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An Evaluation of Welfare Reform in Maryland

Cynthia Minkovitz, MD, MPP; Elizabeth Holt, DrPH; Nancy Hughart, RN, MPH; William Hou, MS; Larry Thomas, PhD; Eugene Dini, MPA; Bernard Guyer, MD, MPH

Arch Pediatr Adolesc Med. 1999;153:1242-1247.

Objective  To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children.

Design  Randomized controlled trial.

Setting  Six AFDC jurisdictions in Maryland.

Intervention  Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not.

Participants  Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups).

Main Outcome Measures  Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year.

Analysis  Comparisons among baseline and postimplementation years 1 and 2.

Results  Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status.

Conclusions  The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

From the Departments of Population and Family Health Sciences (Drs Minkovitz and Guyer, Ms Hughart, and Mr Hou) and International Health (Dr Holt), The Johns Hopkins University School of Hygiene and Public Health, and Schaefer Center for Public Policy, University of Baltimore (Dr Thomas), Baltimore, Md; and Centers for Disease Control and Prevention, Atlanta, Ga (Mr Dini).

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