Running Head: PARENTAL ATTITUDES & CHILDHOOD VACCINES 1

Running Head: PARENTAL ATTITUDES & CHILDHOOD VACCINES 1 Parental Attitudes Toward Childhood Vaccinations: Influences on Decision Making Final Project Stacey Chun Public Administration 706:Applied Data Analysis, Section 1 Professor Sheldon Gen December 12, 2014

PARENTAL ATTITUDES & CHILDHOOD VACCINES 2 ABSTRACT Populations around the world, have at one time or another in their histories, experienced epidemics in their communities. Many of these epidemics could have been prevented through vaccinations. In order to protect public health, we need to understand what types of parents oppose childhood vaccines so that public administrators, healthcare administrators, and providers can focus their educational efforts. This project utilized data from a telephonic survey led by CBS News, 60 Minutes, and Vanity Fair (2011). Chi square tests of independence were performed to evaluate whether parents are less likely to vaccinate their children based on their religion, education level, race, voter status, or location of residence. The results revealed a statistical significant relationship between vaccination approval and race, as well as vaccination approval and education, but not the between the other variables. INTRODUCTION Vaccinations are a standard routine for children in the United States. Most schools in the nation require the completion of certain vaccinations before enrollment and the Centers of Disease Control and Prevention (CDC) provides oversight on vaccination recommendations for the safety of the public. As the CDC (2014) proclaims: We don't vaccinate just to protect our children. We also vaccinate to protect our grandchildren and their grandchildren. With one disease, smallpox, we "stopped the leak" in the boat by eradicating the disease. Our children don't have to get smallpox shots any more because the disease no longer exists. If we keep vaccinating now, parents in the future may be able to trust that diseases like polio and meningitis won't infect, cripple, or kill children. Vaccinations are one of the best ways to put an end to the serious effects of certain diseases. (www.cdc.gov)

PARENTAL ATTITUDES & CHILDHOOD VACCINES 3 Vaccines have helped lower the spread of, if not rid many diseases. It is important for the health of the public to learn why parents decide whether or not to vaccinate their children especially with the current recurrence of cases of highly contagious, preventable conditions such as measles and mumps. This study uncovered characteristics of parents surveyed that are opposed to childhood vaccinations so that public administrations can target campaigns in educating them in the benefits and importance of vaccinations. Specifically, we explored the hypothesis that White parents who are college graduates, religious, registered voters, or live in the suburbs or rural areas are less likely to vaccinate their children. LITERATURE REVIEW Findings show that there are various factors determining which parents decide to vaccinate their children. As reported by Gust et al. (2008) almost 15% of underimmunization in young children can be attributed to parental attitudes, beliefs, and behaviors (p. 499). Patterns in social science research indicate there are basic themes on parents decisions on childhood vaccinations. Reasons related to trust, communication, social network, adverse effects, access, and other reasons (e.g. religion) are common amongst American parents. These variables are not mutually exclusive of each other and are often times related. For example, parents create their network of people they trust and generally, communication is key in building trusting relationships (Bruncon, 2013, p. e1404). Mothers and fathers tend to consult or take other people s opinions into consideration before deciding whether to vaccinate their children (Brunson, 2013, p. e1397). Communication is a key element for refusal or acceptance of childhood vaccinations and trust is built through solid communication. Mills et al. (2005) noted that poor communication was a reason for refusal

PARENTAL ATTITUDES & CHILDHOOD VACCINES 4 of vaccines by parents (p. 1085). Whether it is communication with people within their social network or with physicians, trust plays a significant role in parents decisions to vaccinate kids (Brunson, 2013, p. e1404). As Benin et al. revealed (2006), the more trust parents have in a source of information (e.g. people they know who believe in alternative medicine or traditional medical providers) the more likely they are to adopt the beliefs of those people (p. 1539). Parents may obtain medical knowledge about vaccinations from trusted sources that are non-traditional medical providers. Gust et al. (2008) found that non-hispanic White mothers, reported that they learned from chiropractors that vaccines are not necessary as the body can heal itself (p. 504). Although, vaccinations are outside the scope of chiropractors practice, parents may have trust in their opinions about vaccine since they rely on them for their other medical needs. Sources outside parents immediate networks, such as the media also influence decision-making regarding vaccines. Mass communication can have an impact on the trust parents have of vaccinations or the medical community as a whole. Frederickson et al. (2003) revealed that 52% of the providers they interviewed reported that the most common reason parents refused vaccination for their children is due to fears of side effects heard from media or word of mouth (p. 431). Recent media coverage has provided a lot of attention on the potential harm (e.g. cause of autism) of vaccinations. The media can lead parents to have a perception of a conspiracy from opponents of vaccines or that the target disease for the vaccine is not a health threat and that the medical community does not understand the adverse effects associated with vaccinations (Mills et al., 2005, p. 1084). Although, the media is not directly within parents networks, some still rely solely on the media for their immunization information.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 5 Lack of basic medical immunization knowledge can further perpetuate doubts from parents decisions to vaccinate their children. Providers reported that 69% of parents who decided not to vaccinate their children stated it was because they were concerned that the vaccine could hurt their child (Omer et al., 2009, p. 1985). Also, Mills et al. (2005) explained that nonvaccinating parents described a belief that [they] can control the pathogens their child may be exposed to (p. 1085). Fear about adverse side effects such as pain or secondary conditions (e.g. causing children to be more sick if they had minor illnesses at the time of vaccination) led some parents to decide not to vaccinate their children (Mills et al., 2005, p. 1085). Additionally, not knowing when to vaccinate and which vaccines to provide led to parents refusal of vaccinations (Mills et al., 2005, p. 1084). It is the natural instinct of a parent to protect their child and immunizations can cause fear and doubt for a parent who may not be educated about the risks and benefits. Therefore, it is important for medical providers to be able to address the concerns of their patients (i.e. patients guardians) to help gain trust of parents. Researchers Gellin et al. (2000) found that, children s health care providers were cited as the most important source of information on immunizations (p. 1099). Primary care providers state that vaccine refusal rates tend to be low in the US, but it is still important to be able to address the concerns of parents to ensure that as many people as possible are vaccinated against diseases which could lead to public health hazards (Frederickson et al., 2003, p. 437). Misconceptions about vaccinations and the side effects of vaccinations can be perpetuated through trusting relationships, but education about the importance and basic information about vaccines generally help alleviate parents fears (Kennedy, Brown, & Gust, 2005, p. 257).

PARENTAL ATTITUDES & CHILDHOOD VACCINES 6 Other less common reasons for vaccination refusal was due to non-medical concerns. Religious, moral, or philosophical reasons were indicated as barriers to vaccinations (Mills et. al, 2005, p. 1085; Frederickson et al., 2003, p. 431). Health care providers reported that a low volume of patients (about 8%) refused vaccinations because of anti-government sentiment (Frederickson et al., 2003, p.431). While non-medical related concerns from parents are not often reasons for refusal, healthcare professional should also consider these ideas when working with their patients. As seen in previous research there are different reasons why parents decide to vaccinate their children and the common recommendation is to provide basic education to parents about the pros and cons of vaccinations. It would be helpful to understand which parents to target educational efforts for administrators who have limited resources. Given the evidence of previous research, this project analyzed whether race, education, religion, voter status, or location of residence led parents to be less likely to vaccinate their children. MEDTHODOLOGY SOURCE DATA AND VARIABLES This project analyzed the existing dataset collected by CBS News, 60 Minutes, and Vanity Fair (2011) from their telephonic survey performed in November 2011 to determine which group(s) of people to focus interventions on. The survey was a cross sectional study from the second of three monthly telephonic interview waves about a variety of social and political topics. As presented by CBS News, 60 Minutes, and Vanity Fair (2011), A variation of random-digit dialing (RDD) using primary sampling units (PSUs) was employed, consisting of blocks of 100 telephone numbers identical through the eighth digit and stratified by geographic

PARENTAL ATTITUDES & CHILDHOOD VACCINES 7 region, area code, and size of place. Phone numbers were dialed from RDD samples of both standard land-lines and cell phones. This research focused on the question related to respondents attitudes about the dangers of vaccinations (Figure 1.1). Data were filtered to specifically analyze people who responded that they had children (i.e. parents). It was assumed that this sample is from an independent random sample. Additionally, it was assumed that parents who answered about the dangers of vaccine (Figure 1.1) with 1. They are naive and putting their children and others at risk approved vaccinations whereas parents who answered 2. They are smart because we don't know enough about the possible dangers of vaccines were opposed to vaccines. Figure 1.1 Dependent variable VAC Description: Level of Measurement: Values: Vaccination Approval Which comes closest to your view about parents who choose not to vaccinate their children? 1. They are naive and putting their children and others at risk, or 2. They are smart because we don't know enough about the possible dangers of vaccines. Nominal 0 Opposes vaccines (They are smart because we don't know enough about the possible dangers of vaccines) 1 Approves vaccines (They are naive and putting their children and others at risk) 9 Don t know/no Answer The dependent variable is parents approval of vaccinations and the independent variables are race, education, religion, voter status, and urbanity (Figure 1.2). All variables are nominal and the unit of analysis is parents. HYPOTHESIS The following hypotheses were utilized to investigate whether White parents who are college graduates, religious, registered voters, or live in the suburbs or rural areas are less likely to vaccinate their children.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 8 H 0 : Vaccine approval and X (race, education, religion, voter status or urbanity) are independent (i.e. Vaccine approval and X are not correlated) H 1 : Vaccine approval and X (race, education, religion, voter status or urbanity) are NOT independent (i.e. Vaccine approval and X are correlated) RESEARCH MODEL Descriptive statistics (i.e. measure of central tendency) (Table 1), did not tell enough of the story for public administrators to take action, therefore we applied chi square tests. Although, the raw data showed that most parents were religious, registered voters, White, lived in the suburbs or rural areas, were not college graduates, and approved vaccines, these data did not show the significant relationships between each independent variable with the dependent variable. Table 1. Descriptive statistics Descriptive Statistics Religion Voter Status Race Urbanity Vaccination Approval Education N Valid 683 708 695 581 614 705 Missing 25 0 13 127 94 3 Mode 1.00 1.00 1.00 1.00 1.00.00 Because all variables were nominal, chi square tests of independence were run for each pair of variables (i.e. vaccine approval race, vaccine approval education, vaccine approval religion, vaccine approval voter status, and vaccine approval urbanity). If the null hypothesis for any pair was rejected then post hoc tests were performed to determine the statistical significant proportion that caused the two variables to be correlated. The confidence level for all tests was 90%.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 9 RESULTS Of the 945 people who responded to the survey question (Figure 1.1), 708 people (75%) were parents (Figure 2). Figure 2 Parental status of survey respondents Parental Status 6, 1% 237, 25% Have Children No Children 708, 74% No answer The original hypothesis was partially proven. Only two of the five independent variables were correlated with vaccine approval. With 90% confidence we reject the null hypothesis that vaccine approval and race are independent (Figure 3.1). Therefore, vaccine approval and race are correlated. Specifically, non-white parents opposing vaccinations are over represented. Secondly, with 90% confidence we reject the null hypothesis that vaccine approval and education are independent (Figure 3.2). Therefore, vaccine approval and education are correlated. Particularly, parents who are college graduates opposing vaccinations are under represented.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 10 Religion, voter status, and urbanity all showed to be independent from vaccine approval, therefore there were no relationships between those variables and vaccine approval. Figure 3.1 SPSS Output Race (White) Race * Vaccination Approval Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 606 85.6% 102 14.4% 708 100.0% Race Non- White Race * Vaccination Approval Crosstabulation Vaccination Approval Opposes vaccines Approves vaccines Total Count 18 54 72 Expected Count 10.1 61.9 72.0 White Count 67 467 534 Expected Count 74.9 459.1 534.0 Total Count 85 521 606 Expected Count 85.0 521.0 606.0 Value Chi-Square Tests df Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1-sided) Pearson Chi-Square 8.159 a 1.004** Continuity Correction b 7.159 1.007 Likelihood Ratio 7.058 1.008 Fisher's Exact Test.010.006 Linear-by-Linear Association 8.146 1.004 N of Valid Cases 606

PARENTAL ATTITUDES & CHILDHOOD VACCINES 11 a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 10.10. b. Computed only for a 2x2 table ** Alpha = 10%

PARENTAL ATTITUDES & CHILDHOOD VACCINES 12 Figure 3.2 SPSS Output - College Graduate Education * Vaccination Approval Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 612 86.4% 96 13.6% 708 100.0% Education Not College Grad Education * Vaccination Approval Crosstabulation Vaccination Approval Opposes vaccines Approves vaccines Total Count 62 311 373 Expected Count 52.4 320.6 373.0 College Grad Count 24 215 239 Expected Count 33.6 205.4 239.0 Total Count 86 526 612 Expected Count 86.0 526.0 612.0 Value Chi-Square Tests df Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1-sided) Pearson Chi-Square 5.222 a 1.022** Continuity Correction b 4.691 1.030 Likelihood Ratio 5.425 1.020 Fisher's Exact Test.024.014 Linear-by-Linear Association 5.214 1.022 N of Valid Cases 612 a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 33.58. b. Computed only for a 2x2 table ** Alpha = 10%

PARENTAL ATTITUDES & CHILDHOOD VACCINES 13 CONCLUSION LIMITATIONS OF RESEARCH This research project was limited in its statistical analysis as all variables were nominal. Although, we were able to identify statistical significant relationships between specific variables, further analysis is required to determine which groups of parents are more or less likely to vaccinate their children. Additionally, more accurate and specific analysis such as multiple linear regression could have been performed if scale data were accessible. The data set collected attempts to meet both internal and external validity requirements. In regards to internal validity, the sample was randomized utilizing comparable groups, but there may have been instrument decay depending on who the interviewer was. Interviewer demographic information was also tracked so that these factors could be taken into consideration. For external validity, the sample of people selected varied across different parts of the United States amongst different populations of people (i.e. varied by demographics). Although, research has been done to analyze the influences of parents decision-making and perceptions regarding the vaccination of children there have not been many controlled studies on whether the findings from past studies (i.e. the importance of trust, education, and provider relationships) have an actual effect on the behaviors of parents when vaccinating their children. For example, a study could track samples of parents who were exposed to increased trust building and education versus parents who were not, to identify possible changes in vaccinations rates of their children. Additionally, qualitative studies are crucial in identifying reasons for vaccination, but these studies often lack a large enough sample size to be able to generalize the findings. It may be helpful to learn the characteristics of vaccinated and not vaccinated children, but a deeper dive is required to influence parental decision in the future.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 14 Identifying characteristics of parents who are opposed to vaccinations will assist healthcare professionals in focusing their educational efforts. Although, the majority of parents vaccinate their children, it is also essential to educate parents who plan not to vaccinate their children as their opinions may influence others. POLICY IMPLICATIONS Results from this research are just a starting point in understanding what types of parents could be opposed to vaccinations. Although, these data showed that parents who are college graduates are under represented and non-white are over represented when opposing vaccinations there are numerous extraneous factors that may impact parental decision making on childhood vaccinations. Health educators, providers, and healthcare administrators may cater their vaccination messaging and campaigns to gain the trust of parents who are not college graduates and non-white. Based on the literature review previously presented, they may also utilize tools such as the media to effectively communicate and inform parents of the importance of vaccinating their children. The main goal is to ensure parents are making educated decisions on whether to vaccinate their children.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 15 Figure 1.2 Codebook of Variables Analyzed DEPENDENT VARIABLE APPENDIX ITEM 1 VAC Description: Level of Measurement: Values: Vaccination Approval Which comes closest to your view about parents who choose not to vaccinate their children? 1. They are naive and putting their children and others at risk, or 2. They are smart because we don't know enough about the possible dangers of vaccines. Nominal 0 Opposes vaccines (They are smart because we don't know enough about the possible dangers of vaccines) 1 Approves vaccines (They are naive and putting their children and others at risk) 9 Don t know/no Answer INDEPENDENT VARIABLES ITEM 2 RELI Description: Level of Measurement: Values: ITEM 3 EDUC Description: Level of Measurement: Values: ITEM 4 RACE Description: Level of Measurement: Values: ITEM 5 REG Religion What is your religious preference today? Nominal 0 Not religious ( None ) 1 Religious (Protestant, Catholic, Jewish, or Other ) 9 Don t know/no Answer College Graduate What was the last grade in school you completed? Nominal 0 Not college grad (High school grad or Some college) 1 College grad (College grad or Post- Grad) 9 - Refused Race (White) Are you White, Black, Asian, or some other race? Nominal 0 Not White (Black, Asian, Other ) 1 White or Caucasian 9 Refused Registered Voter

PARENTAL ATTITUDES & CHILDHOOD VACCINES 16 Description: Level of Measurement: Values: ITEM 6 URBN Description: Level of Measurement: Values: Some people are registered to vote and others are not. Are you registered to vote in the election district where you now live, or aren't you? Nominal 0 - No 1 Yes 9 Don t know/no Answer Suburbs or Rural Resident Urbanity Nominal 0 Large Central City (over 500K) or Central City 1 Suburbs or Rural 9 Missing Data

PARENTAL ATTITUDES & CHILDHOOD VACCINES 17 Table 2.1. Statistical significance of proportions Race Chi Square Values Vaccine Approval * Race Opposes Vaccines Approves Vaccines Non-White 6.18** 1.01 White 0.83 0.14 **Chi critical value 2.71; df=1 Table 2.2. Statistical significance of proportions - Education Chi Square Values Vaccine Approval * Education Opposes Vaccines Approves Vaccines Not College Grad 1.76 0.29 College Grad 2.74** 0.45 **Chi critical value 2.71; df=1

PARENTAL ATTITUDES & CHILDHOOD VACCINES 18 Figure 3.3 SPSS Output - Religion Religion * Vaccination Approval Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 597 84.3% 111 15.7% 708 100.0% Religion * Vaccination Approval Crosstabulation Count Religion Not Religious Vaccination Approval Opposes vaccines Approves vaccines Total 8 62 70 Religious 76 451 527 Total 84 513 597 Value Chi-Square Tests df Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1-sided) Pearson Chi-Square.458 a 1.499** Continuity Correction b.244 1.622 Likelihood Ratio.481 1.488 Fisher's Exact Test.586.320 Linear-by-Linear Association.457 1.499 N of Valid Cases 597 a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 9.85. b. Computed only for a 2x2 table ** Alpha = 10%

PARENTAL ATTITUDES & CHILDHOOD VACCINES 19 Figure 3.4 SPSS Output Registered Voter Voter Status * Vaccination Approval Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 614 86.7% 94 13.3% 708 100.0% Voter Status * Vaccination Approval Crosstabulation Count Voter Status Not Registered Vaccination Approval Opposes vaccines Approves vaccines Total 12 49 61 Registered 74 479 553 Total 86 528 614 Value Chi-Square Tests df Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1-sided) Pearson Chi-Square 1.805 a 1.179** Continuity Correction b 1.320 1.251 Likelihood Ratio 1.655 1.198 Fisher's Exact Test.177.127 Linear-by-Linear Association 1.802 1.179 N of Valid Cases 614 a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 8.54. b. Computed only for a 2x2 table ** Alpha = 10%

PARENTAL ATTITUDES & CHILDHOOD VACCINES 20 Figure 3.5 SPSS Output Suburbs or Rural Resident Urbanity * Vaccination Approval Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 512 72.3% 196 27.7% 708 100.0% Count Urbanit y Urbanity * Vaccination Approval Crosstabulation Large Central City or Central City Vaccination Approval Opposes vaccines Approves vaccines Total 17 112 129 Suburbs or Rural 55 328 383 Total 72 440 512 Value Chi-Square Tests df Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1-sided) Pearson Chi-Square.112 a 1.738** Continuity Correction b.035 1.851 Likelihood Ratio.113 1.737 Fisher's Exact Test.884.432 Linear-by-Linear Association.111 1.739 N of Valid Cases 512 a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 18.14. b. Computed only for a 2x2 table ** Alpha = 10%

PARENTAL ATTITUDES & CHILDHOOD VACCINES 21 References Benin, A. L., Wisler-Scher, D. J., Colson, E., Shapiro, E. D., & Holmboe, E. S. (2006). Qualitative analysis of mothers' decision-making about vaccines for infants: The importance of trust. Pediatrics, 117(5), 1532-1541. Brunson, E. K. (2013) The impact of social networks on parents vaccination decisions. Pediatrics, 131(5), e1397-e1404. CBS News, 60 Minutes, & Vanity Fair (2011). CBS News/60 Minutes/Vanity Fair National Poll, November #2, 2011[Data file and code book]. Retrieved from http://www.icpsr.umich.edu/icpsrweb/icpsr/studies/34475/ Centers for Disease Control and Prevention. (2014). Vaccines and Immunizations. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/vaccines/ Fredrickson, D. D., Davis, T. C., Arnold, C. L., Kennen, E. M., Humiston, S. G., Cross, J. T., & Bochhini, J. A. (2003). Childhood immunization refusal: Provider and parent perceptions. Clinical Research and Methods, 36(6), 431-439. Gellin, B. G., Maibach, E. W., & Marcuse, E. K. (2000). Do parents understand immunizations? A national telephone survey. Pediatrics, 106(5), 1097-1102. Gust, D. A., Brown, C., Sheedy, K., Hibbs, B., Weaver, D., Nowak, G. (2005). Immunization attitudes and beliefs among parents: Beyond a dichotomous perspective. American Journal of Health Behavior, 29 (1), 81-92. Gust, D. A., Kennedy, A., Wolfe, S. Sheedy, K., Nguyen, C., & Campbell, S. (2008). Developing tailored immunization materials for concerned mothers. Health Education Research, 23 (3), 499-511.

PARENTAL ATTITUDES & CHILDHOOD VACCINES 22 Kennedy, A. M., Brown, C. J., & Gust, D. A. (2005). Vaccine beliefs of parents who oppose compulsory vaccination. Public Health Reports, 120(3), 252-258. Mills, E., Jada, A. R., Ross, C., & Wilson, K. (2005). Systemic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccination. Journal of Clinical Epidemiology, 58(11), 1081-1088. Omer, S. B., Salmon, D. A., Orenstein, W. A., dehart, M. P. & Halsey, N. (2009) Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. The New England Journal of Medicine, 360(19), 1981-1988.