Factors Influencing African-American Mothers' Concerns About Immunization Safety
Parents Concerned About Vaccine Safety: Differences in Race/Ethnicity and Attitudes
Parental Vaccine Beliefs and Child’s School Type
Underimmunization Among Children: Effects of Vaccine Safety Concerns on Immunization Status
National Immunization Information Hotline: Calls Concerning Adverse Events, 1998–2000
Parent Attitudes Toward Immunizations and Healthcare Providers: The Role of Information
Immunization Attitudes and Beliefs Among Parents: Beyond a Dichotomous Perspective
Parental Concerns and Medical-Seeking Behavior After Immunization

Factors Influencing African-American Mothers’ Concerns about Immunization Safety:
A Summary of Focus Group Findings

Irene Shui, MPH; Allison Kennedy, MPH; Karen Wooten, MA; Benjamin Schwartz, MD; and Deborah Gust, PhD

Objective: To examine the vaccine safety concerns of African-American mothers who, despite concerns, have their children immunized.

Methods: Six focus groups of Atlanta-area African-American mothers who were very concerned about vaccine safety but whose children were fully vaccinated were conducted.

Results: Major factors influencing participants’ concerns about immunizations included: lack of information and mistrust of the medical community and government. Factors that convinced parents to have their child immunized despite their concerns included social norms and/or laws supporting immunization and fear of the consequences of not immunizing. Suggestions given to reduce concerns included improving available information that addressed their concerns and provider-patient communication.

Conclusions: Addressing mothers’ concerns about immunization is important both from an ethical perspective, in assuring that they are fully informed of the risks and benefits of immunizations, as well as from a practical one, in reducing the possibility that they will decide not to immunize their child. Changes in the childhood immunization process should be made to reduce parental concern about vaccine safety. Some changes that may be considered include improved provider communication about immunizations and additional tailored information about the necessity and safety of vaccines.


Parents Concerned About Vaccine Safety: Differences in Race/Ethnicity and Attitudes

Irene M. Shui, MPH, Eric S. Weintraub, MPH, Deborah A. Gust, PhD, MPH

Background: Parental concerns about immunization safety have been covered widely in the media and on the Internet and have been correlated in some studies with under immunization and the late receipt of immunizations.

Objectives: Phase 1: To (1) measure the prevalence of parents with immunization safety concern, specifically those with high-level concern, (2) determine demographic characteristics and attitudes typical for this subgroup of parents, and (3) determine factors that influence such parents, nevertheless, to have their children immunized. Phase 2: To further explore the racial/ethnic difference found in the first-phase results, specifically to compare the immunization attitudes of Hispanic (both black and white) and non-Hispanic black parents with those of non-Hispanic white parents.

Methods: ConsumerStyles (2004) survey data of a nationwide panel of U.S. adults were analyzed in January 2006. In Phase 1, bivariate and logistic regression analyses were used to identify factors associated with parental concerns about immunization safety. In Phase 2, logistic regression was used to compare immunization attitudes among non-Hispanic black; Hispanic (both black and white); and non-Hispanic white parents.

Results: The response rate was 62% (6207/10,000); analysis was restricted to the 2937 (47%) respondents who were parents with a child aged 18 years or younger; 634 (21%) responded with the highest level of concern, 5 on a 1-to-5-point scale. Demographics (Hispanic ethnicity/nonwhite race, low income, and less education) and negative attitudes toward immunization and the child’s healthcare provider were significantly associated with high-level concern. Seventy-two percent of parents with high-level concern responded that the risk of a child getting a disease was their primary reason for having their child immunized, while 17% listed state laws requiring immunizations for school/daycare entry. Importantly, black parents were more likely than white parents to have negative attitudes toward immunizations and their child’s healthcare provider.

Conclusions: One fifth of parents reported high-level concern with the safety of childhood immunizations. To prevent the erosion of childhood immunization rates, healthcare providers need to learn how to recognize and address these concerns.

(Am J Prev Med 2006;31(3):244–251) © 2006 American Journal of Preventive Medicine

Parental Vaccine Beliefs and Child’s School Type

Allison M. Kennedy, Deborah A. Gust

This study examined the vaccination beliefs of parents with children in different educational settings, with a specific focus on homeschools, which are least likely to be influenced by and subject to the rules that apply to the public education system, including those mandating immunization. While this study is cross-sectional, and therefore unable to address causality regarding parental beliefs, these results can be used to suggest and highlight potential differences in the beliefs and behaviors of parents, which will be explored further in future research. These results also can be used to guide the development of tailored messages for use in vaccine communication with parents, research that has been previously suggested as a way of addressing differences in vaccination coverage levels between different types of schools

Methods: Data from the 2003 HealthStyles survey were used for analysis. HealthStyles has been administered every year since 1995 as a follow-up to the ConsumerStyles mail panel survey. ConsumerStyles is produced from a panel of 600,000 households representing a range of demographic characteristics who have agreed to respond to periodic mail surveys.

Results: Parental Parental beliefs regarding vaccine safety and importance differed depending on their child’s school type (Table 3). Overall, 73% of parents believed vaccines are safe or very safe. This proportion was lower among homeschooling parents (52%), than among public (73%) and private school (74%) parents (p = 0.05). Concern that vaccines may cause learning disabilities also was higher among homeschooling parents (30%) than among public (13%) and private (18%) school parents (p = 0.02). Regarding the importance of vaccines, 86% of parents believed vaccines were important or very important to children’s health. Again, this proportion was lower among homeschooling parents (54%) than among public (87%) and private (88%) school parents (p < 0.01). A similar pattern was seen when parents were asked about their concerns regarding severity of and susceptibility to vaccine-preventable diseases. At 25%, homeschools had the largest proportion of parents who were concerned that vaccines are given to prevent nonserious illnesses, compared to 10% and 4% of public and private school parents, respectively (p < 0.01). Similarly, 25% of homeschool parents were concerned that vaccines were given to prevent illnesses that children are unlikely to get, compared to 13% of public and 8% of private school parents (p = 0.04).

Journal of School Health, September 2005, Vol. 75, No.7

Underimmunization Among Children: Effects of Vaccine Safety Concerns on Immunization Status

Deborah A. Gust, PhD, MPH; Tara W. Strine, MPH; Emmanuel Maurice, MS; Philip Smith, PhD; Hussain Yusuf, MBBS, MPH; Marilyn Wilkinson, ScD; Michael Battaglia, MA; Robert Wright, BS; and Benjamin Schwartz, MD

Objective. To examine the attitudes, beliefs, and behaviors of parents whose children were underimmunized with respect to >2 vaccines that have recently received negative attention, compared with parents whose children were fully immunized with respect to the recommended vaccines.

Design. Case-control study.

Setting. A sample of households that participated in the National Immunization Survey were recontacted in 2001.

Main Outcome Measure. Vaccination status was assessed. Case subjects were underimmunized with respect to >2 of 3 vaccines (diphtheria-tetanus-pertussis or diphtheria- tetanus-acellular pertussis, hepatitis B, or measlescontaining vaccines), and control subjects were fully immunized.

Results. The response rate was 52.1% (2315 of 4440 subjects). Compared with control households, case households were more likely to make $0 to $30 000 (adjusted odds ratio [OR]: 2.7; 95% confidence interval [CI]: 1.5– 4.6) than at least $75 000, to have >2 providers (OR: 2.0; 95% CI: 1.3–3.1) than 1, and to have >4 children (OR: 3.1; 95% CI: 1.5– 6.3) than 1 child. With control for demographic and medical care factors, case subjects were more likely than control subjects to not want a new infant to receive all shots (OR: 3.8; 95% CI: 1.5–9.8), to score vaccines as unsafe or somewhat safe (OR: 2.0; 95% CI: 1.2– 3.4), and to ask the doctor or nurse not to give the child a vaccine for reasons other than illness (OR: 2.7; 95% CI: 1.2– 6.1). Among case subjects, 14.8% of underimmunization was attributable to parental attitudes, beliefs, and behaviors.

Conclusions. Attitudes, beliefs, and behaviors indicative of vaccine safety concerns contribute substantially to underimmunization in the United States. Although concerns were significantly more common among parents of underimmunized children, many parents of fully immunized children demonstrated similar attitudes, beliefs, and behaviors, suggesting a risk to the currently high vaccination levels. Efforts to maintain and improve immunization coverage need to target those with attitudes/ beliefs/behaviors indicative of vaccine safety concerns, as well as those with socioeconomic and health care access problems.

Pediatrics 2004;114:e16–e22. URL:
PEDIATRICS Vol. 114 No. 1 July 2004

National Immunization Information Hotline: Calls Concerning Adverse Events, 1998–2000

Gust DA, Gangarosa P, Hibbs B, Pollard R, Wallach G, Chen RT.

Data from the National Immunization Information Hotline (NIIH) concerning vaccine adverse event inquiries were analyzed from 1998 to 2000 (total n¼23,841 [public n¼14,330; health care professionals n¼9,511]). Approximately 20% of calls from the public from 1998 to 2000 concerned vaccine adverse
events. These calls increased 199.5% from 1998 (n¼422) to 1999 (n¼1,264), then declined 12.4% from 1999 to 2000 (n¼1,107). A Lexus Nexus search showed that the number of news stories mentioning vaccine safety showed a similar pattern. Women were more likely to call the NIIH concerning vaccine
adverse events than men, and persons 40–59 years old and persons 60 years old and over were less likely to call about vaccine adverse events than those 20–39 years. The parallel trends in news stories mentioning vaccine safety and calls to the NIIH concerning adverse events suggests that news stories may stimulate questions about vaccine safety. Understanding that news stories may elicit questions
about vaccine adverse events and examining the characteristics of persons who ask vaccine adverse event questions may guide future informational interventions toward those most in need.

Journal of Health Communication, Volume 9: 387–394, 2004

Parent Attitudes Toward Immunizations and Healthcare Providers: The Role of Information

Deborah A. Gust, PhD, MPH, Allison Kennedy, MPH, Irene Shui, MPH, Philip J. Smith, PhD, Glen Nowak, PhD, Larry K. Pickering, MD

Background: Lack of information has been associated with patient anxiety or concern in a number of healthcare areas.

Objectives: (1) Identify the proportion of parents who agreed, were neutral, and disagreed that they had access to enough information to make a decision about immunizing their child; (2) examine how parents who agreed and disagreed differed with respect ton sociodemographic characteristics, and their attitudes about immunizations, their child’s healthcare provider, immunization requirements/exemptions, and immunization policymakers; and (3) identify if differences exist in specific immunization concerns.

Methods: A sample of parents with at least one child aged _6 years (n _642) was analyzed using data from the HealthStyles survey conducted during July and August 2003. Odds ratios and the Mantel–Haenszel chi-square test were used for analysis.

Results: Response rate for HealthStyles was 69% (4035/5845). The largest proportion of parents agreed they had access to enough information (67%) compared to parents who were neutral (20%) or who disagreed (13%). Compared to parents who agreed, parents who disagreed were more likely to be less confident in the safety of childhood vaccines (odds ratio [OR]_5.4, 95% confidence interval [CI]_3.3– 8.9), and to disagree that their child’s main healthcare provider is easy to talk to (OR_10.3, 95% CI_3.7–28.1). There was a significant linear trend in the percentage of parents expressing immunization concerns among those who agreed, were neutral, and who disagreed they had access to enough information (p _0.05; df_1).

Conclusions: While most parents agreed that they had access to enough immunization information, approximately a third did not. Perceived lack of information was associated with negative attitudes about immunizations and toward healthcare providers. Basic information about the benefits and risks of vaccines presented by a trusted provider could go a long way toward maintaining and/or improving confidence in the immunization process.

(Am J Prev Med 2005;29(2):105–112) © 2005 American Journal of Preventive Medicine

Immunization Attitudes and Beliefs Among Parents: Beyond a Dichotomous Perspective

Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G.

Objective: To better understand differences among parents in their attitudes, beliefs, and behaviors regarding childhood immunizations and health-related issues.

Methods: Forty-four survey variables assessing attitudes and beliefs about immunizations and health were analyzed. The K-means clusters technique was used to identify homogeneous groups of parents based upon their responses to the questions.

Results: Five clusters were identified: Immunization Advocates (33.0%), Go Along to Get Alongs (26.4%), Health Advocates (24.8%), Fencesitters (13.2%), and Worrieds (2.6%).

Conclusions: Although only a small percentage of parents are seriously concerned, other parents who are generally supportive of immunizations for their child are also affected by immunization safety issues.

Am J Health Behav 2005 Jan-Feb;29(1):81-92.

Parental Concerns and Medical-Seeking Behavior After Immunization

Deborah A. Gust, PhD, MPH, Scott Campbell, MSPH, Allison Kennedy, MPH, Irene Shui, MPH, Lawrence Barker, PhD, Benjamin Schwartz, MD, MPH

Objective: To examine demographics and immunization attitudes, beliefs, and behaviors of parents who sought medical attention for a child due to an adverse event following immunization (AEFI).

Methods: A sample of households that participated in the National Immunization Survey was re-contacted during 2001. This analysis was conducted in 2004 and 2005.

Results: Of 2286 respondents, 223 (6.9%, weighted) sought medical attention for a child due to an AEFI. Compared with parents reporting no adverse event, parents who sought medical attention were less likely to be African American (adjusted odds ratio [AOR]_0.34, 95% confidence interval [CI]_0.16–0.75) or Hispanic (AOR_0.16, 95% CI_0.07– 0.39) versus white, aged 35 years or older versus 25 to 34 (AOR_0.35, 95% CI_0.17– 0.72), more likely to believe that immunizations cause minor side effects (AOR_5.74, 95% CI_2.99 –11.00), report unwanted yet required childhood immunizations (AOR_3.54, 95% CI_1.45– 8.66), not want a new baby to be fully immunized (AOR_3.48, 95% CI_1.25–9.67), report concern about immunization safety (AOR_2.08, 95% CI_1.07– 4.05), believe that immunizations are dangerous (AOR_3.56, 95% CI_1.14 –11.13), and have a child missing two or more doses of three immunizations (measles-containing vaccine, DTaP/DTP, or hepatitis B) (AOR_2.30, 95% CI_1.17– 4.55).

Conclusions: This study suggests that research is needed to determine whether negative parental attitudes associated with a child’s AEFI might be lessened by improving vaccine safety communication between physician and parent.

(Am J Prev Med 2006;31(1):32–35) © 2006 American Journal of Preventive Medicine

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