摘要：Objectives. We explored factors associated with perception of barriers to immunization among parents of Hmong origin in California, whose children experience persistent immunization inequities even with health insurance. Methods. A partnership of academic researchers and members of the Hmong community conducted a community-based participatory research project. We collected data in naturalistic settings with a standardized instrument. We analyzed responses from 417 parents and caregivers and created a structural equation model to determine factors that contributed to perceived barriers. Results. Of 3 potential contributing factors to perceived barriers—nativity, socioeconomic position, and use of traditional Hmong health care (i.e., consulting shamans and herbalists)—the latter 2 significantly predicted higher perceived barriers to immunization. Nativity, indicated by years in the United States, age of arrival in the United States, and English language fluency, did not predict perceived barriers. Conclusions. Interventions aimed at reducing immunization inequities should consider distinct sociocultural factors that affect immunization rates among different refugee and immigrant groups. Immunization is ranked the number 1 public health achievement in saving lives during the 20th century, as reported by the Centers for Disease Control and Prevention. 1 However, despite recent success in reducing health inequities in immunization rates in young children, 2 among some communities and ethnic groups, immunization rates remain below optimal levels. 3 , 4 A core goal of Healthy People 2010 is eliminating disparities in immunization rates associated with race/ethnicity, income, geographic location, and other factors. 5 Other Healthy People 2010 goals are to reduce health disparities in and deaths from cervical cancer and to decrease cases of chronic hepatitis B infection, which can lead to liver cancer. 5 The incidence of both these cancers can be significantly lowered through immunization. 6 , 7 Rates of liver and cervical cancer are 3 to 4 times as high among the Hmong in California as they are as among other Asians/Pacific Islanders in California. 8 The Hmong are also much less likely than are other ethnic groups in California to have their cancers diagnosed at an early, treatable stage; prevention is key to reducing the cancer burden in this population. 9 Up to 60% of liver cancer and 70% of cervical cancer can be prevented by adequate immunization, 10 but the Hmong are the least likely among Asian/Pacific Islander groups to obtain these immunizations for their children. 11 Our literature searches in MEDLINE and CINAHL revealed little research on specific barriers to immunization among the Hmong. After the end of the Vietnam War in 1975, Hmong refugees from Laos were resettled in several nations, with the majority coming to the United States. By 2000, US residents of solely Hmong origin numbered 169 428, with the largest concentration (65 095 persons) in California. 12 In 2004, California experienced another significant surge of Hmong refugees when the US government reclassified the Hmong held in the Wat Tham Krabok refugee camp in Thailand as refugees and permitted their entry to the United States. 13 These 15 000 Hmong refugees present unique health needs arising from their long internment. Hmong refugees were reported to be underimmunized in the Wat Tham Krabok camp, and upon entrance to the United States they were provided with only the first dose of multiple-dose vaccinations. 14 Adequate immunization coverage requires multiple doses given in specific sequences to be fully effective. 15 Outreach and follow-up are needed—to protect individuals as well as the general public—for the Hmong community. We used the social determinants of health framework to estimate the effects of sociocultural and economic factors on adequate immunization. 16 Previous studies on barriers to immunization indicated that poverty, language usage, education, nativity, race/ethnicity, access to health care, and other factors may contribute to inadequate immunization. 17 – 22 The linkages and relationships among these factors have not been fully explored. To identify sociocultural factors that affect immunization rates among the Hmong, we used structural equation modeling, which allowed us to use manifest (or observed) variables to estimate the causal effects of latent (or unmeasured) variables. In structural equation modeling analysis, each latent variable represents a composite of manifest variables. Each model is tested to determine whether it is consistent with the empirical data. 23 , 24 Structural equation modeling techniques permit a more parsimonious analysis and provide a framework for demonstrating relationships among theoretical constructs in addition to representing data. 25 Structural equation modeling also considers differences among individual survey scores that may account for imperfect score validity and reliability. 23 We hypothesized that nativity, type of health care provider, and socioeconomic position would predict perceptions of barriers to immunization.
