtain immunization in a timely manner and also monitor how well the population is immunized against childhood illnesses. Georgia public health clinics were able to double their vaccination coverage levels in six years through the use of assessment and feedback to health district offices and clinics. Registries hold the potential to improve vaccination coverage, especially for children with many providers, by giving better information to providers and setting up systems of reminder notices. At present only about one-half of children under the age of 6 are covered in an immunization registry.

Another area of the system of service delivery with potential for improvement is the use of acute care visits for immunizations. The Center for Disease Control developed a number of system-changing strategies to improve immunization rates including improved financing of recommended vaccines, improved reminder systems, better information systems for monitoring outcomes of immunization delivery; and continued education of families. Last, the Institute on Medicine has recommended “increased financial and administrative support” for state immunization infrastructure programs. We would hope that such support encompasses additional resources for safety-net providers. The efforts to implement these strategies must continue to be a focus of providers and public health advocates.
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