Series 6

No. 8

Response Errors in Surveys of

Children’s Immunizations

February 1999

Vital and

Health Statistics

From the CENTERS FOR DISEASE CONTROL AND PREVENTION / National Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics
Copyright Information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

Suggested citation

Willis G, Brittingham A, Lee L, et al. Response errors in surveys of children’s

immunizations. National Center for Health Statistics. Vital Health Stat 6(8).

1999.

Library of Congress-in-Publication Data

Response errors in surveys of children’s immunizations.

p. cm.—(Vital and health statistics. Series 6. Cognition and survey

measurement ; no. 8) (DHHS publication ; no. (PHS) 99-1083)

Author, Gordon Willis and others.

Includes bibliographical references.

ISBN 0-8406-0549-8

1. Medical care surveys—Response rate—United States—Evaluation.

2. Immunization of children— United States—Statistics—Evaluation.

3. Vaccination of children —United States—Statistics—Evaluation.

4. Health surveys— United States—Statistics—Evaluation. 5. Medical history

taking— United States—Evaluation. 6. Response consistency.

7. Questionnaires. I. Willis, Gordon. II. National Center for Health Statistics

(U.S.) III. Series. IV. Series: DHHS publication ; no. (PHS) 99-1083.

[DNLM : 1. Immunization Schedule—in infancy & childhood. 2. Data

Collection—methods—United States. 3. Health Surveys—United States.

W2 A N148vf no. 8 1999]

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for Library of Congress 98-37770

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For sale by the U.S. Government Printing Office

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Printed on acid-free paper.
Response Errors in Surveys of

Children’s Immunizations

Series 6:

Cognition and Survey

Measurement

No. 8

Hyattsville, Maryland

February 1999

DHHS Publication No. (PHS) 99-1083

Vital and

Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics
Preface Although five people are listed as

authors on this report, there

were many others whose efforts

were crucial to the research it describes.

The contributions of Kenneth Rasinski

and Jared Jobe, who played key roles

during the early stages of this study, and

Curtis Bailey, Cheryl Gilbert, and Cathy

Haggerty, who skillfully provided

much-needed operations assistance, are

gratefully acknowledged. Larry

Barsalou, Karen Goldstein, Fred Smith,

and Susan Chu reviewed earlier versions

of the report. Also, without the

cooperation of Steven Black, Kathleen

Ensor, and Karen Walsh at the pediatric

clinics, this project would not have been

possible.

This research was carried out under

U.S. Department of Health and Human

Services contract 200–95-7009 from the

National Center for Health Statistics

(NCHS) to the National Opinion

Research Center. Roger Tourangeau,

Ph.D., was the principal investigator.

Gordon Willis, Ph.D., and Pamela

Ching, Sc.D., were the project officers

for the contract. This research was

supported in part by the Centers for

Disease Control and Prevention (CDC)

National Immunization Program, and

partly from a grant to NCHS by the

National Science Foundation.

iii
Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Abstract ............................................................................................... 1

Introduction ........................................................................................... 1

Exploratory Phase: Cognitive Interviewing................................................................... 2

Understanding of Terms ............................................................................... 3

Recall of Vaccination Information ....................................................................... 3

Calendars............................................................................................ 3

Memory-Aid Study...................................................................................... 3

Introduction ......................................................................................... 3

Method ............................................................................................. 3

Results ............................................................................................. 5

Discussion ........................................................................................... 7

Encoding Study ........................................................................................ 7

Introduction ......................................................................................... 7

Method ............................................................................................. 8

Results ............................................................................................. 8

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Proxy Measures Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

General Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Limitations and Caveats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Recommendations for Survey Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Appendixes

I. Materials Used in Memory-Aid Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

II. Materials Used in Encoding Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

III. Materials Used in Proxy Measures Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Text Tables

A. Standard vaccination questions ....................................................................... 2

B. Memory-Aid Study: Percent of children who had ever received a vaccination according to medical records and

respondents, and parental response accuracy measures .................................................... 5

C. Memory-Aid Study: Child’s vaccination status according to medical records and respondents, and parental response

accuracy measures ................................................................................. 6

D. Memory-Aid Study: Mean number of vaccines reported accurately by parents and percent of parents who reported

accurately on the global question ..................................................................... 7

v
E. Encoding Study, Wave 1: Percent of children who received a vaccination during a specific visit according to

medical records and respondents, and parental response accuracy measures ................................... 9

F. Encoding Study, Wave 2: Percent of children who received a vaccination during a specific visit according to

medical records and respondents, and parental response accuracy measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

G. Proxy Measures Study: Child’s vaccination status according to medical records and respondents, and parental

response accuracy measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

H. Proxy Measures Study: Mean number of doses of each vaccine reported by parent, percent of parents who correctly

identified the number of doses their child received, and the percent who correctly indicated that their child had

received the recommended number of doses, by type of vaccine and experimental variable . . . . . . . . . . . . . . . . . . . . . . 13

J. Proxy Measures Study: Proxy measures of up to date status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

K. Percent of respondents reporting correct number of recommended doses, by study and vaccine . . . . . . . . . . . . . . . . . . . 14

L. Strategies for recalling vaccinations, by study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

vi
Objectives

Household surveys of childhood

immunization, such as the NCHS

National Health Interview Survey

(NHIS), typically involve reporting by

parents of the shots that their children

have received. These reports are

sometimes based on parents’

memories, rather than on written

vaccination records. However, the

accuracy of reports based on memory

alone is suspected to be poor (either

biased or unreliable), and it is of

interest to determine whether steps can

be taken to improve such reports

through manipulations that address the

cognitive processes of the respondent.

Methods

The current study explored three

likely causes of inaccurate reporting

(poor initial encoding of the relevant

events, limitations in recall at the time

of the survey, and motivation to

misreport information) and attempted to

implement experimental procedures that

may improve reporting. Accuracy was

assessed through the checking of

immunization histories by making use of

written provider records.

Results

In three studies, it was found that

parental recall of young children’s

immunizations was generally poor and

that the use of retrieval cues was not

helpful in improving recall performance.

Further, an experiment that studied the

influence of encoding limitations by

querying respondents immediately after

their children received immunizations

suggested that much of the error in

reporting is due to failure of initial

encoding, and that steps to improve

recall are therefore unlikely to be

effective. It is concluded that the best

approach to take for immunization

surveys is to follow current NHIS

practice—to depend largely on external

sources of information, and in particular,

on provider records.

Keywords: health survey c memory c

proxy reporting c record-check

Response Errors in Surveys of

Children’s Immunizations

by Gordon Willis, Ph.D., National Center for Health Statistics,

Centers for Disease Control and Prevention; Angela Brittingham,

M.A., Lisa Lee, Ph.D., and Roger Tourangeau, Ph.D., National

Opinion Research Center; and Pamela Ching, National Immunization

Program, Centers for Disease Control and Prevention

Introduction

The President’s Childhood

Immunization Initiative (1)

aimed to increase vaccination

coverage among 2-year-olds, and

several national surveys—in particular,

the National Health Interview Survey

(NHIS) in combination with the

National Immunization Provider

Record Check Study (NIPRCS), and

the National Immunization Survey

(NIS)—have monitored progress in

meeting this goal (2–4). These surveys

rely in part on the reports of parents

for their data. Unfortunately, even the

most conscientious parents may have

difficulty in answering detailed

questions about their children’s

vaccinations. During most of the

period in which this research was

carried out, children were supposed to

receive at least 14 doses of 5 different

vaccines by their second birthday.

Subsequently, a vaccine for varicella

(chicken pox) has been added to this

list. Keeping track of children’s

vaccinations can be quite difficult. To

reduce confusion, many pediatricians

provide parents with an immunization

(shot) card that lists the vaccinations

their children have received.

espondents in both the NHIS and NIS

surveys are encouraged to consult these

cards when reporting about their

children. However, apart from the

finding that shot records may themselves

contain substantial error (3),

approximately one-half of the

respondents do not have such cards

available at the time of the interview

and must provide their answers without

the aid of cards or other records (4).

The accuracy of these unaided

reports in national surveys is still being

explored. However, evaluations of the

accuracy of parental responses to

questions about vaccinations in other

surveys suggest that they are prone to

considerable error. For example,

Goldstein and her colleagues found that

parents overreported the number of

vaccinations their children had received

(5). Across a number of studies that

compare parental reports with provider

records, considerable error, often in the

direction of overreporting, appears to be

the rule (5–9). Some studies also find

net underreporting (3, 10, 11), or a

combination of under- and

overreporting, depending on vaccine (4).

Whatever the direction of the errors, the

fact remains that there are many parents

who provide inaccurate information

about their children’s vaccinations.

Although it is known that these

estimates are often in error, it is of

substantial interest to also determine

(a) the likely reasons that response error

occurs and (b) whether methods to

reduce such error can be developed. The

studies described here investigate

specific sources of error in parents’

survey reports about their children’s

vaccinations and explore methods for

improving the accuracy of those reports.

The hypotheses they test are partly

derived from a model of the cognitive

processes involved in answering

questions. Over the last two decades,

several models of the survey response

process have appeared (12–17).

Although the models differ in many

Page 1
particulars, they share the assumption

that reporting errors arise in surveys

because of problems in one or more of

the underlying cognitive processes

through which survey reports are

generated.

As applied to reports about

children’s vaccinations, these models

point to at least three potential sources

of error. First, some parents may never

have encoded the relevant information

in the first place; that is, they may not

have attended to or understood relevant

information about the administered

vaccines, and as a result, this

information may not be well-represented

in memory. Several characteristics of

vaccination episodes may discourage

careful encoding: vaccinations are quite

routine; the child may receive multiple

vaccinations during a single visit to the

pediatrician; the doctor or nurse may not

take the time to identify the shots being

administered during that visit; and

parents may be too distracted to absorb

this information. Second, if the

respondent cannot retrieve this

information from a shot card at the time

of the interview, he or she must recall

from memory information about each

vaccine. Given the number of

vaccinations and the similarity of the

episodes in which they were

administered, recall is likely to present a

formidable challenge (4). Third, some

respondents may be aware that their

children are not fully vaccinated, but

reticent to admit this.

In the preliminary stages of the

research, cognitive testing was carried

out of the vaccination questions to be

used in the later experiments. Then,

three more formal studies were

conducted. The first of these, the

Memory-Aid Study, investigated the

effectiveness of retrieval aids—such as a

medical events calendar—in facilitating

recall. An Encoding Study then

evaluated how accurately parents

encoded information about vaccinations

immediately after their child received

them and how well they retained this

information for several months

following the vaccination episode.

Finally, the Proxy Measures Study

investigated whether parents can answer

questions about the child’s visits to the

doctor more accurately than they can

direct questions about the child’s

vaccinations, so that answers to the

doctor-visit items might serve as proxy

measures of immunization status.

Additionally, this study determined the

effects of mode of administration as a

method of reducing the effects of social

desirability on reporting.

Exploratory Phase:

Cognitive

Interviewing

One of the outgrowths of the

recent collaboration between

survey researchers and cognitive

scientists has been the development of

the cognitive interview. In this

procedure, volunteer subjects talk aloud

as they answer draft survey questions

and respond to a variety of probe

questions to identify the cognitive

operations involved in answering the

survey questions (16, 18, 19). A set of

cognitive interviews was conducted

during the pretesting phase of this study

to determine sources of response error

in reports on children’s vaccination

histories. During the interviews, a set of

survey questions on immunizations was

presented. Respondents (24 parents of

children under age 4) were asked to

point out unfamiliar terms, paraphrase

questions or instructions, define terms,

‘‘think aloud’’ while arriving at their

answers, and judge their confidence in

their answers. Respondents were not

told prior to the interview that the

interview would involve reporting of

immunizations, so that they would not be

tempted to review any shot records prior

to the interview. They were also instructed

not to refer to shot records in case they

had these at the time of the interview. In

general, the information collected from

these respondents allowed the interviewer

to assess respondents’ familiarity with the

terminology in the questionnaire and to

determine how they arrived at their

answers.

Respondents were also asked to use

calendars during some of the interviews

to determine whether these calendars

helped them recall vaccinations. In the

calendar-aided approach, information

about the child’s medical history (for

example, major illness, injuries, visits to

the doctor, or sources of medical care)

or else about important personal events

during the child’s life (for example,

change in residence, special

celebrations, or vacations) was recorded

on a calendar (using a medical-events

calendar or a personal events history

calendar, respectively). Throughout the

interview, if a respondent had difficulties

remembering vaccinations, he or she

was asked to use the calendar to aid

recall.

Table A lists the main vaccination

questions on the tested questionnaires

(taken from the NHIS and NIS).

Twenty-four parents of children under 4

years of age were asked to recall whether

their child had ever received five

particular vaccines: DTP (diphtheriatetanus-pertussis), Polio (oral or shot),

Table A: Standard vaccination questions

Introductory question:

Has [name] ever received an immunization, that is a shot or drops?

Specific questions:

1a. Has [child] ever received a DTP shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis

shot, baby shot, or three-in-one shot)?

b. How many DTP shots did [child] ever receive?

2a. Has [child] ever received a polio vaccine by mouth, pink drops, or by a polio shot?

b. How many polio vaccine shots did [child] ever receive?

3a. Has [child] ever received a measles or MMR (Measles-Mumps-Rubella) shot?

b. How many measles or MMR shots did [child] ever receive?

4a. Has [child] ever received an Hib shot?

(This is for Meningitis and is called Hemophilus Influenza, Hib vaccine or H Flu vaccine)

b. How many Hib shots did [child] ever receive?

5a. Has [child] ever received a Hepatitis B shot?

b. How many Hepatitis B shots did [child] ever receive?

Global question:

In your opinion, has [child] received all of the recommended shots for (his/her) age?

Page 2 [ Series 6, No. 8
MMR (Measles, Mumps, Rubella), Hib

(Hemophilus Influenza Type B), and Hep

B (Hepatitis B). They were also asked the

number of doses of each received and a

global question about whether their child

had received all of the recommended

vaccinations for his or her age.

Understanding of Terms

When asked to define

‘‘vaccination,’’ most respondents

correctly mentioned the prevention of

illnesses, but only a few knew much

about the particular vaccines and the

diseases that vaccinations prevent.

When asked whether they knew what

illnesses Hib, MMR, and DTP

vaccinations prevent, most of the

respondents could not give a complete

or correct answer. None of the 12

parents who were specifically asked

knew what the Hib vaccination was,

and 4 parents thought it was an

abbreviation for Hepatitis B. The

results were similar for the other

vaccines. There was also some

confusion about combination vaccines

(DTP/Hib and DTP/Hepatitis B) and

TB tests. This finding suggests that

responses might be more accurate if

the terms were explained more

carefully at the time of questionnaire

administration.

Recall of Vaccination

Information

Nearly all respondents (23 out of

24) reported that their children had

received one or more DTP, Polio, and

MMR vaccinations. For Hib and

Hepatitis B, respondents tended to

indicate either that their children had not

received the vaccination or that they did

not know. The greatest number of

‘‘don’t know’’ responses was for Hib.

Overall though, respondents were

generally very confident about whether

or not their child had received a

particular vaccination. Perhaps because

the polio vaccine is particularly salient

(the ‘‘pink drops’’), confidence in

responses for this vaccine was

particularly high. Most respondents

(15 of the 16 who were asked this) were

also very sure that they knew whether

their child was up to date overall in his

or her vaccinations.

Respondents tended to estimate the

number of doses of each vaccine their

child had received based on beliefs

about the recommended number of

doses, the frequency with which the

child received care, memories of the

vaccination card, and conversations with

their child’s pediatrician. It was

concluded that methods that improve the

quality of these estimates might increase

the accuracy of responses.

Calendars

The personal events history

calendar was not helpful in eliciting

responses about vaccinations. Only

rarely did respondents remember

doctors’ visits that occurred around

major events, such as a move or a job

change. Further, most respondents did

not refer to the personal events calendar

while answering the vaccination

questions. Many did not remember any

major personal events in the relevant

period, and those who had did not

associate them with doctor visits.

The medical events calendar

seemed more helpful than the personal

events calendar because it encouraged

respondents to draw specifically on

memories of doctor visits and illnesses.

In particular, its structure was helpful in

laying out the 2-year reference period

clearly. This calendar seemed to help

respondents recall the months in which

their children received vaccinations, but

not which vaccines were given. Overall,

only the medical events calendar

appeared to be worthy of further

investigation.

Memory-Aid Study

Introduction

A memory-aid study was next

conducted to allow the investigators to

measure reporting accuracy when

respondents reported from memory, and

to manipulate variables that might

improve reporting. Parents were

interviewed about their childrens’

vaccinations, and the accuracy of those

reports was assessed by comparing them

to the records of the child’s health care

provider(s). The cognitive interviews

suggested two possible means for

improving vaccination reporting. The

first was a medical events calendar: if

memories for individual vaccination

episodes had merged into a generic

memory, a medical events calendar

might help respondents to reconstruct

the specific episodes (20). To test

whether such a calendar might improve

recall, half of the respondents were

asked to record information about their

child’s medical providers, illnesses, and

pediatric visits on a calendar before

answering immunization questions; the

other half answered a standard set of

questions about their children’s

vaccinations without a calendar.

Based on the hypothesis that

answers to the vaccination questions are

often estimates, the experiment also

sought to determine whether the answers

might be improved if respondents had

accurate anchoring information for these

estimates as recall aids. The experiment

therefore also varied the presentation of

a show card listing the names of the

vaccines and the number of doses

recommended for each one.

In addition, the issue of whether

answers were affected by the order in

which the questions were asked was

examined; questions concerning each

specific vaccine were placed either

before or after a global question asking

whether the child had received all the

vaccinations recommended for a child of

that age. It was hypothesized that

answering the specific questions first

might lead to more careful consideration

of the child’s status on each vaccine and

thus a more accurate appraisal of the

child’s overall up to date status.

Method

Sampling Pretest

A pretest was first conducted to

determine the sample size necessary to

obtain sufficient numbers of children

who were not up to date on

vaccinations, according to a criterion of

4 Diptheria/Tetanus/Pertussis (DTP),

3 Polio, 1 Measles/Mumps/Rubella

Series 6, No. 8 [ Page 3
(MMR), 3 Hemophilus Influenza (Hib),

and 3 Hepatitis B (Hep B). The most

common definition of up to date status

has been the ‘‘4-3-1-3’’ designation,

which excludes Hep B. However, the

full 4-3-1-3-3 criterion was used for this

study because the President’s Childhood

Immunization Initiative (1) has modified

the definition of up to date status by age

2 to include Hep B. This change will

likely be increasingly implemented in

immunization survey practice starting in

the year 2000.

The pediatric clinic in Chicago,

where parents were to be recruited,

provided the National Opinion Research

Center (NORC) with a file containing

the chart numbers, names, and birthdates

of 2- and 3-year-olds (n = 3,482). A

sample of 100 children between the ages

of 24 and 47 months was selected

systematically and their medical records

were reviewed to obtain vaccination

information. These records contained

vaccination information for 94 of the

100 sample children. The records

indicated that substantial numbers of

children were not up to date: Just over

one-third of the children had received

all recommended doses for DTP, Polio,

and MMR. When the Hepatitis B and

Hib vaccines were considered as well,

so that the full 4-3-1-3-3 criterion was

used, only about 12 percent of children

were up to date. Although some of the

children may have received vaccinations

from other medical providers, the pretest

indicated that oversampling for children

who were behind in their vaccinations

would probably not be necessary.

Overall, the sampling pretest indicated

that this respondent group was much

less likely than the general population to

contain fully immunized children.

Sample

The 221 respondents in the

Memory-Aid Study were the primary

caretakers (usually parents) of 2- and

3-year-old children who attended a

private pediatric clinic that serves a

generally lower-income area of Chicago.

The clinic provided NORC with a list of

all 2- and 3-year-old children—ranging

in age from 24 to 47 months—who

were patients there, along with

caretakers’ names and addresses.

Children were sampled from this list

and randomly assigned to experimental

groups. In recruiting respondents to

report about the sample child, the person

who usually took him or her for visits to

the doctor was asked for. A very high

percentage of respondents (94 percent)

were the mothers or female guardians of

the sample child; another 5 percent were

grandparents; and the remaining few

were fathers, aunts, or uncles. About

85 percent of the respondents had

completed high school and 46 percent

had some college education.

Questionnaire

The key questionnaire items were

the same vaccination history questions

used in the NIS and NHIS (see

Appendix I). This standard set of

questions first asks respondents whether

the child had ever received any

vaccinations, in either the form of shots

or drops. If the child had ever received

a vaccination, respondents were then

asked whether the child had received

each specific vaccine (DTP, Polio,

MMR, Hib, and Hep B), and, if so, the

number of doses they had received for

each one. Besides the standard questions

about the five recommended vaccines,

we added similar items about

vaccinations for smallpox, varicella, and

pneumococcal disease; children were

unlikely to have received any of these

vaccines (this study was done before the

varicella vaccine was given regularly),

and these items were included to

determine whether respondents had a

general tendency to overreport

vaccinations. Finally, the standard

vaccination history questions included

an item assessing the child’s global

vaccination status (‘‘In your opinion, has

[child] received all of the recommended

shots for his/her age?’’).

In addition to the vaccination

history items, the questionnaire

included items assessing the

respondents’ knowledge about

vaccines. For each vaccine, the

respondent was asked what illness or

illnesses the vaccination was intended

to prevent, and how many doses the

child was supposed to have received

by 2 years of age. Finally, the last

section of the questionnaire collected

basic demographic information about

the respondent.

Procedure

Each respondent was paid $30 to

travel to the NORC Chicago office to

participate in a 20-minute interview.

Three interviewers completed a total of

221 interviews. Respondents were

presented the questionnaire under one of

eight conditions, produced by crossing

calendar (medical events calendar

versus no calendar), show card

(immunization show card versus no

show card), and presentation order

(global or specific vaccination items

first) variables according to a 2×2×2

factorial design.

The calendar-aided questionnaire

attempted to create a rich set of

contextual and chronological cues to

prompt accurate recall of the number

and dates of each vaccination. Under

this approach, half of the respondents

recorded health-related information on

a medical events calendar before they

answered the five standard vaccination

questions. After completing the

calendar, the respondents were

administered the standard

questionnaire items. The

calendar-aided questionnaires were

contrasted with questionnaires that

included only the standard vaccination

questions. The second experimental

variable was whether the respondent

was presented a show card that listed

each vaccination and the number of

doses recommended by 2 years of age

(see Appendix I). In half of the

questionnaires, respondents were given

a show card while answering the

standard vaccination questions; in the

remaining half, respondents answered

the vaccination questions without the

aid of the show card. The final

experimental variable was the order in

which global and specific vaccination

questions were asked. In half the

questionnaires, the global vaccination

status item came after the questions

about the specific vaccines; in the

remaining half of the questionnaires,

the global item preceded the items on

each vaccination series.

Page 4 [ Series 6, No. 8
Collection of Vaccination

Record Data

At the conclusion of the interview,

respondents were asked to list all of the

medical providers from which the child

had received medical care and to sign a

permission form giving the investigators

access to the child’s medical records

(NCHS Institutional Review Board

clearance was obtained for all

information-gathering procedures used

in this research project). Any additional

medical providers (beyond those at the

clinic from which the children had

originally been selected) were contacted

and asked to provide information about

the vaccinations they had administered

to the sample child. Completed medical

records were obtained for 189 of the

221 sample children (85.5 percent).

Coding of Parental Reports and

Medical Record Data

Measures of the accuracy of

parental reports about their child’s

vaccination status were derived by

comparing the respondent’s answers to

the questionnaire items with the

child’s medical records. Based on the

questionnaire data, children could be

classified as being reported up to date

for each vaccine (if the number of

doses reported for the vaccine matched

or exceeded the recommended

number) or not up to date. Similarly,

the child’s overall (4-3-1-3-3) up to

date status could be determined from

the medical records. Although there

are multiple performance measures

that can be used (4), four measures of

the accuracy of the respondents’

reports for each vaccine were

constructed:

1. The net bias (the difference between

the percent classified as up to date in

the two data sources)

2. The parental report false negative

rate (the proportion of children

reported as NOT up to date in the

questionnaire who were classified as

up to date based on medical record

data)

3. The false positive rate (the

proportion of children reported as up

to date in the questionnaire who

were classified as NOT up to date

based on medical record data)

4. The phi correlation between the

questionnaire report and medical

records regarding up to date status

The net bias indicates whether

respondents, in aggregate, have

misreported (either overreported or

underreported) the child’s vaccination

status. The false negative and false

positive rates measure the frequency of

the two types of errors (of omission and

of commission) that parents may make.

The phi correlation captures the

magnitude of the relationship between

the parent’s report and the vaccination

record; a higher degree of agreement

between these two sources of

information yields a higher value.

Results

Overall Accuracy

In general, there was little

relationship between parental reports

and the child’s actual vaccination status.

Reports concerning whether the child

had ever received each vaccine,

regardless of the number, were first

examined. Table B shows the various

measures of accuracy of parents’

responses to questions concerning

whether the children had ever received

each of the five basic vaccines. There

was a significant relationship between

the parental report and the vaccination

record only for the MMR vaccine

(Chi-square (1) = 10.14, p <0.01) and

the Hepatitis B vaccine (Chi-square (1)

= 10.47, p <0.01). Although false

negative rates were generally below

5 percent (Hib is an exception), the false

positive rates were quite high, ranging

from 67 to 100 percent, indicating that

regardless of whether the child had

received a given vaccine, the

respondents were prone to report that he

or she had received it. It should be

noted, however, that the sample sizes

used to calculate false-positives were

generally small, since most children had

received at least one dose of each

vaccine.

Overreporting was also evident on

the questions concerning vaccines the

children were unlikely to have received:

the smallpox, varicella, and

pneumococcal vaccines. The smallpox

vaccine is no longer administered in the

United States, the varicella vaccine was

being introduced at the time of this

survey, and the pneumococcal vaccine is

rarely given to children. However,

24 percent of the respondents reported

that their child had received the

smallpox vaccination, 30 percent

reported the varicella vaccine, and

3 percent reported the vaccine for

pneumococcal disease.

Table B. Memory-Aid Study: Percent of children who had ever received a vaccination according to medical records and respondents, and

parental response accuracy measures

Vaccine (n)

1

Percent who

received

according to

records

Percent who

received

according to

respondents

Net

bias

False negative False positive

Rate (n) Phi 2 Rate (n)

3

DTP . . . . . . . . . . . . . . . . . . . . 185 95.1 99.5 4.4 0.6 (176) 100 (9) −0.02

Polio . . . . . . . . . . . . . . . . . . . . 185 94.6 98.9 4.3 1.1 (175) 100 (10) −0.02

MMR . . . . . . . . . . . . . . . . . . . . 181 80.1 92.8 12.7 4.1 (145) 80.6 (36) 0.24

Hib . . . . . . . . . . . . . . . . . . . . . 166 94.6 81.3 −13.3 17.8 (157) 66.7 (9) 0.09

Hepatitis B . . . . . . . . . . . . . . . . 176 75.6 92.6 17.0 3.8 (133) 81.4 (43) 0.24

1Totals are less than 189 because of ‘‘Don’t Know’’ and ‘‘Refusal’’ answers, and because of interviewer coding errors.

2(n) is the number of children who had received a shot of this type, and is the base for potential false negative parental reports.

3(n) is the number of children who had NOT received a shot of this type, and is the base for potential false positive parental reports.

NOTE: Reports are in response to the question ‘‘Has [child] ever received a (shot/vaccine)?’’

Series 6, No. 8 [ Page 5
A second analysis ascertained the

child’s up to date status by taking into

account the number of each vaccine that

was both reported and received. Table C

shows the levels of accuracy, by

vaccine, and for the global status

(4-3-1-3-3) question, for respondents

who reported that the sample child had

received at least one dose of each

vaccine (or who had ever received a

vaccine, in the case of the global item),

and who were then asked either the

number received (for the individual

vaccines) or whether their child was up

to date (for the global question). Using a

percent of up to date reports

ccording to both provider records and

respondent reports as data, reports were

found to be significantly more accurate

than chance only for the global item

(Chi-square (1) = 10.11, p <0.01) and

for MMR (Chi-square (1) = 4.55,

p <0.05).

However, even for those items,

there were high levels of error in the

respondents’ reports. On the global

status item, about 83 percent of the

respondents whose children were not up

to date, according to medical records,

reported that the children had received

all of their recommended vaccinations.

The net bias on the global status item is

quite large (53.4 percent) and is in the

direction of overreporting. Similarly,

almost all respondents indicated that

their children had received one or more

doses of the MMR vaccine (only one

dose is recommended), including 26 of

27 of the respondents reporting on

children who had not received that

vaccine, according to their medical

records.

In contrast to the global status and

MMR questions, responses to the

questions about three of the four other

specific vaccines show net

underreporting. These four vaccines all

require three to four doses. The false

negative rates for these vaccines ranged

from 44 percent for polio to 56 percent

for Hib; that is, about half the

respondents whose children had received

all the recommended doses for these

vaccines did not report that the child

had received enough doses for them to

be up to date. For each of these

vaccines, the false-positive rates are

somewhat lower (ranging from about 41

to 44 percent) but indicate that a number

of parents also mistakenly overreport

their child’s status. Chance levels of

accuracy would yield false negative and

false positive rates that do not differ

significantly from 50 percent. In fact, for

the four vaccines involving multiple

recommended doses, the phi

correlations, false positive rates, and

false negative rates all indicate

approximately chance levels of

accuracy. Interestingly, although a

small sample was used in this study,

the pattern of over- and underreporting

of single vaccines was markedly

similar to those reported by

Ezzati-Rice and colleagues (4).

Overall then, respondents were not

very accurate in reporting how many

vaccinations their children received. The

results suggest that many respondents

were uncertain about their child’s

vaccination status and had a tendency to

respond that the child had received each

of the vaccinations they were asked

about. This tendency leads to overreporting on the global question and the

questions concerning whether the child

had ever received a particular vaccine.

Further, because respondents were

uncertain about the number of doses the

child received, those reporting about up

to date children were likely to

underreport the number of doses and

those reporting about children who were

not up to date were likely to overreport

the number.

Effects of the Experimental

Variables

The three experimental variables

(use of the calendar, presentation of the

show card, and global question order)

had little impact on whether the

respondent’s report agreed with the

records regarding the child’s up to date

status. As table D shows, parents’

accuracy was similar across the eight

versions of the questionnaire. The mean

number of vaccines for which parents

reported their child’s status accurately

did not differ significantly across

versions of the questionnaire

(F(7,181) = 0.77, n.s.). There appears to

be a drop in accuracy for the two

versions in which neither a calendar nor

a show card was presented. However,

when accuracy in these versions (that is,

Table C. Memory-Aid Study: Child’s vaccination status according to medical records and respondents, and parental response accuracy

measures

Vaccine (n)

1

Percent

up to date

according to

records

Percent

up to date

according to

respondent

Net

bias

False negative False positive

Rate (n)

2 Rate (n)3 Phi

DTP . . . . . . . . . . . . . . . . . . . . 158 70.9 45.6 −25.3 52.7 (112) 41.3 (46) 0.05

Polio . . . . . . . . . . . . . . . . . . . . 165 78.2 52.7 −25.5 44.2 (129) 41.7 (36) 0.12

MMR . . . . . . . . . . . . . . . . . . . . 149 81.9 99.3 17.4 0.0 (122) 96.3 (27) 0.17

Hib . . . . . . . . . . . . . . . . . . . . . 123 81.3 43.9 −37.4 56.0 (100) 43.5 (23) 0.00

Hepatitis B . . . . . . . . . . . . . . . . 142 45.8 47.2 1.4 49.2 (65) 44.2 (77) 0.07

Global . . . . . . . . . . . . . . . . . . . 189 34.9 88.4 53.5 1.5 (66) 82.9 (123) 0.23

0.0 Quantity more than zero but less than 0.05.

1(n) is the number of children for whom parents reported that the child had ever received this vaccination, or for the Global (4–3–1–3–3) measure, that the child had received ANY vaccination.

2(n) is the number of children who had received at least the recommended number of vaccines of that type (or who were globally up to date), and who provide the basis for false negatives through

parental reporting of fewer shots (or, a report that the child was globally not up to date).

3(n) is the number of children who had received LESS than the recommended number of vaccines of that type (or who were globally NOT up to date), and who provide the basis for false positives

through parental reporting of a greater number of shots (or, a report that the child was up to date).

NOTE: Reports are in response to the question ‘‘How many (shots/vaccines) did [child] ever receive?’’

Page 6 [ Series 6, No. 8
mean number of vaccines reported

accurately) is directly compared to

accuracy in the versions using a

memory aid, no significant differences

are found (F(1,187) = 2.13, p <0.15).

Analyses of reporting on individual

vaccines showed similar results.

Three-way logit analyses were carried

out examining the effects of the

experimental variables on answers to the

global question and the five questions

on specific vaccines. There was only

one significant effect out of 42 possible

(7 effects in each model × 6 models).

Knowledge About Vaccinations

One possible explanation for the

respondents’ low accuracy is their

failure to encode the relevant

information when the vaccines were

given to children. Even if respondents

knew the child had been vaccinated,

they may not have been told by the

physician what the vaccine was for, or

they may have found it difficult to

understand what they were told. This

hypothesis was tested by comparing the

reports of parents who demonstrated a

high level of knowledge about

vaccinations with those demonstrating a

low level. A knowledge score that

combined accuracy in naming the

diseases the vaccines are intended to

prevent and accuracy regarding the

number of recommended doses was

calculated for each respondent.

Respondents were divided into two

groups based on the median knowledge

score. Those above the median in their

knowledge about vaccinations gave

more accurate reports than those below

it, correctly reporting the child’s status

on an average of 2.6 out of the 5

vaccines (versus 1.7 for the respondents

below the median); t (170) = −4.11,

p <0.01. Because half of the respondents

received a show card listing the

vaccines and their recommended doses,

this should have improved their

knowledge scores. Respondents who

received the show card were more

accurate on the questions about the

number of recommended doses for each

vaccine (answering an average of 2.1

versus 1.5 for no-show card group);

t (187) = −2.45, p <0.05. However, as

already reported, the show card itself

did not improve accuracy on the key

vaccination-history questions.

In general, respondents’ knowledge

about vaccinations was quite limited.

For instance, on DTP, 47 percent of the

respondents were unable to name even

one disease prevented by the vaccine

and only 9 percent could name all three.

The results were similar for the other

vaccines, with the exception of Hepatitis

B. Perhaps because of that vaccine’s

name, 78 percent were able to identify

the disease prevented by the Hepatitis B

vaccine. Performance was also poor on

the items assessing knowledge of the

number of doses recommended for each

vaccine.

Discussion

The most striking findings from the

Memory-Aid Study were the low levels

of reporting accuracy and the effects of

knowledge about vaccinations on

accuracy. Overall, respondents

performed barely above chance in

reporting the vaccination status of

sample children. Further, none of the

three experimental variables (calendar,

show card, and order of global and

specific questions) had significant effects

on reporting accuracy. A further pattern

found in the study is that when a child

has never received a particular vaccine,

parents tend to falsely report that the

child had received it.

The best predictor of accuracy was

the level of knowledge about the

vaccinations. It is possible that many

respondents have difficulty encoding

information about the vaccinations their

children received at each visit to the

doctor simply because they lack the

necessary background knowledge. This

suggests that procedural variations

designed to prompt fuller recall, such as

those tested in the Memory-Aid Study,

will have limited impact, since

respondents have stored little

information in memory in the first place.

To test this hypothesis, in the next study

parents’ encoding of information about

the vaccines their children had received,

as well as the time course of forgetting

of this information, were examined more

directly.

Encoding Study

Introduction

This study examined two sources of

error that may reduce the accuracy of

parental reports. First, parents’ reports

may be in error because they encoded

little information about the vaccinations

at the time they were administered. If

information is not well encoded initially,

the accuracy of reports will be low

regardless of available retrieval cues.

Second, parents’ memories about

vaccinations may degrade over time. In

this study, an attempt was made to

measure both encoding and forgetting

by assessing parents’ recall of

vaccinations immediately and 10 weeks

after a doctor visit. If poor encoding is

the source of reporting errors, reporting

accuracy should be low even when

parents are interviewed immediately

after the child’s visit to the doctor. If

memory retention is a problem, then

performance after 10 weeks should be

Table D. Memory-Aid Study: Mean number of vaccines reported accurately by parents and

percent of parents who reported accurately on the global question

Global question

Calendar No calendar

Show

card

No show

card

Show

card

No show

card

Mean number of vaccines for which parents

reported child’s status accurately

Global first . . . . . . . . . . . . . . . . . . . . . 2.1 2.0 2.5 1.9

Global last . . . . . . . . . . . . . . . . . . . . . 2.6 2.1 2.1 1.8

Percent of parents who reported accurately

on the global question

Global first ..................... 52.2 48.1 52.0 27.3

Global last ..................... 55.6 52.4 42.1 32.0

Series 6, No. 8 [ Page 7
markedly lower than immediately after

the doctor’s visit.

Parents whose children had just

received one or more vaccinations were

interviewed as they left a vaccination

clinic at a private health maintenance

organization in Oakland, California.

Parents were asked which vaccines, if

any, their child had received that day.

The parents’ reports were compared

with the clinic’s records. This

comparison provided a basis for

assessing the accuracy of the initial

encoding of information about the visit,

since the interval between encoding and

retrieval was only a few minutes. To

examine how this information was

transformed in memory over time,

respondents were contacted again after

10 weeks had elapsed. At the same time,

we interviewed an additional group of

parents whose children had also been

vaccinated at the clinic during the same

period as the first group of respondents,

but who were not interviewed

previously; this comparison group

allowed us to determine whether the

initial interview affected the encoding

and retention of information in memory.

Method

Sample

Respondents were parents of

children who were patients at a private

pediatric clinic in Oakland, California.

All of the children were less than 7

years of age. Of the parents interviewed,

81 percent were the mothers of the

children and 19 percent were fathers.

Respondents were highly educated, with

97 percent having completed high

school and 46 percent having obtained a

college degree.

Procedure

Data were collected in two waves.

During the first wave, two NORC

interviewers visited the vaccination

clinic and were stationed outside of the

clinic exit. Parents arrived at the clinic

with their child and signed the clinic’s

consent form, which listed the names of

the vaccines that the child was to

receive that day. Parents were also given

an information sheet that described the

risks and benefits of each vaccine. After

the child was vaccinated, a doctor or

nurse either filled out the child’s

vaccination card or gave them a new

card. As they were leaving the clinic, an

interviewer asked them to participate in

the survey. A total of 103 parents agreed

to take part. About two-thirds of these

parents (n = 70) completed a short

interview about their child’s medical

visit and also provided information to

enable investigators to contact them

later (parents were instructed not to

refer to shot records during

administration of the interview). The

remaining parents (n = 33) were asked

only for locating information so they

could be contacted later. Every

respondent was asked to sign a form

giving the researchers permission to

obtain information from the child’s

medical record regarding that day’s

visit.

The second wave of data collection

was done by telephone 10 weeks after

the initial data collection. Of the 103

respondents, 80 were successfully

contacted and reinterviewed. Of these

80, 54 had been asked the vaccination

questions 10 weeks earlier and the

remaining 26 had not. In Wave 2,

respondents were asked about the

medical treatment the child received

during his or her doctor visit 10 weeks

earlier.

Questionnaires

The questionnaire gave respondents

two opportunities to report vaccinations.

First, respondents answered a general

(‘‘free recall’’) question that asked what

had happened during the medical visit

that day (‘‘To start off, would you tell

me in your own words what happened

during the child’s visit today?’’). Later,

respondents were asked more specific

questions (‘‘cued recall’’) about whether

the child had received any shots that

day and the purpose of the shots (‘‘Did

[child] get any shots today? What were

the shots for?’’). The follow-up

questionnaire used when parents were

contacted 10 weeks later was essentially

the same, but with minor changes to

reflect the passage of time (see

Appendix II).

Coding of the Parents’

Responses

A comparison of answers to the free

recall and cued recall questions revealed

virtually no differences between the two

sets of responses. For example, 36

parents reported the polio vaccine in

response to the free recall question, and

38 parents reported it in the cued recall

question. The phi correlations between

the two types of questions were highly

significant for all five vaccines, with the

lowest being 0.71 for Hib. Therefore,

responses to the two types of questions

were combined in the remaining

analyses, so that if a parent reported that

the child had received a vaccine in

response to either item, the parent was

counted as having reported the vaccine.

Further, a parent was counted as

reporting a particular vaccination even if

the respondent only named one

component of the vaccine (for example,

‘‘measles’’ for MMR). If a parent had

indicated that the child received the

combination Hib/DTP shot, or

‘‘Tetramune,’’ both Hib and DTP were

counted as having been reported.

As in the Memory-Aid Study, four

measures of accuracy were constructed

by comparing the parent’s report with

the vaccination record. These accuracy

measures were the net bias (the

difference between the proportions of

children who received the vaccine

according to the medical record and the

parent’s report), the false negative rate

for each vaccine (the proportion of

children who received the vaccine

according to the record but whose

parents did not report it), the false

positive rate (the proportion of children

who did not receive the vaccine but

whose parents reported it), and the phi

correlation between the parent’s report

and the medical record.

Results

Accuracy of Wave 1 Responses

Even immediately after the

vaccinations had been administered,

most parents had little knowledge about

which vaccinations their children had

received that day. Although children had

received an average of three

Page 8 [ Series 6, No. 8
vaccinations during their visit to the

clinic, parents correctly named only

about half of these; across the five shots,

the false negative rate averaged

49 percent. Parents also occasionally

reported shots their children had not

received (overall, the false positive rate

was 18 percent) but, in general,

underreporting was more prevalent than

overreporting. McNemar tests showed

significant underreporting for every shot

except MMR (all p’s <0.01, which was

significantly overreported (z = 3.21).

Overall, only two vaccines (DTP and

Polio) were reported with better than

chance accuracy (Chi-square (1) = 7.01,

p <0.01 for DTP and Chi-square (1) =

12.17, p <0.1 for polio), and even these

two were systematically underreported.

Table E lists the four accuracy

measures by vaccine for the Wave 1

reports. The type and magnitude of the

reporting errors differed greatly by

vaccine. The four vaccines that most of

the children had received—Hepatitis B,

DTP, Polio, and Hib—were generally

underreported, with the net bias ranging

from −24.3 percent to −64.3 percent.

The tendency toward underreporting of

these four vaccines was also apparent in

the high false negative rates, which

ranged from 33.9 percent for polio to

86.5 percent for Hib. Averaging across

the five vaccines, parents were about as

likely not to report a vaccine their child

had received as to report it.

Hib was the most underreported

vaccine of all, which is consistent with

the results of the Memory-Aid Study. As

the false negative and false positive

rates demonstrate, many parents

mistakenly reported that their child did

not receive this vaccine and no parents

mistakenly reported that the child did

receive it. The tendency to not report

Hib—whether or not the child actually

received it—could be due to its

complicated name and the unfamiliarity

of the relevant disease (a form of

meningitis). Overall, as the Memory-Aid

Study demonstrated, many parents are

completely unfamiliar with the Hib

vaccine.

The general tendency to underreport

was apparent for all vaccines except

MMR. Only one dose of MMR is

required by 2 years of age, but the

results of the Memory-Aid Study

suggested that parents are relatively

more familiar with this vaccine

(especially the measles component) than

the others. This greater familiarity with

the vaccine may account for the

overreporting. Although only 4.3 percent

of the children received the vaccine

during their visit, 21.4 percent of parents

reported it.

Accuracy of Wave 2 Responses

After a 10-week period, parental

reports were only slightly less accurate

than they were immediately after the

vaccinations were given (table F). In the

second wave of data collection, reports

about DTP and polio were still

significantly related to whether the child

had received these vaccinations (for

DTP, Chi-square (1) = 8.54, p <0.01; for

polio, Chi-square (1) = 4.75, p <0.05).

The average false negative rate during

Wave 2 was 54.6 percent, only a slight

increase over the 49.4 percent

average rate in Wave 1. The average

false positive rate across the five

vaccines—14.1 percent in Wave 1—

rose only to 18.2 percent in Wave 2.

These slight increases in the error rates

may reflect some memory loss.

Table F reveals that differences in

accuracy across the types of vaccines

are just as apparent in Wave 2 as they

were in Wave 1. For the four shots

received by most of the children

(Hepatitis B, DTP, Polio, Hib),

underreporting was common and the net

biases were negative. This is apparently

due to the fact that so many children

received these four shots, creating more

opportunities for false negatives than for

false positives. For MMR, which few of

the sample children actually received

that day, net overreporting was

observed.

Comparison of Wave 1 and

Wave 2

Phi correlations were computed to

examine the consistency between Wave

1 and Wave 2 reports for the 54

respondents who answered the

vaccination questions in both. These

correlations reveal that in Wave 2

parents tended to reproduce the answers

they gave 10 weeks earlier, regardless of

their accuracy (DTP, phi = 0.52; polio,

phi = 0.59; MMR, phi = 0.39; p <0.01

for all comparisons). In fact, comparing

the phi correlations between responses

in the two waves to the phi correlations

in tables E and F confirm that parents’

responses are generally more consistent

than they are accurate. McNemar tests

indicated that there was no significant

Table E. Encoding Study, Wave 1: Percent of children who received a vaccination during a specific visit according to medical records and

respondents, and parental response accuracy measures

Vaccine (n)

1

Percent

who

received

according

to records

Percent

who

received

according to

respondents

Net

bias

False negative False positive

Rate (n)

2 Rate (n)3 Phi

DTP . . . . . . . . . . . . . . . . . . . . 70 82.9 51.5 −31.4 41.4 (58) 16.7 (12) 0.32

Polio . . . . . . . . . . . . . . . . . . . . 70 80.0 55.7 −24.3 33.9 (56) 14.3 (14) 0.42

MMR . . . . . . . . . . . . . . . . . . . . 70 4.3 21.4 17.1 33.3 (3) 19.4 (67) 0.23

Hib . . . . . . . . . . . . . . . . . . . . . 70 74.3 10.0 −64.3 86.5 (52) 0.0 (18) 0.20

Hepatitis B . . . . . . . . . . . . . . . . 70 85.7 44.3 −41.4 51.7 (60) 20.0 (10) 0.20

0.0 Quantity more than zero but less than 0.05.

1(n) is the total number of children in the initial interview sample (those for whom parents completed an initial interview about the child’s medical visit).

2(n) is the number of children in the initial interview sample who had received a shot of this type, and is the base for potential false negative reports.

3(n) is the number of children in the initial interview sample who had NOT received a shot of this type, and is the base for potential false positive reports.

NOTE: Reports are in response to the question ‘‘What were the shots or immunizations [child] received for?’’, asked as the parents were leaving the clinic.

Series 6, No. 8 [ Page 9
forgetting (failure to report vaccinations

that they had previously reported) or

new reporting (reporting vaccines that

they did not report previously).

Further, to determine whether

previous questioning affected recall,

Wave 2 accuracy measures for the group

that was questioned about vaccines

during Wave 1 (n = 54) was compared

with those of the group that was not

(n = 26). The two groups performed

similarly in terms of false negative and

false positive reports. Chi-square tests

were then carried out to determine

whether there was a relationship

between being questioned previously

and reporting each vaccine (regardless

of whether vaccine was actually

received), or between being questioned

previously and reporting each vaccine

accurately. Respondents who were

previously questioned were more likely

to report Hepatitis B and less likely to

report MMR vaccinations than were

respondents not previously questioned

(for Hepatitis B, 38.9 percent versus

15.4 percent and, for MMR,

20.4 percent versus 42.3 percent;

p <0.05 for both comparisons).

However, there were no significant

effects for the other types of vaccines

and there were no significant

relationships between being questioned

previously and reporting accuracy. In

summary, previous questioning

increased the number of reports for

Hepatitis B and MMR, but did not

affect the accuracy of the reports for

any vaccines.

As a final analysis, although

previous studies have sometimes

focused on subgroup differences in

reporting accuracy (3), none of the

demographic characteristics of either the

respondents or of the sample children

were significantly related to reporting

accuracy in either Wave 1 or 2.

Discussion

The results from the Encoding

Study suggest that a major source of

vaccination-related reporting error may

be failure to encode the details of what

had occurred during the vaccination

episode. As they left the pediatric clinic

minutes after the child had been

vaccinated, only 12 respondents out of a

total of 70, or about 17 percent, reported

all of the vaccinations their children had

received and only those vaccinations.

Ten weeks later, the proportion declined

to 11 percent; only 9 out of 80

respondents accurately described the

vaccinations their children had received.

In both interviews, the relationships

between which shots were reported and

which shots the child had received were

little better than chance, despite the fact

that parents had signed consent forms

that listed the vaccines the child was

getting, received information sheets

about the vaccines, witnessed the

vaccinations themselves, and received a

shot record to take home (although they

were asked not to look at them during

the interview). It seems quite likely that

many respondents were aware that the

child received one or more vaccinations

during the visit, but that they were

simply guessing which ones.

Proxy Measures Study

Introduction

Taken together, the results of the

Memory-Aid Study and Encoding Study

suggest that further efforts to improve

recall for specific vaccinations (for

example, through enhancements to the

calendar) are likely to yield little payoff.

If parents never absorb the information

in the first place, they cannot recall their

children’s vaccinations later on. It may

be better to ask them instead about

events they can recall. One relevant type

of event that parents may find easier to

recall is their child’s visit to the

pediatrician’s office. If parents can

report accurately on their adherence to

the recommended schedule of well-baby

visits, then it may be possible to infer

the child’s vaccination status. Further, if

parents are reluctant to report accurately

to an interviewer because they do not

wish to reveal that their child is not up

to date, then a self-administered

questionnaire format, which allows more

confidential reporting, may help. The

Proxy Measures Study examined the

effectiveness both of the use of indirect

questions and of self-administration in

yielding accurate measures of children’s

vaccination status.

In the Proxy Measures Study, a set

of indirect questions that inquired

specifically about the child’s medical

visits was developed and tested. Parents

were asked whether their child always

had a usual source of care, whether the

child made all the recommended

Table F. Encoding Study, Wave 2: Percent of children who received a vaccination during a specific visit according to medical records and

respondents, and parental response accuracy measures

Vaccine (n)

1

Percent

who

received

according

to records

Percent

who

received

according to

respondents

Net

bias

False negative False positive

Rate (n)

2 Rate (n)3 Phi

DTP . . . . . . . . . . . . . . . . . . . . 80 80.0 45.0 −35.0 46.9 (64) 12.5 (16) 0.33

Polio . . . . . . . . . . . . . . . . . . . . 80 80.0 61.2 −18.8 32.8 (64) 37.5 (16) 0.25

MMR . . . . . . . . . . . . . . . . . . . . 80 2.5 22.5 20.0 50.0 (2) 26.9 (78) 0.08

Hib . . . . . . . . . . . . . . . . . . . . . 80 73.8 17.5 −56.3 78.0 (59) 4.8 (21) 0.20

Hepatitis B . . . . . . . . . . . . . . . . 80 86.3 31.3 −55.0 65.2 (69) 9.1 (11) 0.19

1(n) is the total number of children in the initial interview sample (those for whom parents completed an initial interview about the child’s medical visit).

2(n) is the number of children in the initial interview sample who had received a shot of this type, and is the base for potential false negative reports.

3(n) is the number of children in the initial interview sample who had NOT received a shot of this type, and is the base for potential false positive reports.

NOTE: Reports are in response to the question ‘‘What were the shots or immunizations [child] received for?’’, asked 10 weeks after the visit to the clinic.

Page 10 [ Series 6, No. 8
‘‘well-baby’’ visits, whether the child

received vaccinations during these visits,

and what the doctor said about the

child’s vaccination status. It was

concluded that answers to these

questions would provide a basis for

inferring, statistically, the child’s

vaccination status.

Further, patterns of overreporting in

the Memory-Aid Study pointed to the

possible influence of social desirability

on responses. Parents may be reluctant

to tell an interviewer that their child has

not received all their recommended

shots. Therefore, a self-administered

questionnaire may alleviate these

concerns by allowing parents to report,

without embarrassment, that their child

is not up to date. In the Proxy Measures

Study, data were collected through both

interviewer-administered and

self-administered questionnaires.

Method

Sample Selection

Subjects were the primary

caregivers of 2- and 3-year-old children

from the same pediatric clinic in

Chicago from which the Memory-Aid

Study respondents were recruited. The

initial goal was to interview 150

respondents. The clinic provided NORC

with a list of all 2- and 3-year-old

children who had been patients there

within the 12 months prior to sample

selection. Prior experience with the

clinic suggested that much of the

address and telephone information in

clinic records was outdated. As a result,

a large sample of 599 children was

fielded, and field work was continued

until 153 cases were completed.

Record checking was done

prospectively: Interviewers trained in

medical records abstraction obtained

vaccination records for each child. Data

sufficient to determine whether the child

was up to date on all vaccinations were

available for 134 of the 153 children.

Complete data from all providers the

parent listed was obtained for 118

children; for 16 cases, the data from one

or more providers were missing, but the

interviewer was still able to determine

that the child had received all the

recommended shots based on the records

collected. Thus, the sample size was 134

in some analysis and 118 for others

requiring complete data. Data were not

available for the remaining children

primarily for one of two reasons: the

records could not be located by the

provider or the provider did not respond

to repeated requests for the records.

Questionnaires

The questionnaire included the

standard vaccination questions that

appear in the NIS and NHIS surveys

(see Appendix III). As in the

Memory-Aid Study, additional items on

the smallpox, pneumococcal disease,

and varicella vaccines were included as

well. While answering the standard

questions, respondents viewed a show

card that listed recommended vaccines

and the number of doses that children

should receive before 2 years of age.

Immediately after the questions on the

individual vaccines, respondents were

administered the global question, in

which they were asked whether the

child had received all recommended

shots for his or her age. The

questionnaire also included, in the final

two sections, items that tested the

respondent’s knowledge about

vaccinations and a set of demographic

questions.

A major purpose of the Proxy

Measures Study was to determine

whether the child’s vaccination status

could be determined from the parent’s

responses to an additional set of

questions about the child’s pediatric

care, in order to assess whether

responses to these indirect questions

provided the basis for a more accurate

classification of the children than the

parents’ responses to the standard

questions on vaccinations. The indirect

questions appeared either directly before

the standard vaccination questions or

immediately after them.

The second experimental variable

was whether the questionnaire was

self-administered (SAQ) or administered

by an interviewer (IAQ). In the IAQ

condition, the interviewer both read the

questions and recorded the respondent’s

answers. In the SAQ, the respondent

read and completed a paper

questionnaire without help from the

interviewer; the interviewer was present

but did not observe the answers given

by the respondent.

Procedure

Six experienced interviewers were

trained to recruit and interview

respondents at their homes. The family

member listed in the clinic record as the

child’s guardian (usually the mother)

was contacted. In most cases, this

person had primary responsibility for the

child’s health care or was able to refer

the interviewer to the person with

primary responsibility, who then served

as the respondent for the study.

Respondents were then sent a letter

explaining the purpose of the study, and

an interviewer visited the household and

conducted the interview in person.

These interviews lasted an average of 20

minutes.

The children about whom the

parents were interviewed ranged in age

from 24 to 47 months. All of the

respondents were female, about

three-quarters had at least a high school

degree, and about 16 percent of them

were currently married, with the

remainder being single or formerly

married.

At the conclusion of the interview,

respondents were asked permission to

use vaccination information from the

child’s medical records and to indicate

all the sources from which their child

had received medical care. For

respondents who gave consent, these

additional doctors were contacted and

asked to provide information about the

vaccinations they had administered to

the respondent’s child. Only one

respondent declined to give consent to

obtain vaccination records, and no

medical records were obtained for this

case.

Coding of Parents’ Reports

The parental reports were analyzed

in the same way as in earlier studies.

For each child, it was determined

whether the child was up to date on

each vaccine, based on the parent’s

report and the medical records. Reports

about the number of doses of each

Series 6, No. 8 [ Page 11
vaccine that the child had received were

used to determine whether the child was

up to date for that vaccine. Overall

reports of up to date status were based

on answers to the global question, ‘‘In

your opinion, has [CHILD’S NAME]

received all of the recommended shots

for his or her age?’’

Results

Overall Accuracy

As table G shows, similar to the

previous experiments, parents frequently

incorrectly reported their child’s overall

vaccination status on the global question

and their status on each vaccine. Unlike

the first (Memory-Aid) study, the errors

were all in the direction of

overreporting, with significant levels of

overreporting (by McNemar test) for

DTP (z = 2.19, p <0.05), MMR

(z = 4.90, p <0.01), Hepatitis B (z = 2.11,

p <0.05), and the global status item

(z = 7.95, p <0.01).

Clearly, parents have difficulty

reporting the actual number of vaccines

their child received. They were no more

accurate in reporting whether their child

had ever received a vaccine. Among the

small number of children not receiving a

particular vaccine, parents usually

incorrectly reported that the child did

receive the vaccine. False positive rates

ranged from 89 to 100 percent across

the five vaccines; phi correlations

ranged from −0.08 to 0.04.

Overreporting was also evident in

responses to the varicella, pneumococcal

disease, and smallpox items. Although

the medical records indicated that only

7 children in the sample had received

the varicella vaccine, 27 parents

(23 percent) reported that their child had

received it (these analyses are based on

the 118 children for whom complete

vaccination records could be obtained).

Four of these parents were correct in

their assessment and 23 were mistaken.

Even though the smallpox vaccine is no

longer given, 14 parents (12 percent)

believed that their children had been

vaccinated against this disease. Further,

four parents (3 percent) reported that

their child received the vaccine for

pneumococcal disease; the records

indicated that none of the children

received it. The relatively low number

of false positives on pneumococcal

disease (compared with varicella and

smallpox) suggests that parents base

their responses in part on how familiar

they are with a particular vaccine. As

was the case with the Hib vaccine,

parents may be more likely to indicate

their child has received a vaccine or to

overreport the number of doses received

if they have heard of it.

Effects of Questionnaire Mode

and Order of the Indirect

Questions

Although the overreporting of

overall up to date status in the

Memory-Aid Study might be due to

effects of social desirability, no evidence

was found that collecting the data via

self-administered questionnaires

improved the accuracy of reports. Of the

parents who completed an IAQ,

91 percent reported their child as up to

date, versus 95 percent of those who

completed an SAQ (Chi-square (1) =

0.84, n.s.). In addition, the mean number

of doses reported for each vaccine was

quite similar for those who completed

the SAQ and the IAQ. Likewise, the

percent reporting up to date status

correctly did not differ by mode of data

collection or whether the indirect

questions came before or after the

standard questions (see table H).

Inferring Vaccination Status

From Indirect Questions

Contrary to expectation, parents’

reports about events related to vaccination

status did not predict actual status. There

was little variability in the responses to

these items. Most parents indicated that

they had always had a regular doctor for

their child (97 percent), that they made all

well-baby visits (87 percent), and that the

doctor had not indicated that the child was

behind in his or her vaccinations

(88 percent). An examination was made of

the relationship between whether the child

was up to date according to the records

and whether the parent reported that the

child had always had a regular doctor,

made all the well-baby visits, and was

never said to be behind in his or her shots.

As table J shows, phi values were near

zero, and none of these three measures

was significantly related to actual up to

date status.

Table G. Proxy Measures Study: Child’s vaccination status according to medical records and respondents, and parental response accuracy

measures

Vaccine (n)

1

Percent

who

received

according

to records

Percent

who

received

according to

respondents

Net

bias

False negative False positive

Rate (n)

2 Rate (n)3 Phi

DTP . . . . . . . . . . . . . . . . . . . . 118 65.3 78.0 12.7 20.8 (77) 75.6 (41) 0.04

Polio . . . . . . . . . . . . . . . . . . . . 117 70.1 72.6 2.5 28.0 (82) 74.3 (35) −0.02

MMR . . . . . . . . . . . . . . . . . . . . 115 79.1 100.0 20.9 0.0 (91) 100.0 (24) 0.00

Hib . . . . . . . . . . . . . . . . . . . . . 98 69.4 79.6 10.2 20.6 (68) 80.0 (30) 0.01

Hepatitis B . . . . . . . . . . . . . . . . 106 51.9 65.1 13.2 27.3 (55) 56.9 (51) 0.17

Global . . . . . . . . . . . . . . . . . . . 129 41.1 93.0 51.9 7.3 (53) 90.8 (76) 0.11

0.0 Quantity more than zero but less than 0.05.

1(n) is the total number of children in the initial interview sample (those for whom parents completed an initial interview about the child’s medical visit).

2(n) is the number of children in the initial interview sample who had received a shot of this type, and is the base for potential false negative reports.

3(n) is the number of children in the initial interview sample who had NOT received a shot of this type, and is the base for potential false positive reports.

NOTE: Reports are in response to the question ‘‘How many (shots/vaccines) did [child] ever receive?’’

Page 12 [ Series 6, No. 8
Discussion

In the final Proxy Measures Study,

the approach taken attempted to sidestep

problems related to reporting errors due

to encoding failure by asking questions

instead about information the respondent

was likely to have encoded—in

particular, whether the child had missed

any well-baby visits. Further, an attempt

was made to reduce social desirability

pressures by using self-administered

questionnaires. Neither of these methods

increased the accuracy of the parents’

reports. The direction of reporting errors

suggests that parents were not simply

guessing when they did not know their

child’s vaccination status, but were

systematically overreporting. This

overreporting was as common in the

self-administered condition as it was

under interviewer administration.

General Discussion

One consistent finding from all

three experiments is that,

consistent with past research,

parents’ unaided reports about their

children’s vaccination status were

inaccurate. Similarly, across vaccines,

there were high rates of both types of

errors—reports that children had not

received all the recommended doses

when the records indicated that they

had, and reports that children had

received all the recommended doses

when the records showed that they had

not. Leaving aside MMR (for which

only a single dose is recommended), for

those reporting that the child had

received a vaccine at least once, the

false negative rates for the vaccines in

the Memory-Aid and Proxy Measures

Studies ranged from 20.6 to

56.0 percent; the false positive rates

ranged from 41.3 to 80.0 percent. For

MMR, the rate of false positives was

near 100 percent in both studies.

What accounts for these low levels

of accuracy? Three possible sources of

error in parents’ reports were

examined—encoding failure, forgetting,

and deliberate misreporting. Of these,

the evidence most strongly supports

encoding failure as a source of reporting

error. In the Encoding Study, parents

had difficulty identifying the shots their

children received minutes after they had

received them; only about one

respondent in six was able to report

accurately the vaccines their children

received that day. It is possible that the

respondents would have done better had

the interviewer used a more sensitive,

recognition-based test, rather than a

cued recall item. Still, the respondents

had several opportunities to learn which

Table H. Proxy Measures Study: Mean number of doses of each vaccine reported by parent, percent of parents who correctly identified the

number of doses their child received, and the percent who correctly indicated that their child had received the recommended number of

doses, by type of vaccine and experimental variable

Vaccine (n)

1

Self-administered (SAQ) Interviewer administered (IAQ)

Standard

questions

first

Proxy

questions

first

Standard

questions

first

Proxy

questions

first

Mean number of doses reported by the parent

DTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 3.5 3.6 3.7 3.6

Polio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 3.0 3.1 3.0 2.9

MMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 1.0 1.2 1.1 1.1

Hib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 3.0 3.0 2.5 2.6

Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 2.3 2.1 2.1 2.8

Percentage of parents who correctly identified the

number of doses their child received

DTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 42.3 34.4 42.3 50.0

Polio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 42.3 28.1 23.1 38.2

MMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 53.9 56.3 53.9 73.5

Hib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 34.6 28.1 23.1 23.5

Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 34.6 34.4 34.6 32.4

Percentage of parents who correctly indicated whether or

not their child had received at least the number of

recommended doses

DTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 53.8 46.9 57.7 64.7

Polio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 53.8 53.1 50.0 55.9

MMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 61.5 62.5 69.2 82.4

Hib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 50.0 62.5 46.1 47.1

Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 65.4 56.3 42.3 64.7

Percentage of parents who correctly indicated that their

child either was or was not up to date, overall

Global question . . . . . . . . . . . . . . . . . . . . . . . . . 118 42.3 37.5 23.1 44.1

1(n) is the sample size.

NOTE: This table includes only the 118 cases for which all medical records were available.

Series 6, No. 8 [ Page 13
vaccines the child was to receive that

day. Further, an additional finding

supports an encoding failure hypothesis;

in the Memory-Aid Study, the more

respondents knew about the vaccines,

the more accurately they reported. In

general, respondents’ knowledge about

the vaccinations was very limited. Few

respondents, for example, knew the

number of doses recommended for each

vaccine (see table K). Knowledge about

the vaccines might serve to facilitate

encoding of vaccinations at the time

they were given.

There is less evidence from this

study that retrieval failure accounts for

much inaccuracy. Some losses over time

were observed in the Encoding Study;

the proportion of respondents who

correctly reported which vaccines their

child received during the relevant visit

dropped slightly over 10 weeks. On the

whole, though, there was surprising

consistency between the immediate

reports and those given 10 weeks later.

The respondents in the Encoding Study

seemed to remember what they knew at

the time of the first interview well

enough; the problem was that this

information was generally inaccurate.

The failure to find any significant effects

of either the calendar or show card in

the Memory-Aid study also suggests

that forgetting was not an important

source of error; if memory failure is not

responsible for most misreporting,

memory aids will, of course, not have

much effect on reporting accuracy.

The evidence from this study is less

clear regarding the influence of

deliberate misreporting as a source of

error. Self-administration often increases

the proportion of respondents willing to

make embarrassing admissions (21). If

respondents are willing to admit they

use illicit drugs on self-administered

questionnaires, it seems unlikely they

would withhold the information that

their child had missed a vaccination or a

well-baby visit. However, the Proxy

Measures Study produced no indication

that self-administration or the use of

indirect (and presumably less sensitive)

questions reduced reporting errors. On

the other hand, when respondents were

asked the overall vaccination status of

their children in both the Memory-Aid

and Proxy Measures Studies, they

tended to overreport the proportion of

children who had received all the

recommended vaccinations. There is

some evidence, then, of a general

tendency toward overreporting on the

global status question. However, this

may not reflect the influence of social

desirability of the responses as much as

it does respondents’ mistaken beliefs

that their children are up to date.

Given the sketchy information that

parents seem to have about their

children’s vaccinations, a natural

question is how the respondents are able

to answer the standard vaccination

questions at all, if they do not have

access to shot cards. During the

cognitive pretests and again during the

Memory-Aid and Proxy Measures

Studies, information was gathered on the

strategies respondents used to answer

the vaccination questions. The protocols

generated by the respondents were

coded in the cognitive interviews; in

addition, an item was included in the

Memory-Aid and Proxy Measures

questionnaires asking respondents what

strategy they used in answering the

vaccination questions. The results were

reasonably consistent across the studies;

the most popular strategy seemed to be

to attempt to recall the information on

the vaccination card (table L). The

respondents were apparently aware of

the shortcomings of their memories of

specific vaccination episodes and, in

answering the questions, most of them

used strategies that attempted to rely on

other information instead.

Limitations and Caveats

Clearly, although the basic results

of the study were replicated in several

sites, there may be limitations in the

external validity of the findings,

especially because a random sample of

the relevant population was not studied.

To the extent that the subject

populations were atypical, or for

whatever reasons represent a biased

sampling of the relevant domain, the

study may not serve as a clear

description of either the cognitive

processing, or the survey reporting

tendencies, of parents who are

administered immunization questions.

On the one hand, the respondents were

Table J. Proxy Measures Study: Proxy measures of up to date status

Parent reported that... (n)

1

Percent

up to date

according

to records Phi

Child always had a regular doctor

Yes . . . . . . . . . . . . . . . . . . . . . . . . 129 41.9 0.06

No . . . . . . . . . . . . . . . . . . . . . . . . . 4 25.0

Child went to all well-baby visits

Yes . . . . . . . . . . . . . . . . . . . . . . . . 116 43.1 0.11

No . . . . . . . . . . . . . . . . . . . . . . . . . 18 27.8

Doctor indicated that child was up to date

Yes . . . . . . . . . . . . . . . . . . . . . . . . 113 44.3 0.14

No . . . . . . . . . . . . . . . . . . . . . . . . . 14 21.4

1(n) is the sample size.

Table K. Percent of respondents reporting correct number of recommended doses, by

study and vaccine

Vaccine

MemoryAid

study

Proxy

measures

study

DPT (4) . . . . . . . . . . . . . . . . . . 30 28

Polio (3) . . . . . . . . . . . . . . . . . . 47 26

MMR (1) . . . . . . . . . . . . . . . . . . 35 32

Hib (3) . . . . . . . . . . . . . . . . . . . 23 27

Hep B (3) . . . . . . . . . . . . . . . . . 47 31

Page 14 [ Series 6, No. 8
at about the educational level of the

general public, so one might conclude

that they were fairly representative. On

the other hand, respondents tended to be

less likely than the general public to

have fully immunized their children, and

for a number of associated reasons may

have been less able to report on this

topic. On balance, especially given the

severely low levels of accurate reporting

that were observed, the interviewers had

few indications that even the use of a

large, randomly selected sample would

materially change the results. At the

same time, it is important not to overgeneralize these results.

Recommendations for

Survey Practice

If failure to encode the relevant

information in the first place is the

primary reason that vaccination

reporting accuracy is so low, it will be

difficult to increase accuracy through

improvements to the questions or aids

provided to respondents (such as the

show card). Asking parents to recall

their children’s vaccinations may be, for

many, to ask for information they

simply do not have. The best methods to

improve reporting may be the ones

already used in the NIS and the NHIS:

(a) encouraging respondents to use their

vaccination cards and (b) obtaining

medical provider data and then

developing statistical corrections based

on the relationship between the survey

reports and the provider data. The

movement toward the use of medical

provider records in national surveys

such as the NIS and NHIS/NIPRCS

therefore appears to be a step in the

right direction.

References

1. Centers for Disease Control and

Prevention. Reported vaccinepreventable diseases—United States,

1993. MMWR 43:57–60. 1994.

2. Ezzati-Rice TM, Zell ER, Battaglia MP,

Ching P, Wright RA. The design of the

National Immunization Survey. In:

Proceedings of the Section on Survey

Research Methods, 668–72. 1995.

3. Zell ER, Ezzati-Rice TM, Massey JT,

Brick JM. Response errors associated

with household reports of

immunizations: Analysis of subgroup

differences. In: Proceedings of the

Section on Survey Research Methods,

341–6. 1996.

4. Ezzati-Rice TM, Zell ER, Massey JT,

Nixon MG. Improving the assessment

of vaccination coverage rates with the

use of both household and medical

provider data. In: Proceedings of the

Section on Survey Research Methods,

335–40. 1996.

5. Goldstein KP, Kviz FJ, Daum RS.

Accuracy of immunization histories

provided by adults accompanying

preschool children to a pediatric

emergency department. J Am Med

Assoc 270: 2190–4. 1993.

6. Hawe P, Wilson A, Fahey P, Field P,

Cunningham A, Barker M, Leeder S.

The validity of parental report of

vaccination as measure of a child’s

measles immunization status. Med J

Aust 155:681–6. 1991.

7. Kalsbeek W, Weigle K, Allred N, Liu

P. A comparison of survey designs for

estimating childhood immunization

rates. In: Proceedings of the Section on

Survey Research Methods, 175–80.

1991.

8. Killewo J, Makwaya C, Munubhi E,

Mpembeni R. The protective effect of

measles vaccine under routine

vaccination conditions in Dar Es

Salaam, Tanzania: A case-control study.

International Journal of Epidemiology

20:508–514. 1991.

9. McKinney P, Alexander F, Nicholson

C, Cartwright R, Carrette J. Mothers’

reports of childhood vaccinations and

infections and their concordance with

general practitioner records. J Public

Health Med 13:13–22. 1991.

10. Gergen PJ, Ezzati T, Russell H. DTP

immunization status and tetanus

antitoxin titers of Mexican American

children ages 6 months through 11

years. Am J Public Health 78:1446–50.

1988.

11. Valadez J, Weld L. Maternal recall

error of child vaccination status in a

developing country. Am J Public Health

82:120–2. 1992.

12. Cannell C, Miller P, Oksenberg L.

Research on interviewing techniques.

In: Leinhardt S, ed. Sociological

methodology. San Francisco:

Jossey-Bass, 389–437. 1981.

13. Strack F, Martin L. Thinking, judging,

and communicating: A process account

of context effects in attitude surveys.

In: Hippler H, Schwarz N, Sudman S,

eds. Social Information Processing and

Survey Methodology. New York:

Springer-Verlag, 123–48. 1987.

14. Tourangeau R. Cognitive science and

survey methods. In: Jabine T, et al.,

eds. Cognitive aspects of survey

design: Building a bridge between

disciplines. Washington: National

Academy Press, 73–100. 1984.

15. Tourangeau R, Rasinski K. Cognitive

processes underlying context effects in

attitude measurement. Psychol Bull

103:229–314. 1988.

16. Willis G, Royston P, Bercini D. The

use of verbal report methods in the

development and testing of survey

questionnaires. Applied Cognitive

Psychol 5:251–67. 1991.

17. Jobe J, Herrmann D. Implications of

models of survey cognition for memory

theory. In: Johnson M, Herrmann D,

McEvoy C, Hertzog C, Hertel P, eds.

Basic and applied memory research:

Practical Applications. Mahwah, NJ:

Erlbaum. 1996.

Table L. Strategies for recalling vaccinations, by study

Strategy

Number of

cognitive

interviews

Memory-Aid Proxy measures

Number Percent Number Percent

Recall each visit to the doctor . . . . . . . . . . . 22 51 (27) 31 (24)

Recall information on child’s

shot card . . . . . . . . . . . . . . . . . . . . . . . 20 74 (39) 70 (55)

Recall the number of vaccinations the

child was supposed to get . . . . . . . . . . . . . 14 21 (11) 4 (3)

Recall what doctor had told them

about child’s vaccination status . . . . . . . . . . 7 18 (9) 17 (13)

Recall whether they had taken the

child to all scheduled doctor visits . . . . . . . . - - - 20 (11) 6 (5)

Other strategy . . . . . . . . . . . . . . . . . . . . . 22 5 (3) – –

- - - Not applicable.

– Quantity zero.

Series 6, No. 8 [ Page 15
18. Royston P, Bercini D, Sirken M,

Mingay D. Questionnaire design

research laboratory. Proceedings of the

Section on Survey Methods Research,

American Statistical Association,

703–7. 1988.

19. Jobe J, Mingay D. Cognitive research

improves questionnaires. Am J Public

Health 79:1053–5. 1989.

20. Means B, Loftus E. When personal

history repeats itself: Decomposing

memories for recurring events. Applied

Cognitive Psychol 5:297–318. 1991.

21. Bradburn N, Sudman S, and Associates.

Improving interview methods and

questionnaire design: Response effects

to threatening questions in survey

research. San Francisco: Jossey-Bass.

1979.

Page 16 [ Series 6, No. 8
Appendix I: Materials Used in Memory-Aid Study

Memory-Aid Study Questionnaire

Case ID:

Date:

Interviewer:

Start time:

End time:

SURVEY OF CHILDREN’S HEALTH

NORC

University of Chicago

Information contained on this form which would permit identification of any individual or establishment has been collected with a

guarantee that it will be held in strict confidence by the contractor and NCHS, will be used only for purposes stated in this study,

and will not be disclosed or released to anyone other than authorized staff of NCHS without the consent of the individual or the

establishment in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m). Public reporting burden for

this collection of information is estimated to be 30 average minutes per response. Send comments regarding this burden estimate

or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance

Officer, ATTN: PRA; Humphrey Building, Room 721-H, 200 Independence Avenue, SW; Washington, DC 20201; and to the Office

of Management and Budget, Paperwork Reduction Project (0920–0264), Washington, DC 20503.

Series 6, No. 8 [ Page 17
VERSION 1: CALENDAR, SHOW CARD

GLOBAL QUESTION FIRST

INTERVIEWER: GIVE RESPONDENT A COPY OF THE CONSENT FORM.

We request that you read and then sign this consent form. Please follow along while I read it aloud.

READ CONSENT FORM TO RESPONDENT AND OBTAIN CONSENT, AS INDICATED BY RESPONDENT’S SIGNATURE

ON THE CONSENT FORM.

INTERVIEWER, PLEASE INDICATE TYPE OF INTERVIEW (CHECK ONE):

One parent only

Two parents

parent 1 (primary caretaker)

parent 2 (secondary caretaker)

Page 18 [ Series 6, No. 8
Children’s Health Questionnaire

INTERVIEWER: COMPLETE THE VACCINATION HISTORY CALENDAR BEFORE PROCEEDING TO SECTION A.

SECTION A: VACCINATION HISTORY

I would like to confirm your child’s name. Is it [CHILD’S NAME] ?

Let me confirm that [CHILD’S NAME]’s birthdate is // ?

MO DAY YR

A1. Has [NAME OF CHILD] ever received an immunization, that is a shot or drops?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO B1

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

A2. In your opinion, has [CHILD NAME] received all of the recommended shots for (his/her) age?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

INTERVIEWER: DISPLAY SHOW CARD 1 FOR QUESTIONS A3 THROUGH A7.A.

A3. Has [NAME OF CHILD] ever received a D-T-P shot (sometimes called a D-P-T shot, diphtheria- tetanus-pertussis shot, baby

shot, three-in-one shot, DTaP, or it may have been included as part of the Tetramune shot)?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A4

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A4

REFUSED ........................................... 7

A3.A. How many D-T-P shots did [NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A4. Has [NAME] ever received a polio vaccine by mouth, pink drops or by a polio shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A5

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A5

REFUSED ........................................... 7

Series 6, No. 8 [ Page 19
A4.A. How many polio vaccines did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A5. Has [CHILD NAME] ever received a measles or M-M-R (Measles-Mumps-Rubella) shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A6

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A6

REFUSED ........................................... 7

A5.A. How many measles or M-M-R shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A6. Has [CHILD NAME] ever received an Hib shot? (This is for Meningitis and is called Hemophilus Influenza {HA-MA-FI-LAS

IN-FLU-EN-Z}, H-I-B vaccine, H Flu vaccine, or it might have been included as part of the Tetramune shot?)

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A7

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A7

REFUSED ........................................... 7

A6.A. How many Hib shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A7. Has [CHILD NAME] ever received a Hepatitis B shot? This might have been called ‘‘Heptavax’’ or ‘‘Engerix B.’’

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A8

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A8

REFUSED ........................................... 7

A7.A. How many Hepatitis B shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Page 20 [ Series 6, No. 8
INTERVIEWER: REMOVE SHOW CARD 1.

A8. Has [CHILD NAME] ever received a varicella or chicken pox shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A9

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A9

REFUSED ........................................... 7

A8.A. How many varicella shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A9. Has [CHILD NAME] ever received shots to prevent pneumococcal disease?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A10

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A10

REFUSED ........................................... 7

A9.A. How many pneumococcal shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A10. Has [CHILD NAME] ever received a smallpox shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A11

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A11

REFUSED ........................................... 7

A10.A. How many smallpox shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Series 6, No. 8 [ Page 21
A11. Has [CHILD NAME] received any other vaccinations that I have not asked you about?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A12

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A12

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 GO TO A12

A11.A.How many other shots are there (that I have not asked you about)?

Number ............................................... RECORD NAMES AND DATES

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GO TO A12

A11.B. What is the name of the [FIRST, SECOND, . . .] other shot?

FOUR-IN-ONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

BCG (TUBERCULOSIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

TYPHOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

YELLOW FEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

MALARIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

DTaP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06

DTP/Hib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

DTP/Hep B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08

OTHER (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 GO TO A12/ NEXT SHOT

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 GO TO A12/ NEXT SHOT

A12. Are you the person who took [CHILD NAME] for most of (his/her) shots? (Most means at least 1/2 of the shots.)

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

A13. In answering these questions about how many vaccinations [CHILD NAME] has received, did you mostly . . .

Try to remember each visit to the doctor

in which a vaccination was given? . . . . . . . . . . . . . . . . . . . . . . . 01

Try to recall information from the shot card? . . . . . . . . . . . . . . 02

Try to remember the number of vaccinations

the child was supposed to get? . . . . . . . . . . . . . . . . . . . . . . . . . . 03

Try to remember something the doctor had told you

about your child’s vaccination status? . . . . . . . . . . . . . . . . . . . . 04

Try to recall whether you had taken the child to

all scheduled checkup or well-baby visits? . . . . . . . . . . . . . . . . 05

Or did you do something else? . . . . . . . . . . . . . . . . . . . . . . . . . . 06

Specify

Page 22 [ Series 6, No. 8
A14. Do you have a shot record that shows all the vaccinations your child has received?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

A14.A. When was the last time you looked at it?

RIGHT BEFORE COMING TO THE INTERVIEW . . . . . . . . 01

WITHIN THE LAST WEEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

WITHIN THE LAST MONTH . . . . . . . . . . . . . . . . . . . . . . . . . . 03

MORE THAN A MONTH AGO . . . . . . . . . . . . . . . . . . . . . . . . 04

DON’T KNOW/CAN’T REMEMBER . . . . . . . . . . . . . . . . . . . 06

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

SECTION B: KNOWLEDGE ABOUT VACCINATIONS

B1. What illnesses is the MMR shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

B1.A. How many MMR shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B2. What illnesses is the DTP shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

B2.A. How many DTP shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B3. How many doses of the Polio vaccine is a child supposed to receive by age two?

NUMBER OF DOSES

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B4. What illness is the Hib shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

Series 6, No. 8 [ Page 23
B4.A. How many Hib shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B5. What illness is the Hepatitis B shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

B5.A. How many Hepatitis B shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B6. Did [CHILD’S NAME]’s doctor recommend a schedule of check-ups or well-baby visit for when he/she was a newborn?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 GO TO B11

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 GO TO B11

B7. When were these visits to have taken place?

IF A CALENDAR WAS COMPLETED, INDICATE THESE DATES ON THE CALENDAR.

LIST DATES:

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B8. Did you go to all of these visits according to the doctor’s recommended schedule?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 GO TO B11

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B9. How many visits had to be rescheduled?

Number of visits

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

B10. How many did you miss?

Number of visits

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Page 24 [ Series 6, No. 8
B11. When was the date of your last visit to the pediatric clinic?

[ENTER DATE] / /

MO DAY YR

WITHIN THE LAST WEEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

WITHIN THE LAST MONTH . . . . . . . . . . . . . . . . . . . . . . . . . . 02

MORE THAN A MONTH AGO . . . . . . . . . . . . . . . . . . . . . . . . 03

DON’T KNOW/CAN’T REMEMBER . . . . . . . . . . . . . . . . . . . 06

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

SECTION C: DEMOGRAPHICS

C1. Including the adults and all the children, how many people live in your household?

NUMBER OF PEOPLE

C1A. How many children do you have who are above the age of 4 years?

NUMBER OF CHILDREN

C1B. How many children do you have who are under the age of 4 years?

NUMBER OF CHILDREN

C1C. How many children do you have ages 2 through 4 years?

NUMBER OF CHILDREN

C2. What is your relationship to [CHILD NAME]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR FEMALE

GUARDIAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

FATHER (STEP, FOSTER, ADOPTIVE) OR MALE

GUARDIAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

SISTER OR BROTHER (STEP/FOSTER/HALF/ADOPTIVE) 03

IN-LAW OF ANY TYPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

AUNT/UNCLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

GRANDPARENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06

OTHER FAMILY MEMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

FRIEND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C3. What is the highest level of education you have completed?

LESS THAN HIGH SCHOOL . . . . . . . . . . . . . . . . . . . . . . . . . . 01

SOME HIGH SCHOOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

HIGH SCHOOL GRADUATE/GED . . . . . . . . . . . . . . . . . . . . . 03

SOME COLLEGE/VOCATIONAL SCHOOL . . . . . . . . . . . . . . 04

COLLEGE/VOCATIONAL SCHOOL GRADUATE . . . . . . . . . 05

Series 6, No. 8 [ Page 25
PROFESSIONAL/GRADUATE SCHOOL . . . . . . . . . . . . . . . . 06

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C4. Are you now married, widowed, divorced, separated, or have you never been married?

MARRIED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

WIDOWED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

DIVORCED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

SEPARATED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

NEVER MARRIED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C5. Aside from the pediatric clinic, how many other sources of care has [CHILD NAME] ever had?

Number of sources

INTERVIEWER: GIVE RESPONDENT A COPY OF THE PERMISSION FORM.

As part of this study we would like to obtain a limited amount of vaccination information from your child’s medical files. To

obtain this information we will need your permission indicated by signing this form. Note that there is no penalty for choosing not

to allow NORC access to this information. Payment for your participation in the study does not depend on whether you choose to

sign the form. Please be assured that like all of the information you have given us in this study, your child’s vaccination

information will be treated with complete confidentiality.

READ PERMISSION FORM TO RESPONDENT. OBTAIN PERMISSION TO CONTACT CHILD’S HEALTH CARE

PROVIDERS, AS INDICATED BY RESPONDENT’S SIGNATURE ON THE PERMISSION FORM.

Page 26 [ Series 6, No. 8
Medical Events History Calendar
Memory-Aid Study: Show Card

Recommended Number of Doses by Age 2

for Each Vaccine

DPT ................................................................. 4

Polio ................................................................ 3

MMR ............................................................... 1

Hib ................................................................... 3

Hep B .............................................................. 3

Page 28 [ Series 6, No. 8
Example of Data Abstraction Form

Vaccination History Form-Child Immunization Project

Clinic/Physician Name:

To protect each child’s privacy, records are identified only by number, not by name. Please refer to the attached Permission Form

for the child’s name and other identifying information.

Please complete this form and detach it from the Permission Form. Keep the Permission Form for your records and return this

form to us in the postage-paid envelope provided.

Instructions:

Enter the dates (month/day/year) that each vaccination was given.

Example:

Polio/OPV 5/30/95 8/30/95

Child’s ID Number:

Vaccine Dates Vaccinations Given

Polio/OPV

DTP

MMR/Measles

Hepatitis B

Hib

Varicella

If no vaccinations were given please check here .

If no vaccination record is found please check here .

Series 6, No. 8 [ Page 29
Appendix II: Materials Used in Encoding Study

Encoding Study Questionnaire

FILL IN TODAY’S DATE: / /

MO DAY YR

RESPONDENT NUMBER:

INTERVIEWER INITIALS:

SECTION A. BACKGROUND QUESTIONS

Hi. I’m NAME from the National Opinion Research Center. We’re doing a short survey of some people visiting the clinic today as

part of an important study for the U.S. Public Health Service. It will only take a few minutes. To begin with, I need some

background information about you and your child.

1. What is your name?

RESPONDENT NAME

2. What is the child’s name?

CHILD’S NAME

Information contained on this form which would permit identification of any individual or establishment has been collected with a

guarantee that it will be held in strict confidence by the contractor and NCHS, will be used only for purposes stated in this study,

and will not be disclosed or released to anyone other than authorized staff of NCHS without the consent of the individual or the

establishment in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m). Public reporting burden for

this collection of information is estimated to be 30 average minutes per response. Send comments regarding this burden estimate

or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance

Officer, ATTN: PRA; Humphrey Building, Room 721-H, 200 Independence Avenue, SW; Washington, DC 20201; and to the Office

of Management and Budget, Paperwork Reduction Project (0920–0264), Washington, DC 20503.

Page 30 [ Series 6, No. 8
3. When was CHILD’S NAME born?

/ /

MO DAY YR

4. What is the child’s MR number?

Number

5. What is your relation to CHILD’S NAME?

MOTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

FATHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

STEPMOTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

STEPFATHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

GRANDMOTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

GRANDFATHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06

AUNT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

UNCLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08

OTHER FEMALE RELAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 09

OTHER MALE RELAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

NONRELATIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

6. What is the highest level of education you have completed?

DID NOT FINISH HIGH SCHOOL . . . . . . . . . . . . . . . . . . . . . 00

HIGH SCHOOL GRADUATE . . . . . . . . . . . . . . . . . . . . . . . . . . 01

VOCATIONAL, TRADE SCHOOL AFTER HS . . . . . . . . . . . . 02

ATTENDED COLLEGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

COLLEGE GRADUATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

ATTENDED GRADUATE/PROF SCHOOL . . . . . . . . . . . . . . . 05

7. Are you currently in school?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8. What is your marital status? Are you now . . .

Married .............................................. 1

Not married, but living with a partner ..................... 2

Widowed ............................................ 3

Divorced ............................................. 4

Separated, or ......................................... 5

Have you never been married? ........................... 6

9. How would you describe yourself? Are you . . .

Hispanic ............................................. 1

Black, not of Hispanic origin ............................ 2

White, not of Hispanic origin ............................ 3

Asian/Pacific Islander .................................. 4

Series 6, No. 8 [ Page 31
Native American/American Indian/Eskimo ................. 5

Or something else? .................................... 6

10. How many brothers and sisters does CHILD’S NAME have?

NUMBER OF SIBLINGS (IF NONE, ENTER 0 AND GO TO SECTION B)

11. Is CHILD’S NAME the oldest among his/her brothers and sisters, the second oldest, or what?

OLDEST ............................................ 1

2ND OLDEST ........................................ 2

3RD OLDEST ........................................ 3

4TH OLDEST ........................................ 4

5TH OR LATER CHILD ............................... 5

SECTION B. TODAY’S VISIT

The next few items concern CHILD NAME’s visit to the clinic.

1. To start off, would you tell me in your own words what happened during the child’s visit today?

YES NO

a) CHILD RECEIVED IMMUNIZATION(S) ............................. 1 2

IF YES, LIST IMMUNIZATIONS:

1)

2)

3)

4)

b) CHILD RECEIVED ROUTINE EXAM ............................... 1 2

c) CHILD WAS TREATED FOR AN ACUTE ILLNESS ................... 1 2

IF YES, RECORD ILLNESS (E.G., EAR INFECTION):

d) CHILD RECEIVED FOLLOW-UP TREATMENT FOR EARLIER

CONDITION .................................................... 1 2

IF YES, RECORD EARLIER CONDITION:

e) CHILD TREATED FOR A CHRONIC CONDITION .................... 1 2

IF YES, PROBE FOR AND RECORD CONDITION:

f) CHILD TREATED FOR AN EMERGENCY ........................... 1 2

If YES, PROBE FOR AND RECORD NATURE OF EMERGENCY

Page 32 [ Series 6, No. 8
g) OTHER ......................................................... 1 2

If YES: RECORD NATURE OF OTHER TREATMENTS

BOX A: DID R SAY THE CHILD RECEIVED ANY SHOTS OR IMMUNIZATIONS?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (SKIP TO QUESTION 3)

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (GO TO QUESTION 2)

2. Did CHILD’S NAME get any shots today?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO QUESTION 4)

3. What were the shots for? (IF NECESSARY, PROBE: What diseases will the shots prevent?)

YES NO

a) POLIO/ORAL POLO/OPV/IPV ..................................... 1 2

b) HAEMOPHILUS INFLUENZAE TYPE B/HIB/H FLU/MENINGITIS ...... 1 2

c) MEASLES/MUMPS-MEASLES-RUBELLA/MMR ..................... 1 2

d) DIPHTHERIA-TETANUS-PERTUSSIS/DPT/DT/

THREE-IN-ONE SHOT ............................................ 1 2

e) HEPATITIS B/HEP B .............................................. 1 2

f) COMBINED HIB-DTP/FOUR-IN-ONE/TETRAMUNE .................. 1 2

g) VARICELLA/CHICKEN POX I ..................................... 1 2

h) OTHER: SPECIFY 1 2

4. Did your child receive any (other) immunizations by mouth today?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO BOX B)

5. What were these (other) immunizations for? YES NO

a) POLIO/ORAL POLIO/OPV ......................................... 1 2

b) OTHER: SPECIFY 1 2

BOX B: DID R REPORT ANY SHOTS/VACCINATIONS? (2 OR 4 = 1)

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (GO TO QUESTION 6)

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO QUESTION 8)

Series 6, No. 8 [ Page 33
6. Did the doctor, a nurse, or someone else give the shots (or administer the oral vaccines)?

DOCTOR ............................................ 1

NURSE ............................................. 2

SOMEONE ELSE ..................................... 3

7. Did you receive a shot record or immunization card showing what shots CHILD’S NAME got today?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8. Has your child received any immunizations—either here or somewhere else—before today?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO QUESTION 10)

NOT SURE, DON’T KNOW ............................ 3 (SKIP TO QUESTION 10)

9. Can you recall the number of earlier visits—either here or somewhere else—when CHILD’S NAME received an immunization?

ONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TWO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THREE OR MORE .................................... 3

10. During today’s visit, did anyone mention to you whether CHILD’S NAME has received all of the recommended shots?

YES, I WAS TOLD CHILD HAS HAD ALL SHOTS ........ 1

NO, I WAS TOLD CHILD STILL NEEDS SHOTS .......... 2

NO, I WASN’T TOLD EITHER WAY ..................... 3

11. Did you discuss the schedule for any future visits for immunizations for CHILD’S NAME?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

SECTION C. FOLLOW-UP INFORMATION

It would help us greatly if we could contact you for more information about your child’s health later on.

1. Could I please have your telephone number?

( ) TELEPHONE NUMBER

2. Could I have your home address?

Page 34 [ Series 6, No. 8
SECTION D. DATA ON VISIT FROM MEDICAL RECORD

Visit Date: / /

MO DAY YR

Child’s Name:

1) Immunizations Received

YES NO

OPV/Oral Polio ..................................................... 1 2

Haemophilus Influenzae B/HIB ........................................ 1 2

Diphtheria-Pertussis-Tetanus/DPT ....................................... 1 2

Combined DPT-HIB/Tetramune ........................................ 1 2

Hepatitis B/Hep B ................................................... 1 2

Measles-Mumps-Rubella/MMR/Measles ................................. 1 2

Varicella/Chicken Pox ................................................ 1 2

Other Immunizations ................................................. 1 2

Specify:

2) Other Treatments Received

YES NO

Any Other Treatments Received? ....................................... 1 2

Specify:

— Thank you very much for helping with this study! —

Series 6, No. 8 [ Page 35
Encoding Study Follow-Up Questionnaire

DATE OF INTERVIEW COMPLETION: / /

MO DAY YR

RESPONDENT NUMBER:

INTERVIEWER:

RESPONDENT NAME:

RESPONDENT PHONE NUMBER:

RESPONDENT ADDRESS:

CHILD’S NAME:

CHILD’S DATE OF BIRTH:

Hi. May I please speak with RESPONDENT NAME?

IF NOT AVAILABLE, ASK WHEN TO CALL BACK, AND INDICATE THE DATE AND TIME BELOW.

ONCE YOU ARE SPEAKING WITH RESPONDENT:

Hi. I’m from the National Opinion Research Center. We spoke with you two months

ago at the Injection Clinic during a study for the U.S. Public Health Service. We need to ask you a few follow-up questions,

which should take less than five minutes. Is now a convenient time for you?

To begin with, do you remember taking CHILD’S NAME to the injection clinic on

DATE OF CLINIC VISIT: ?

Page 36 [ Series 6, No. 8
These questions will be concerning that visit to the clinic.

SECTION B. THE VISIT

1. To start off, would you tell me in your own words what happened during the child’s

visit on DATE? YES NO

a) CHILD RECEIVED IMMUNIZATION(S) ............................. 1 2

IF YES, LIST IMMUNIZATIONS:

1)

2)

3)

4)

b) CHILD RECEIVED ROUTINE EXAM ............................... 1 2

c) CHILD WAS TREATED FOR AN ACUTE ILLNESS ................... 1 2

IF YES, RECORD ILLNESS (E.G., EAR INFECTION):

d) CHILD RECEIVED FOLLOW-UP TREATMENT FOR EARLIER

CONDITION .................................................... 1 2

IF YES, RECORD EARLIER CONDITION:

e) CHILD TREATED FOR A CHRONIC CONDITION 1 2

IF YES, PROBE FOR AND RECORD CONDITION:

f) CHILD TREATED FOR AN EMERGENCY ........................... 1 2

If YES, PROBE FOR AND RECORD NATURE OF EMERGENCY

g) OTHER ......................................................... 1 2

If YES: RECORD NATURE OF OTHER TREATMENTS

BOX A: DID R SAY THE CHILD RECEIVED ANY SHOTS OR IMMUNIZATIONS?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (SKIP TO QUESTION 3)

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (GO TO QUESTION 2)

Series 6, No. 8 [ Page 37
2. Did CHILD’S NAME get any shots during the visit?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO QUESTION 4)

3. What were the shots for? (IF NECESSARY, PROBE: What diseases will the shots prevent?) YES NO

a) POLIO/ORAL POLIO/OPV/IPV ..................................... 1 2

b) HAEMOPHILUS INFLUENZAE TYPE B/HIB/H FLU/MENINGITIS ...... 1 2

c) MEASLES/MUMPS-MEASLES-RUBELLA/MMR ..................... 1 2

d) DIPHTHERIA-TETANUS-PERTUSSIS/DPT/DT/THREE-IN-ONE SHOT . . . 1 2

e) HEPATITIS B/HEP B .............................................. 1 2

f) COMBINED HIB-DTP/FOUR-IN-ONE/TETRAMUNE .................. 1 2

g) VARICELLA/CHICKEN POX ...................................... 1 2

h) OTHER: SPECIFY ................................................ 1 2

4. Did your child receive any (other) immunizations by mouth during the visit on DATE?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO BOX B)

5. What were these (other) immunizations for? YES NO

a) POLIO/ORAL POLIO/OPV ........................................ 1 2

b) OTHER: SPECIFY ................................................ 1 2

BOX B: DID R REPORT ANY SHOTS/VACCINATIONS? (2 OR 4 = 1)

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (GO TO QUESTION 6)

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO QUESTION 8)

6. Did the doctor, a nurse, or someone else give the shots (or administer the oral vaccines)?

DOCTOR ............................................ 1

NURSE ............................................. 2

SOMEONE ELSE ..................................... 3

7. Did you receive a shot record or immunization card showing what shots CHILD’S NAME got during the visit on DATE?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8. Had your child received any immunizations—either at that clinic or somewhere else—before that particular visit to the clinic?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO QUESTION 10)

NOT SURE, DON’T KNOW ............................ 3 (SKIP TO QUESTION 10)

Page 38 [ Series 6, No. 8
9. Can you recall the number of earlier visits—either at that clinic or somewhere else—when CHILD’S NAME received an immunization?

ONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TWO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THREE OR MORE .................................... 3

10. During the visit on DATE did anyone mention to you whether CHILD’S NAME had received all of the recommended shots?

YES, I WAS TOLD CHILD HAS HAD ALL SHOTS ........ 1

YES, I WAS TOLD CHILD STILL NEEDS SHOTS ......... 2

NO, I WASN’T TOLD EITHER WAY ..................... 3

11. Since that visit on DATE, has CHILD’S NAME received any other vaccinations from any clinic?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

IF YES, THEN ASK:

12. What vaccinations did CHILD’S NAME receive?

Series 6, No. 8 [ Page 39
Appendix III: Materials Used in Proxy Measures Study

Proxy Measures Questionnaire

Case ID:

Date:

Interviewer:

Start time:

End time:

SURVEY OF CHILDREN’S HEALTH

NORC

University of Chicago

Information contained on this form which would permit identification of any individual or establishment has been collected with a

guarantee that it will be held in strict confidence by the contractor and NCHS, will be used only for purposes stated in this study,

and will not be disclosed or released to anyone other than authorized staff of NCHS without the consent of the individual or the

establishment in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m). Public reporting burden for

this collection of information is estimated to be 30 average minutes per response. Send comments regarding this burden estimate

or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance

Officer, ATTN: PRA; Humphrey Building, Room 721-H, 200 Independence Avenue, SW; Washington, DC 20201; and to the Office

of Management and Budget, Paperwork Reduction Project (0920–0264), Washington, DC 20503.

Page 40 [ Series 6, No. 8
Children’s Health Questionnaire

SECTION A: VACCINATION HISTORY

I would like to confirm your child’s name. Is it [CHILD’S NAME] ?

Let me confirm that [CHILD’S NAME]’s birthdate is // ?

MO DAY YR

For use in Version 2 where Section B comes before Section A: IF ANSWER TO B4=YES THEN SKIP A1.

A1. Has [NAME OF CHILD] ever received an immunization, that is a shot or drops?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO B1

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

INTERVIEWER: DISPLAY SHOW CARD 1 FOR QUESTIONS A2 THROUGH A6.A.

A2. Has [NAME OF CHILD] ever received a D-T-P shot (sometimes called a D-P-T shot, diphtheria- tetanus-pertussis shot, baby

shot, three-in-one shot, DTaP, or it may have been included as part of the Tetramune shot)?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A3

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A3

REFUSED ........................................... 7

A2.A. How many D-T-P shots did [NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A3. Now I’d like to ask more specifically about each vaccine.

Has [NAME] ever received a polio vaccine by mouth, pink drops or by a polio shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A4

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A4

REFUSED ........................................... 7

A3.A. How many polio vaccines did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Series 6, No. 8 [ Page 41
A4. Has [CHILD NAME] ever received a measles or M-M-R (Measles-Mumps-Rubella) shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A5

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A5

REFUSED ............................................7

A4.A. How many measles or M-M-R shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A5. Has [CHILD NAME] ever received an Hib shot? (This is for Meningitis and is called Hemophilus Influenza {HA-MA-FI-LAS

IN-FLU-EN-Z}, H-I-B vaccine, H Flu vaccine, or it might have been included as part of the Tetramune shot?)

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A6

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A6

REFUSED ............................................7

A5.A. How many Hib shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A6. Has [CHILD NAME] ever received a Hepatitis B shot? This might have been called ‘‘Heptavax’’ or ‘‘Engerix B.’’

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A7

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A7

REFUSED ............................................7

A6.A. How many Hepatitis B shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

INTERVIEWER: REMOVE SHOW CARD

A7. Has [CHILD NAME] ever received a varicella or chicken pox shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A8

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A8

REFUSED ............................................7

Page 42 [ Series 6, No. 8
A7.A. How many varicella shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A8. Has [CHILD NAME] ever received shots to prevent pneumococcal disease?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A9

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

A8.A. How many pneumococcal shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A9. Has [CHILD NAME] ever received a smallpox shot?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A10

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A10

REFUSED ........................................... 7

A9.A. How many smallpox shots did [CHILD NAME] ever receive?

NUMBER OF SHOTS

ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

A10. Has [CHILD NAME] received any other vaccinations that I have not asked you about?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO A11

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GO TO A11

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 GO TO A11

A10.A. How many other shots are there (that I have not asked you about)?

Number ............................................... RECORD NAMES AND DATES

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GO TO A11

A10.B. What is the name of the [FIRST, SECOND, . . .] other shot?

FOUR-IN-ONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

BCG (TUBERCULOSIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

Series 6, No. 8 [ Page 43
TYPHOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

YELLOW FEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

MALARIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

DTaP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06

DTP/Hib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

DTP/Hep B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08

OTHER (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 GO TO A11/ NEXT SHOT

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 GO TO A11/NEXT SHOT

A11. Are you the person who took [CHILD NAME] for most of (his/her) shots? (Most means at least 1/2 of the shots.)

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

A12. In your opinion, has [CHILD NAME] received all of the recommended shots for (his/her) age?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

A13. In answering these questions about how many vaccinations [CHILD NAME] has received, did you mostly . . .

Try to remember each visit to the doctor in which a vaccination

was given? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

Try to recall information from the shot card? . . . . . . . . . . . . . . 02

Try to remember the number of vaccinations the child was

supposed to get? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

Try to remember something the doctor had told you about your

child’s vaccination status? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

Try to recall whether you had taken the child to all scheduled

checkup or well-baby visits? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

Or did you do something else? . . . . . . . . . . . . . . . . . . . . . . . . . . 06

Specify

A14. Do you have a shot record that shows all the vaccinations your child has received?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

Page 44 [ Series 6, No. 8
A14.A. When was the last time you looked at it?

RIGHT BEFORE COMING TO THE INTERVIEW . . . . . . . . 01

WITHIN THE LAST WEEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

WITHIN THE LAST MONTH . . . . . . . . . . . . . . . . . . . . . . . . . . 03

MORE THAN A MONTH AGO . . . . . . . . . . . . . . . . . . . . . . . . 04

DON’T KNOW/CAN’T REMEMBER . . . . . . . . . . . . . . . . . . . . 06

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

SECTION B: VISITS TO THE DOCTOR

B1. Sometimes when people move or are in the process of changing doctors, they may not have a specific doctor that they go to.

During the first two years of [CHILD NAME]’s life, did [he/she] always have a specific doctor or clinic to go to or were there

times when [he/she] did not have a any specific doctor or clinic?

ALWAYS HAD SPECIFIC SOURCE OF CARE . . . . . . . . . . . . 1 GO TO 3

TIMES WHEN DID NOT HAVE A SPECIFIC ..............2

B2. During the period before [CHILD NAME] turned two, how long did [he/she] not have a specific doctor or clinic to go to?

Would you say a two months or less, two to six months, or six months or more?

TWO MONTHS OR LESS .............................. 1

THREE TO SIX MONTHS ............................. 2

SIX MONTHS OR MORE .............................. 3

B3. Many doctors recommend a series of check-ups or ‘‘well-baby visits’’ before the baby turns two. Here is the schedule that

many doctors follow, starting with visits every two months. Of course not everyone is able to make all of these visits. Do you

think [CHILD] made all of these recommended routine visits?

YES, MADE ALL ..................................... 1

MADE SOME AND MISSED SOME ..................... 2

MADE NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 GO TO B5

[REMOVE SHOW CARD 2]

B4. Often vaccinations—that is, shots or drops— are given during these routine visits. However, it is very common for children to

miss one or more of their vaccinations. Sometimes parents are not able to keep the appointments, or sometimes the doctor

might not be aware that the child was supposed to receive a particular vaccine. It is possible that many children will miss one

or more their recommended vaccines.

Can you remember [CHILD NAME] getting any shots during these visits?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

B5. Think back to the last time that [CHILD NAME] went to the doctor or clinic. Did [he/she] receive any vaccinations—that is,

shots or pink drops?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 END

Series 6, No. 8 [ Page 45
B6. During that last visit, did the doctor or nurse say that [CHILD NAME] needed more shots or did the doctor say that [CHILD

NAME] was now caught up on [his/her] vaccinations?

CAUGHT UP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 END

NEEDED MORE SHOTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GO TO 7

DIDN’T SAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 END

DON’T REMEMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 END

B7. Do you recall which shots [CHILD NAME] still needs?

YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 END

B8. Which vaccinations were those? YES NO

HIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

DTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

MMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

POLIO ............................................................ 1 2

HEPATITIS B ...................................................... 1 2

OTHER (SPECIFY

SECTION C: KNOWLEDGE ABOUT VACCINATIONS

C1. What illnesses is the MMR shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

C1.A. How many MMR shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C2. What illnesses is the DTP shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

C2.A. How many DTP shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Page 46 [ Series 6, No. 8
C3. How many doses of the Polio vaccine is a child supposed to receive by age two?

NUMBER OF DOSES

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C4. What illness is the Hib shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

C4.A. How many Hib shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C5. What illness is the Hepatitis B shot supposed to prevent?

DON’T KNOW ....................................... 6

REFUSED ........................................... 7

C5.A. How many Hepatitis B shots is a child supposed to receive by age two?

NUMBER OF SHOTS

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

C6. When was the date of [CHILD NAME]’s last visit to the doctor?

[ENTER DATE] / /

MO DAY YR

WITHIN THE LAST WEEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

WITHIN THE LAST MONTH . . . . . . . . . . . . . . . . . . . . . . . . . . 02

WITHIN THE LAST TWO MONTHS . . . . . . . . . . . . . . . . . . . 03

WITHIN THE LAST THREE MONTHS . . . . . . . . . . . . . . . . . 04

MORE THAN THREE MONTHS AGO . . . . . . . . . . . . . . . . . . 05

DON’T KNOW/CAN’T REMEMBER . . . . . . . . . . . . . . . . . . . 06

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

C7. What is the name of the doctor or clinic you saw at this last visit?

Series 6, No. 8 [ Page 47
SECTION D: DEMOGRAPHICS

D1. Including all the adults, the children, and yourself, how many people live in your household?

NUMBER OF PEOPLE

D2. HOUSEHOLD ENUMERATION

FIRST NAME

RELATION TO CHILD

AGE

D3. What is the highest level of education you have completed?

LESS THAN HIGH SCHOOL . . . . . . . . . . . . . . . . . . . . . . . . . . 01

SOME HIGH SCHOOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

HIGH SCHOOL GRADUATE/GED . . . . . . . . . . . . . . . . . . . . . 03

SOME COLLEGE/VOCATIONAL SCHOOL . . . . . . . . . . . . . . 04

COLLEGE/VOCATIONAL SCHOOL GRADUATE . . . . . . . . . 05

PROFESSIONAL/GRADUATE SCHOOL . . . . . . . . . . . . . . . . 06

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

D4. Are you now married, widowed, divorced, separated, or have you never been married?

MARRIED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

WIDOWED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

DIVORCED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

SEPARATED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

NEVER MARRIED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

REFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

D5. How many sources of care has [CHILD NAME] ever had?

Number of sources

INTERVIEWER: CHECK THAT THIS NUMBER OF HEALTH CARE PROVIDERS IS LISTED ON BACK OF THE

MEDICAL PROVIDER PERMISSION FORM.

Page 48 [ Series 6, No. 8
Vital and Health Statistics

series descriptions

SERIES 1. Programs and Collection Procedures—These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the methods

used to collect and process the data, definitions, and other

material necessary for understanding the data.

SERIES 2. Data Evaluation and Methods Research—These reports

are studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies also

include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

SERIES 3. Analytical and Epidemiological Studies—These reports

present analytical or interpretive studies based on vital and

health statistics. These reports carry the analyses further than

the expository types of reports in the other series.

SERIES 4. Documents and Committee Reports—These are final

reports of major committees concerned with vital and health

statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

SERIES 5. International Vital and Health Statistics Reports—These

reports are analytical or descriptive reports that compare U.S.

vital and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States.

SERIES 6. Cognition and Survey Measurement—These reports are

from the National Laboratory for Collaborative Research in

Cognition and Survey Measurement. They use methods of

cognitive science to design, evaluate, and test survey

instruments.

SERIES 10. Data From the National Health Interview Survey—These

reports contain statistics on illness; unintentional injuries;

disability; use of hospital, medical, and other health services;

and a wide range of special current health topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household interview survey.

SERIES 11. Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United

States and the distributions of the population with respect to

physical, physiological, and psychological characteristics, and

(2) analyses of trends and relationships among various

measurements and between survey periods.

SERIES 12. Data From the Institutionalized Population Surveys—

Discontinued in 1975. Reports from these surveys are

included in Series 13.

SERIES 13. Data From the National Health Care Survey—These

reports contain statistics on health resources and the public’s

use of health care resources including ambulatory, hospital,

and long-term care services based on data collected directly

from health care providers and provider records.

SERIES 14. Data on Health Resources: Manpower and Facilities—

Discontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of health resources are now

included in Series 13.

SERIES 15. Data From Special Surveys—These reports contain

statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

systems of the National Center for Health Statistics.

SERIES 16. Compilations of Advance Data From Vital and Health

Statistics—Advance Data Reports provide early release of

information from the National Center for Health Statistics’

health and demographic surveys. They are compiled in the

order in which they are published. Some of these releases

may be followed by detailed reports in Series 10–13.

SERIES 20. Data on Mortality—These reports contain statistics on

mortality that are not included in regular, annual, or monthly

reports. Special analyses by cause of death, age, other

demographic variables, and geographic and trend analyses

are included.

SERIES 21. Data on Natality, Marriage, and Divorce—These reports

contain statistics on natality, marriage, and divorce that are

not included in regular, annual, or monthly reports. Special

analyses by health and demographic variables and

geographic and trend analyses are included.

SERIES 22. Data From the National Mortality and Natality Surveys—

Discontinued in 1975. Reports from these sample surveys,

based on vital records, are now published in Series 20 or 21.

SERIES 23. Data From the National Survey of Family Growth—

These reports contain statistics on factors that affect birth

rates, including contraception, infertility, cohabitation,

marriage, divorce, and remarriage; adoption; use of medical

care for family planning and infertility; and related maternal

and infant health topics. These statistics are based on

national surveys of women of childbearing age.

SERIES 24. Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy—

These include advance reports of births, deaths, marriages,

and divorces based on final data from the National Vital

Statistics System that were published as supplements to the

Monthly Vital Statistics Report (MVSR). These reports provide

highlights and summaries of detailed data subsequently

published in Vital Statistics of the United States. Other

supplements to the MVSR published here provide selected

findings based on final data from the National Vital Statistics

System and may be followed by detailed reports in Series 20

or 21.

For answers to questions about this report or for a list of reports published

in these series, contact:

Data Dissemination Branch

National Center for Health Statistics

Centers for Disease Control and Prevention

6525 Belcrest Road, Room 1064

Hyattsville, MD 20782-2003

(301) 436–8500

E-mail: nchsquery@cdc.gov

Internet: www.cdc.gov/nchswww/
DHHS Publication No. (PHS) 99-1083, Series 6, No. 88-0791 (2/99)

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