Research Article: Parental attitudes and perceptions associated with childhood vaccine exemptions in high-exemption schools

Date Published: June 14, 2018

Publisher: Public Library of Science

Author(s): Heidi L. Pottinger, Elizabeth T. Jacobs, Steven D. Haenchen, Kacey C. Ernst, Vijayaprasad Gopichandran.


Previous work demonstrates that individuals who obtain exemptions from school immunization requirements are geographically clustered, making regional differences in vaccination coverage a significant concern. Even where exemption levels are high, there are still parents that vaccinate. School-level assessments have determined that exemptors are more likely to attend wealthier schools with fewer minorities. Few studies have assessed divergent opinions within the context of a higher-exemption community to examine subtle differences in opinion surrounding vaccinations. Therefore, the objective of this work was to assess attitudes and perceptions towards vaccinations and compare them for exemptors and non-exemptors. We administered surveys to parents in high-exemption (>10%) elementary schools in Arizona during the 2012–13 school year. A total of 404 surveys were completed by parents among schools in Maricopa (n = 7) and Yavapai (n = 2) counties. Of these, 35% (n = 141) were exemptors and 65% (n = 261) were non-exemptors. Exemptors were more likely than non-exemptors to be concerned about serious side-effects (p<0.001). They were more likely to report knowing someone who had been diagnosed with a vaccine-preventable disease (p<0.001) but less likely to report that this had been a serious illness in that person (p<0.001) and they believed it is better for a child to develop immunity through illness than vaccination (p<0.001). They were less likely to trust physicians (p<0.001) and information about vaccines (p<0.001) and were more likely to obtain their health care from a naturopath (p<0.001). In summary, exemptors in these Arizona schools do not appear to be exempting their children from vaccinations due to convenience, as has been hypothesized in other settings. Based on the divergent views within high-exemption schools and reported distrust of the medical establishment, target interventions for high-exemption schools are discussed. Additionally, given the lack of effective non-policy based interventions to-date, the negligible declines in personal belief exemption rates, and vaccine preventable disease rate increases in Arizona, especially in high-exemption areas, legislative action in Arizona may also warrant further investigation.

Partial Text

Vaccine exemptions are currently an area of intense interest in public health, particularly in light of the measles outbreaks in 2015 and 2016 [1]. Over the last century, universal recommendations for vaccination in the United States (US) have substantially reduced the morbidity and mortality from vaccine-preventable diseases (VPDs) [2]. While there can be rare adverse events after vaccination, the Institute of Medicine (IOM) unequivocally reported in 2011 that the benefits far outweigh any risk [3]. In 2013, the Institute of Medicine (IOM) reported that a growing trend of delaying vaccinations or exempting from them altogether has contributed to increases in vaccine-preventable outbreaks and mortality in the US [4].

This study was reviewed by the University of Arizona and Arizona Department of Public Health Institutional Review Boards, as well as by applicable Maricopa and Yavapai Counties and public school systems. The study was determined to be ethical and of minimal risk.

Of the 27 schools meeting inclusion criteria, 15 responded and nine agreed to participate in the study, for a response rate of 33.3%. The mean kindergarten permanent PBE rate, based on 2010–11 data for these nine schools, was 18.5%. Among the participating schools, surveys reached approximately 2800 households via email or paper copy, with responses received from 404 parents (S1 Data), for a response rate of 14.4%. The mean age of respondents was 37.2 ±6.3 years and the average number of children the parents reported having was 2.7±1.3 children (Table 1). The majority of respondents were female (85.0%); white (87.6%); married (82.9%); held a Bachelor’s degree or higher (55%); had private insurance (74.0%); visited an M.D. (83.1%); were employed (63.0%) and/or had a partner who was employed (84.0%); and earned a household income greater than or equal to $50,000 annually (75.5%; Table 1).

The overall findings of the present study indicate that there are major differences between vaccine-exempting and non-exempting parents from Arizona schools located in regional clusters with high PBE rates. Compared to non-exemptors, exemptors were significantly more likely to visit a Naturopath or a D.O. rather than a M.D. They were also less likely trust medical professionals and information that they receive about vaccinations. In addition, exemptors were significantly more likely to be concerned about safety of vaccinations and to believe that children receive too many shots.

Based on the results reported herein, compared to non-exempting parent respondents, exemptors in Arizona high-exemption schools were more likely to report perceptions that VPDs are not severe and believe it is better for their child to develop immunity through illness rather than vaccination. Exempting parents were also less likely to trust physicians and information about vaccines, and were more likely to obtain their health care from a naturopath. Exempting respondents did not appear to have exempted their child from vaccination out of convenience but instead due to true personal beliefs. Within the limitation of a low response rate to the survey in this preliminary study, some general recommendations include the following for high-exemption schools in Arizona. First, there is a great need for development and provision of tailored educational materials and efforts that not only cite sources which the target audience trusts, but are also tested for impact prior to implementation. However, given the lack of successful interventions to-date, messaging to reduce PBE rates in high-exemption schools may be ineffective or counter-productive. If PBE and VPD rates continue to increase in high-exemption areas, resources to develop effective messaging for various populations and delivery methods may be unavailable. As states with easier nonmedical vaccine exemption policies are more likely to experience a VPD outbreak compared to those with more difficult policies [6–9], Arizona may need to consider other alternatives, such as more stringent requirements for PBEs and/or imposing processing fees to discourage high rates of PBEs. Considerable efforts remain to address the issue of PBEs in a comprehensive manner as the reasons for exemption appear to be multi-faceted. Further research and collaborative efforts among stakeholders are needed to address the issues outlined here.




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