distributing them. But removing the financial barriers will not, by itself, achieve full immunization of preschool children. Reaching and sustaining a commitment to universal and systematic delivery of immunization services will require addressing not only the costs of vaccine and of delivering services but also barriers that lie in the organization and delivery of health care (e.g., the fragmentation of primary care services, the inaccessibility of services, incomplete information about children's immunization status, and the complexities of the immunization schedule); the practices of individual health care providers (e.g., missed immunization opportunities at health care visits); and the knowledge, attitudes, and behavior of children 's families (e.g., apprehensions about the safety of vaccines and lack of appreciation for the risks of vaccine-preventable diseases) (NVAC, 1991, 1992).


To examine these other, largely nonfinancial barriers and to identify opportunities to overcome them, the Institute of Medicine (IOM) held a 2-day workshop on December 8–9, 1993, led by an eight-member steering committee. Participants included leaders of programs that have tried various approaches to reducing barriers to immunization, experts in the social and behavioral sciences, and pediatricians and other health care providers, including those familiar with health care for underserved populations. Funding was provided by the Carnegie Corporation of New York, the Centers for Disease Control and Prevention (CDC), and IOM's Board on Health Promotion and Disease Prevention. The National Vaccine Program Office of the U.S. Public Health Service provided nonfinancial assistance.

This report, based on the presentations and discussions at the workshop, reflects the committee's assessment of the problem of underimmunization of preschool children. It makes no formal recommendations, but it reviews specific responses that could make a significant difference in the immunization status of preschool children in the short term and in the longer term. Issues of particular importance are accountability for delivery of immunization services, improving and protecting public health resources for providing immunization services, and effective collaboration between public and private providers. Although the report focuses on nonfinancial factors affecting immunization, it also covers important economic issues that were discussed at the workshop. The committee's special concern is those issues that require the attention of state-level decisionmakers, including government officials, public health officials, and leadership in the health professions. The report also addresses issues of importance to local government and public health officials, national leaders in government and the health professions, and public- and private-sector developers of health care reform plans.

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