assess the effectiveness of such programs because limited studies have been conducted to evaluate their impact.

There are several potential barriers to the implementation of school-based vaccination programs. These barriers can include difficulties in coordinating among different programs, staff training requirements, disruption of school routines, and confidentiality concerns.

Child Care Centers. Children in child care centers are at increased risk for communicable diseases. In 1995, approximately one-third of preschool children (31 percent) were cared for in such settings (information provided by Children’s Health Working Group). Child care center interventions involve efforts to encourage vaccination of preschool children (younger than age 5) by assessing each child’s immunization status upon entry into child care and at some point or at periodic intervals during the child’s enrollment. Vaccination interventions can also include education or notification of parents, referral of underimmunized children to health care providers, and sometimes provision of vaccinations on site. TFCPS concluded that there is insufficient evidence available to assess the effectiveness of such interventions (Briss et al., 2000).

Addressing Missed Opportunities

Many researchers and health care providers used to attribute the lack of complete immunization coverage to poverty and the economic barriers that discouraged families from seeking vaccines or gaining access to a primary care provider. In the wake of the 1989–1991 measles outbreak, however, it was found that underimmunized children had substantially more access to the health care system than had previously been assumed. The 1988 National Health Interview Survey on Child Health, for example, revealed that 90 percent of children had a source of routine health care, although only 77 percent of 2-year-olds had achieved full immunization coverage (St. Peter et al., 1992). This finding was reinforced by a later analysis of the 1993 National Health Interview Survey, which demonstrated that 90 percent of underimmunized children reported having a usual source of health care (Tatande et al., 1996).

These findings caused many researchers and health professionals to rethink traditional strategies for improving vaccination coverage levels and to focus on addressing missed opportunities in health care and other public service settings (Santoli et al., 1998). Researchers recommended several new strategies aimed at encouraging providers to vaccinate both children and adults. These strategies included checking records of immunization status and implementing reminder-recall systems for public and

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