Universal Interventions 447rates for young children have increased, and most children
are immunized by the time they enter school.
Parental attitudes are not a barrier to immunization.
Rather, the primary barrier to immunization is poverty and
factors associated with poverty (National Vaccine Advisory
Committee). Studies have shown that families adhere to im-
munization recommendations when barriers are reduced
(Melman, Nguyen, Ehrlich, Schorr, & Anbar, 1999; The
National Vaccine Advisory Committee, 1999). For example,
state implemented, federal entitlement programs and state
legislation mandating coverage of immunizations by insur-
ance companies have improved the availability of vaccine
while standards for immunization practice has facilitated de-
livery of immunization (Freed et al., 1993; National Vaccine
Advisory Committee).
A subcommittee on immunization coverage of the Na-
tional Vaccine Advisory Committee summarized the litera-
ture on immunization efforts and made recommendations
for further improving immunization rates (National Vac-
cine Advisory Committee). The task force found that at-
tempting to immunize in emergency rooms and relying on
educating parents were not suf“cient interventions to in-
crease immunization rates. Instead, improvement requires
addressing barriers on these multiple systems levels. As an
example of research into the effectiveness of interventions
to increase immunization rates, Sinn, Morrow, and Finch
(1999) reported on the development of an immunization task
force committee as a quality improvement initiative. They
reviewed immunization rates and practices after three assess-
ments and suggested innovations designed to improve immu-
nization rates. Over a two-year period, mean practice
immunization rates improved signi“cantly to 69.7% from
50.9% at baseline, and age at immunization decreased.
The increased rates were attributed to improved record keep-
ing and tracking and screening for immunization at every
of“ce visit. In another intervention, Goldstein, Lauderdale,
Glushak, Walter, and Daum (1999) reported on the effective-
ness of a community-based outreach program in a Chicago
public housing development. In this three-year intervention,
they found that door-to-door canvassing by trained emer-
gency technicians was effective in ascertaining immunization
status of children, enrolling them in an immunization pro-
gram, improving rates of immunization, and increasing the
percentage of children with up-to-date immunization cover-
age (from 37% to 50%). Support for tracking and outreach as
effective and cost-ef“cient procedures for improving immu-
nization was found in a randomized, controlled study con-
ducted in nine primary care sites (Rodewald et al., 1999).
Efforts to improve childhood immunization are most ef-
fective on a systems level, impacting health care delivery and
public policy. Child health psychologists have an important
role to play in guiding the development of interventions such
as these, particularly concerning suggestions for overcoming
barriers, improving communication between primary care
provider and parents, and developing user-friendly reminder
systems. The emerging area of immunization for sexually
transmitted diseases will require child health psychologists to
consider individually focused interventions due to the inter-
action of adolescent developmental considerations with fam-
ily and health care priorities (see Fortenberry & Zimet, 1999;
Webb, Zimet, Mays, & Fortenberry, 1999; Zimet, Mays, &
Fortenberry, 2000).Prevention of Unintentional InjuriesInjuries are the major causes of death and disability for chil-
dren. As a result of injuries, approximately 22,000 children
and adolescents die each year; seven to eight times more are
permanently disabled and require continued care. Injuries
account for 15% of medical spending in pediatrics (Miller,
Romano, & Spicer, 2000). The most common and costly
causes of unintentional injuries are falls, motor vehicle acci-
dents (pedestrian, bicyclist, or occupant), poisonings, “re,
and burns (Kronenfeld & Glik, 1995; Miller et al., 2000).
Factors that place children at risk for unintentional injuries
are best characterized as related to one•s behavior (e.g., age,
gender, temperament, estimation of physical ability) or to
one•s environment (e.g., low socioeconomic status and un-
safe physical environment; Finney et al., 1993; Miller et al.,
2000). The term accidentimplies fate, luck, or uncontrollable
forces; therefore, the term injury,which allows for empirical
consideration of contributing factors and preventive inter-
ventions, is preferred. The focus of this section is on uninten-
tional injuries, in contrast to intentional injuries or those that
result from physical abuse, neglect, and sexual abuse. Child
health psychologists are called on to rule out, assess, and ad-
dress child maltreatment, which affects an estimated 437,500
children per year in the United States (Knutson & DeVet,
1995). However, the scope of this literature is too broad
to adequately review in this chapter (see Belsky, 1993;
Edgeworth & Carr, 2000; Reece, 2000; Wolfe, 1991, for
information).
Prevention efforts, targeting increased safe behaviors, de-
creased risky behaviors, and increased safety of the environ-
ment have generally been shown to be cost effective (Miller
et al., 2000). Education of the parent and having the parent
make rules will not be enough to reduce the risk of injury for
children in part because having information does not neces-
sarily lead to changes in injury-related behaviors (Finney
et al., 1993). Even if behaviors are modi“ed and attempts to