reported at the workshop that 61 percent of parents in a Rochester, New York, study could not remember when their children needed immunizations, and 81 percent of the parents of underimmunized children thought that their children had received all scheduled vaccine doses.

Families also may not know that children with mild illnesses can be safely immunized. A study of families using Salt Lake City's immunization clinics found that 45 percent had delayed bringing a child in for immunization because the child was ill (Abbotts and Osborn, 1993). The authors concluded that most of those illnesses were not true contraindications to immunization.

Workshop participants suggested that, in some families, meeting the health care needs of well children may be given a lower priority than providing day-to-day necessities such as food and shelter. Providers encounter parents who have not taken the time to have their children immunized until school or day-care requirements prompt action. In his pediatrics practice, James Feist has found that even physicians ' children may not be immunized as recommended. The failure of many insurance plans to cover immunizations also may suggest that they (and other excluded preventive care measures) are not truly important.

Other parents are concerned about the safety of vaccines or object to immunization because it introduces substances into the body that parents perceive to be unnatural. Tracy Lieu noted that parental concerns about vaccine safety are not necessarily a deterrent to immunization; among families in the Northern California Kaiser Permanente HMO, children with parents worried about the safety of vaccines were less likely than other children to receive their immunizations late, suggesting a general parental concern for their children's health.

Unanticipated findings such as Lieu's suggest that “conventional wisdom” about parental attitudes should be tested to ensure that planning for immunization programs is based on accurate assumptions. Lance Rodewald and David Salisbury both noted that providers thought that parents would object to the simultaneous administration of multiple vaccines. When asked, parents were, in fact, willing to have all appropriate immunizations given at one visit.

Immunization programs are using a variety of incentives, penalties, and legal requirements to encourage families to have their children immunized. The scale of the positive or negative stimulus can affect the character of the response (e.g., Bandura, 1986; Fiske and Taylor, 1991). Large incentives or penalties can become so important in themselves that they deflect attention from their original purpose—encouraging immunization to protect a child's health, for example. Laws requiring immunization for school entry succeed in their immediate purpose but do not promote the message that children should be immunized at much younger ages or the intrinsic value of protecting one's child from preventable illness. In general, small incentives remain cues to take a particular action and do not become the main motive for action. All parents



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