The European Journal of Public Health Advance Access originally published online on November 27, 2008
The European Journal of Public Health 2009 19(1):69-72; doi:10.1093/eurpub/ckn109
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Infant, Child and Adolescent Health |
The influence of public or private paediatric health care on vaccination coverages in children in Catalonia (Spain)
E. Borràs1,2, A. Domínguez1,3, M. Oviedo1,2, J. Batalla1,2 and L. Salleras1,3
1 CIBER Epidemiología y Salud Pública (CIBERESP), Spain
2 Directorate of Public Health, Department of Health, Generalitat of Catalonia, Barcelona, Spain
3 Department of Public Health, University of Barcelona, Barcelona, Spain
Correspondence: Dr Eva Borràs, Directorate of Public Health, Department of Health, Generalitat of Catalonia, c/ Roc Boronat, 81-95, 08005 Barcelona, Spain, tel: 0034 93 551 39 00, fax: 0034 93 551 7514, e-mail: eva.borras{at}gencat.cat
Received May 26, 2008, accepted October 10, 2008
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Abstract |
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Background: Maintaining high vaccination coverages is necessary in order to control vaccine-preventable diseases. We studied vaccination coverages in a representative sample of 630 children aged <3 years in Catalonia in order to determine the relationship between vaccination coverages and socioeconomic factors. Methods: Sampling was carried out in a representative sample of the health regions in Catalonia stratified according to habitat. A sample of 630 parents of children aged <3 years born in October 2001 were interviewed by telephone. Information collected included sociodemographic data, type of health care provider (public or private) and information on vaccination coverage for the basic plus booster immunization series (BBI) which consisted of: four DTP, four OPV, one MMR and the doses of Hib and MenC necessary according to age of administration of the first dose. Results: A total of 87.62% of the children were vaccinated with the BBI series, and no statistically significant differences in coverage between public (87.93%) and private (88.30%) paediatric providers, or between social classes (high: 87.58%, low: 88.81%) were found. Vaccination coverage was associated with attending a day-care centre (OR: 1.89; 95% CI: 1.12–3.21) and maternal university education (OR: 1.84; 95% CI: 1.01–3.33). Conclusion: Vaccination coverages are high and are similar between types of provider, probably due to preventive policies which have made a concerted effort to ensure universal vaccination.
Keywords: children, health care, vaccination coverage
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Introduction |
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Immunization is highly effective in reducing the morbidity and mortality of vaccine-preventable diseases. Maintaining high vaccination coverages is essential to control these diseases and therefore, monitoring of vaccination coverages is necessary.
In Catalonia, a region in the northeast of Spain with seven million inhabitants, vaccines included in the routine vaccination schedule are offered free of charge, unlike some other countries where the cost of vaccines can be a barrier.1,2
There is a relationship between less vaccination and some socioeconomic characteristics3,4 and it is also known that health care providers can influence immunization rates by answering parents’ questions and addressing misconceptions.5–7
Although vaccination coverages are high in Catalonia,8–11 monitoring of coverages is necessary to determine the factors associated with undervaccination and no vaccination.
We studied vaccination coverages in a sample of children aged <3 years in Catalonia in order to determine the relationship between vaccination coverages and socioeconomic factors and the type of health care provider.
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Methods |
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A retrospective, cross-sectional descriptive study was carried out by means of stratified random probabilistic sampling of children born in October 2001 and registered as resident in Catalan municipalities. Information was obtained from municipal residence registers. The sample was selected in two stages, first according to health region and second according to municipality: rural (<10 000 inhabitants) or urban (
10 000 inhabitants). The sample size was calculated with a precision of 0.05 and an expected probability of routine vaccination coverage of 0.97. Therefore, the sample size required was 45 children from rural and 45 from urban habitats for each of the seven health region, except for Barcelona city (90 children), resulting in a total sample of 630 children. Parents were interviewed by telephone by a trained interviewer between October 2003 and September 2004. Information collected included sociodemographic data (occupation, maternal education, attendance at day-care centres and number of children), information received on vaccines, the source of information and parental evaluation of its usefulness, type of health care provider (public or private), and vaccination coverage. Parents were requested to send a photocopy of the vaccination card to validate the data.
Variables and definitions
We defined the basic plus booster immunization series (BBI) according to the recommended immunization schedule of the Department of Health of the Generalitat of Catalonia in 2001 (table 1). The BBI series was considered as: four DTP, four OPV, one MMR, and the necessary doses of Hib and MenC according to age of administration of the first dose. Although we collected data on hepatitis B, hepatitis A, varicella and the 7-valent pneumococcal conjugated vaccines (Pnc-7), these data were analysed separately and were not included in the definitions of the vaccination series, as some were not included in the recommended immunization schedule in 2001. We calculated the coverage of these vaccines according to the number of doses recommended by the Spanish Paediatric Association,12 which coincides with other international recommendations.13,14
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Maternal education was defined as university or non-university (other studies or none). Occupations were defined in two categories: high (classes I–II) and low (classes IV and V) socioeconomic class.15 No participants were excluded due to language difficulties. A family member other than the parents was required to act as a translator in three cases.
Statistical analysis
Descriptive analyses were performed on all outcomes. All estimates of vaccination coverage were calculated with their associated 95% confidence intervals (CI) using the exact binomial method. The odds ratio (OR) and 95% CI were calculated in order to assess the association between the study variables and vaccine coverage. The Chi square and Fisher's exact tests were used to compare rates. A level of P < 0.05 was considered statistically significant. Data were analysed using the SPSS Version 15.0 (SPSS Inc. Chicago, IL) program.
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Results |
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Of the 630 children selected, 12 families (1.80%) refused to participate and 25 families were not found. These families were replaced by others until the sample of 630 children was complete. A total of 87.62% of the children studied were vaccinated with the BBI series. A photocopy of the vaccination card was sent by 46.88% of parents. No statistically significant differences were found between vaccination coverages of non-routine vaccines and rural (86.30%) or urban (88.61%) habitat.
The BBI series was administered in public health centres in 68.66% of children and in private offices in 31.34%. There were no statistically significant differences in BBI coverages between public and private paediatric offices (table 2). The percentage of subjects refusing vaccination in users of the public providers and private was 4.2% and 7.1%, respectively (P = 0.12).
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The differences in coverages of non-routine vaccines were as follows: for the varicella vaccine, 36.54% of children receiving the vaccine did so in public health centres and 63.46% in private offices; for the Pnc-7 vaccine, 52.63 and 47.37%, respectively, with a higher number of children with an incomplete number of doses being observed in children vaccinated privately (32.50% vs. 27.42%, respectively; P = 0.39); for the hepatitis B vaccination 48.91% and 52.22%, respectively; and, for the hepatitis A + B vaccine 57.14% and 42.86%, respectively.
An association was found between only two sociodemographic variables and vaccination coverage (table 3): attending a day-care centre (OR: 1.89; 95% CI: 1.12–3.21) and maternal university education (OR: 1.84; 95% CI: 1.01–3.33).
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There were no differences in coverage of the BBI series between social classes (high; 87.58% and low: 88.81%; P = 0.68). Information on vaccinations was received by 63% of parents, of which 65% evaluated it as adequate. Private paediatric care was associated with receiving more information (OR: 1.52; 95% CI: 1.05–2.21) and with receiving more information given directly by the paediatrician (OR: 12.07; 95% CI: 2.86–50.90) (table 4).
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Vaccination coverage was associated with receiving information in families receiving private paediatric care (OR: 2.92; 95% CI: 1.21–7.11) but not in those receiving public paediatric care (OR: 1.11; 95% CI: 0.61–1.21).
No statistically significant differences in the coverages of the BBI series were observed according to the type of provider in parents who stated they had received information (public: 88.37% and private: 91.97%; P = 0.26) or in parents who considered they had received adequate information (public: 89.37% and private: 92.70%; P = 0.37).
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Discussion |
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The estimated vaccination coverage for the BBI series in children <3 years of age was high and compared satisfactorily with that obtained in other countries.3,16–19
Coverage of the BBI series according to the type of health provider showed very small differences and does not seem to be an essential factor in vaccination coverages in Catalonia. This similarity, together with the high level of overall coverage is probably due to preventive policies where a concerted effort to achieve universal vaccination has been made.9–11,20
In the United States,16,21 where 56% of children are covered by private insurance, children with private-only health care have a higher vaccination coverage (80%) than those with public-only health (56%), with the cost of vaccines being reported as an important factor.1
The vaccines not included in the vaccination schedule are administered in a similar fashion by both types of providers.
Maternal education,3,4,22 receiving information on vaccines and receiving information directly from the paediatrician5,7,18,23,24 have been associated with higher vaccination coverages. Although only attending a day-care centre and maternal university education were associated with higher coverages in our study, receiving information, receiving information directly from the paediatrician and being the first-born child resulted in higher coverages; the low number of children in each category could explain why the differences were not statistically significant.
The higher coverage in children attending day-care centres is reflected by other reports4,25 and may be explained by the centres’ admission policies and by paternal concerns that their children are more exposed to infection when mixing with large numbers of children.
Families attending private centres received both more information and more information directly from paediatricians compared with those attending public centres. However, receiving information on vaccination was only associated with vaccination coverage in children attending private centres. This may be due to greater adhesion to vaccination protocols in public centres.
Possible limitations of the study include the refusal of some parents to participate and errors in collecting information on vaccinations. However, the randomly-selected population represented the diverse sociodemographic makeup of the Catalan population and the type of health care provided. The low proportion (1.90%) of families that refused to participate is within the range found by other studies26,27 and does not, we believe, invalidate the results. Some bias might have occurred when parents were asked for information on vaccines received. However, as the parents were asked to recite the dates of vaccinations received as they appeared on the vaccination card and as, in addition, the information was verified in nearly half the cases by scrutiny of photocopies of the vaccination card, with an almost 100% correlation, we believe this possibility to be very low.
In conclusion, the results of this study show that, in Catalonia, only the level of maternal education and attending a day-care centre was associated with vaccination coverages.
New studies on vaccines and vaccination and the source and time spent providing the information should be potentiated in order to aid parental decisions, resolve their doubts and to increase the coverage of booster doses.
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Funding |
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Instituto de Salud Carlos III, Madrid (RCESP-project n° C03/09 and the FIS-project n° PI 052366, partial).
Conflicts of interest: None declared.
Key points
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Acknowledgements |
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We are grateful to the Public Health Agency of Barcelona, and to the other municipalities who collaborated in obtaining the study sample and to all the parents who participated.
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References |
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