Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Mary Barger, PhD, MPH, RN, CNM, FACNM, Chairperson Lois C. Howland, Dr PH, MSN, RN Susan R. Hints, MD, MS EPI


child development, follow-up studies, premature infants, rural health, theory


Prematurity is a significant public health problem and preterm infants face well described risks of adverse neurodevelopmental outcomes. Bronfenbrenner’s bioecological theory of development describes interactions between biological and environmental factors and explains how these interactions can impact development. Systematic follow-up of preterm, high-risk infants is recommended for early identification of problems and provision of interventions and support services. Most research on follow-up attendance has involved small, single sites. A retrospective analysis of population based data available in the California Children’s Services High Risk Infant Follow-up Quality of Care Initiative (HRIF-QCI) data system was performed to examine factors associated with attendance at the second recommended visit.

Applying the bioecological theory of development to the high-risk infant population reveals the numerous biologic, family, social, cultural, and political factors that influence development. This theory supports the provision of early intervention services to this population.

Only 74% of those infants seen for the first visit attended the second recommended visit. Infants with birth weights equal to or less than 750 grams were almost twice as likely to attend the visit compared with those with birth weights greater than 1,250 grams. Private insurance, two parents as caregivers, completion of the first visit during the recommended interval and enrollment in early intervention during the first visit were all associated with higher attendance rates. Public insurance, a single parent as caregiver, or maternal race of Black or Asian were all associated with decreased attendance. Infants with maternal race of Black were 45% less likely to attend the second visit, and the factor with the strongest association with lack of visit two attendance.

Rural residence was associated with decreased HRIF attendance (they were 30% less likely to attend) and there were marked differences between the rural and non-rural population, with rural caregivers being younger, less educated, and with lower rates of employment. There were marked differences in attendance rates between different HRIF programs, with risk-adjusted rates ranging from 34.4% to 89.9%. These findings offer new knowledge into factors associated with HRIF clinic attendance and suggest future research opportunities to improve clinical practice with this population.

Document Type

Dissertation: Open Access