Vaccine Attitudes, Concerns, and Information Sources Reported by Parents of Young Children: Results From the 2009 HealthStyles Survey

Vaccine-Related Attitudes and Concerns

The majority of the parents reported high overall confidence in vaccine safety, a finding that is reinforced by high vaccination-coverage levels among both infants and school-aged children in the United States, as well as the low proportion of infants nationally (0.6%) who have received no vaccines.^27,28 Most parents also believe that vaccines are important to children's health; however, given that ∼1 in 5 of the parents surveyed were not fully confident in the safety or importance of vaccines, education regarding the benefits of vaccines and the potential dangers of the diseases they prevent are still important components of vaccine communication. It is not surprising that low perceived susceptibility to or severity of vaccine-preventable diseases, along with concerns about vaccine safety, have been associated with vaccine refusal by parents.^9,21,22,29 Our findings are consistent with the results of both past and recent research on parental vaccine attitudes.^2,25 In a telephone survey of parents of young children conducted in 1999, Gellin et al² reported that parents were supportive of vaccines overall, yet approximately one-fourth of them were concerned about the number of vaccines children receive and the perceived negative effect of vaccines on a child's immune system. Recent work by Freed et al²⁵ among parents of young children and adolescents also revealed that confidence in the necessity of vaccines to protect children's health was high, yet concerns about issues such as potential adverse effects were common.²⁵

Despite overall confidence in vaccines, parents in our survey did report their specific vaccine concerns. Our findings emphasize that parents' vaccine-related concerns vary and, as a consequence, effective communication will likely need to be responsive to the array of concerns that individual parents are most likely to feel and consider. A child's pain from vaccines was the most common concern among respondents, and concerns about the number of vaccines and potential short-term and long-term adverse effects were also common. Of the potential concerns listed on our survey, the most common fell into broad categories such as number and timing of vaccines, potential adverse effects or reactions (both short-term and long-term), and vaccine ingredients. Past research reports have described parental vaccine attitudes as a spectrum rather than a dichotomy and have similarly suggested the need for communication approaches that recognize individual information needs.^20,25 For example, Gust et al²⁰ described some parents as “fence-sitters”—parents who are uncertain about whether the benefits of vaccines outweigh the risks, although their children are currently being vaccinated. Another important aspect of ongoing research will be to continue to assess these subgroups of parents over time to find whether they grow in number, how their concerns change over time, and if these concerns are associated with vaccine delay or refusal. Research is currently underway to address each of these questions.

These findings also underscore the potential importance of pharmacologic and behavioral interventions in addressing the most common overall concern among parents: their child's pain from vaccination. Interventions such as breastfeeding, sweet-tasting solutions, pacifiers, distraction, and topical local anesthetics have been associated with decreased pain and crying time for infants.^30,–,33 In addition to benefiting the infant, such measures may also benefit the parent, because parental stress has been found to be significantly related to infants' crying time.³³ Making the immunization encounter less painful for infants and less stressful for parents may also help to reduce the number of concerns parents have about vaccines in general. Teaching parents and empowering them to use evidence-based, soothing interventions that they can offer their children during vaccine administration might help parents have more of a sense of control and engagement in each immunization encounter. Memorable events over which a person feels that he or she has little control, such as a stressful immunization encounter, are perceived as presenting a higher level of risk than more mundane events that a person feels able to influence.³⁴

Vaccine-Information Sources and the Role of the Health Care Provider

Our results regarding vaccine-information sources are similar to those from past research, which have repeatedly indicated that health care providers are parents' preferred and trusted source of vaccine information.^2,11 Given the potential complexity of vaccine communication and the competing demands of the well-child visit, vaccine-communication resources are available for health care providers to supplement discussions with parents regarding questions or concerns that may arise regarding childhood immunization. In partnership with the American Academy of Pediatrics and the American Academy of Family Physicians, the Centers for Disease Control and Prevention has developed “Provider Resources for Vaccine Conversations With Parents” (www.cdc.gov/vaccines/conversations). These resources were developed with extensive input from parents and include information for health care providers on communicating effectively with parents about vaccines, as well as information about vaccine-preventable diseases and vaccine safety.

Resources are also available to help health care providers address some of the specific concerns raised by parents in our survey. For example, Vaccine Information Statements (www.cdc.gov/vaccines/pubs/vis) are required by law to be provided to each child's legal representative (eg, parent, guardian) before administration to the child of any vaccine that is covered by the National Vaccine Injury Compensation Program.³⁵ Along with information on specific vaccines and vaccine-preventable diseases, the statements contain information on vaccination benefits and risks, including common vaccine reactions such as fever. Other resources, such as those available from the California Department of Health (www.cdph.ca.gov/programs/immunize/Pages/ComfortMeasuresforInfants.aspx), offer suggestions on how to reduce pain and anxiety of immunizations for infants and young children. As a final example, the American Academy of Pediatrics (www.aap.org/immunization/families/toomany.html) offers resources for parents to help explain the reasons for the number and timing of vaccines on the recommended immunization schedule and to describe the safety of simultaneous administration of vaccines.

Limitations

These findings are subject to several potential limitations. First, because the attitudes and concerns are self-reported, they are subject to social-desirability bias; that is, parents may feel compelled to give a socially expected answer when discussing their children's health rather than report their actual attitudes or behaviors. The mail survey, which is filled out by the respondent without the help of an interviewer, might have helped to minimize the potential for this bias. Second, because these surveys did not attempt to verify the immunization status of the respondents' children, we do not know if or how a respondent's vaccine attitudes or concerns affected their actual behavior. Similarly, we are unable to interpret causality because of the cross-sectional nature of the data. Finally, at 65% the response rate of the survey was low, and it is possible that nonrespondents would have answered the questions in a systematically different way. The data were weighted in part to address this potential nonresponse bias.