OBJECTIVE: Holmes County, Ohio, one of the largest Amish communities in the world, has persistently low immunization rates. Studies of other Amish communities have revealed that parents do not immunize their children because of lack of access to immunizations. Our study explored reasons that Amish parents in the previously uninvestigated Holmes County population exempt themselves from immunizations.
METHODS: In January 2007, questionnaires for assessing attitudes regarding immunizations were mailed to a random sampling of 1000 Amish parents in Holmes County.
RESULTS: Thirty-seven percent of the parents responded. Among the 359 respondents, 68% stated that all of their children had received at least 1 immunization, and 17% reported that some of their children had received at least 1 immunization. Only 14% of the parents reported that none of their children had received immunizations. Eighty-six percent of the parents who completely exempted their children from vaccines stated that the main reason they do not vaccinate their children is concern over adverse effects. Many parents indicated that they allow their children to receive only some vaccines because of concern about the way certain vaccines are produced.
CONCLUSIONS: The reasons that Amish parents resist immunizations mirror reasons that non-Amish parents resist immunizations. Even in America's closed religious communities, the major barrier to vaccination is concern over adverse effects of vaccinations. If 85% of Amish parents surveyed accept some immunizations, they are a dynamic group that may be influenced to accept preventative care. Underimmunization in the Amish population must be approached with emphasis on changing parental perceptions of vaccines in addition to ensuring access to vaccines.
WHAT'S KNOWN ON THIS SUBJECT:
Underimmunized communities are reservoirs of preventable childhood diseases in the United States. Many Amish communities have low immunization rates. Previous research among the Amish has revealed that the major barrier to immunization is lack of access to health care.
WHAT THIS STUDY ADDS:
Among the Amish in Holmes County, Ohio, the major barrier to immunization is parental concerns over adverse effects of vaccines. Decision-making about vaccination among Amish parents is complex; many Amish parents accept some vaccines for their children but refuse others.
Despite the efforts of pediatric providers nationwide to advocate for immunizations, some parents choose not to vaccinate their children.1,2 Children who live in closed communities with high vaccine-exemption rates are particularly vulnerable to vaccine-preventable diseases.3,4 The Amish, a separatist Christian sect, have had persistently low immunization rates. Multiple outbreaks of vaccine-preventable infections including pertussis, rubella, measles, and Haemophilus influenzae type b have been described in underimmunized Amish communities.5,–,9
Although vaccination is not specifically prohibited by Amish religious doctrine, the reasons for the low immunization rates have not been clearly identified. Authors of a previous study cited limited access to health care as a barrier to immunization among the Amish.10 Among the Amish in Lancaster County, Pennsylvania, investigators found that only 16% of children aged 6 months to 5 years were fully immunized. A survey of Amish families in Lancaster County found that 75% reported that they would immunize their children if vaccinations were offered locally.9 The generalizability of the Lancaster County findings to other Amish communities has not been determined. Holmes County, Ohio, is one of the largest settlements of Amish in the world, yet this population's attitudes regarding immunizations have not been researched.11 In 2006, 45% of the Holmes County population was reported to be fully immunized, compared with a statewide Ohio immunization rate of 80% and a national rate of 85% (based on children aged 19–35 months who received the 4:3:1:3:3 [≥4 doses of diphtheria, tetanus toxoid, and any acellular pertussis vaccine, ≥3 doses of poliovirus vaccine, ≥1 dose of measles, mumps, rubella vaccine, ≥3 doses of H influenzae type b vaccine and ≥3 doses of hepatitis B vaccine] series) (Sally Hofsetter, director, personal health services, Holmes County Department of Health, Millersburg, OH, personal communication, July 14, 2006).12 The Holmes County Department of Health (DoH) has increased the availability of vaccinations by holding immunization clinics near community gatherings such as livestock auctions and by offering to administer vaccines at parochial schools. Also, most physicians provide vaccines through government-supplemented programs at minimal cost. However, low immunizations rates persist, which suggests that the barriers to immunization among the Holmes County Amish differ from those described among the Amish in Lancaster County.
MATERIALS AND METHODS
Sample and Instrument
This study consisted of a mailed 25-question survey to Amish parents in Holmes County. Survey questions were designed with input from Amish community leaders, physicians who serve Amish families, the Holmes County DoH staff, and previous studies of parental attitudes toward immunization (Nancy E. Rosenstein, personal communication, July 14, 2006).13 The questions explored basic demographic information, family-specific immunization status, parental attitudes toward immunization, religious ideas regarding immunization, and exposure to potential adverse effects of immunizations. Most questions offered multiple-choice answers with an option to write in comments. A few questions were open-ended. The survey was reviewed by a small group of Amish parents to ensure clarity. The study was approved by the institutional review board at Akron Children's Hospital. The mailing addresses of Amish parents were obtained from the 2005 Ohio Amish Directory, which is a comprehensive directory of Amish families living in Holmes County and its vicinity in 2005.14 The directory lists the names and birth dates of children in each household. Although addresses were selected at random, only addresses of families with children born after 1980 were used. Such purposeful sampling from a random component of a specific population has been used in other exploratory studies of barriers to immunization.15 A list of 1000 families (5% of the population) was generated. The survey was sent with a cover letter and a self-addressed, stamped reply envelope. No incentive was offered for survey completion. All surveys were anonymous.
The data were analyzed by performing cross-tabulations, and significant differences were established by χ2 statistics using SPSS 15.0.16 Some respondents did not select answers to all 25 questions. Missing data were handled by using available case analysis so that all available responses were used to calculate each statistic, and the number of responses varied across analyses.17
We examined the answers to questions and comments written by survey respondents for thematic trends. The end result of this exploration was to provide pertinent themes and specific quotes to illustrate the key findings.18,19
Of 1000 surveys distributed, 360 completed surveys were returned and 33 were returned as undeliverable, which resulted in a response rate of 37%. One survey was completed by a Mennonite and, thus, was excluded from analysis. Demographic characteristics obtained from the respondents included gender (67% female), age (range: 24–69 years; mean: 39.1 years), religious affiliation (85% Old Order Amish, 12% New Order Amish, 3% other Amish church), and insurance coverage (95% uninsured).
The parents were asked to state whether all, some, or none of their children had received immunizations. They were not asked to clarify how many or which immunizations their children had received. Of the 359 respondents, 68% stated that all of their children had received immunizations, 17% stated that some of their children had been immunized, and 14% stated that none of their children had been immunized.
A majority of the Amish in Holmes County classify themselves as Old Order (more traditional) or New Order (less traditional).20 All New Order Amish respondents stated that they had their children immunized. In contrast, 84% of Old Order Amish had some or all of their children immunized, but 16% did not have any of their children immunized (P = .02).
To assess familiarity with the technology of immunization, 1 question asked about immunization of animals. Of the 243 parents who responded that all of their children had received vaccinations, 40% immunized their animals. Of the 49 parents who replied that none of their children had received vaccinations, only 18% immunized their animals (P < .001).
Reasons for Acceptance of Vaccination and Selective Immunization
Among the 280 parents who vaccinated at least some of their children, 100% agreed that vaccinations are “protective against disease.” Nearly half of the parents who vaccinated at least some of their children indicated that their physician or nurse recommended vaccinations for their children. More than 30% of the parents who vaccinated at least some of their children stated that they had been vaccinated as children.
Parents who allow some, but not all, recommended immunizations reported several explanations for their decision to use selective immunization. Of the 140 respondents who allowed selective immunization, 42% felt that “giving all the shots at once is too hard on a baby,” 27% were concerned that “some shots were manufactured from aborted babies,” 25% were concerned that “there are too many recommended shots,” and 19% felt that “babies are too young to handle shots.” Only 6% reported that it was “too hard to get to the doctor's office/clinic for shots,” and 2% said that they could “not afford to get all the shots.” Responses varied according to parental age; only 14% of parents aged 40 years or older reported that “some shots were manufactured from aborted babies” as a reason for allowing selective immunization for their children compared with 39% of the younger parents (P = .001).
Reasons for Exemption From Vaccination
Table 1 lists the reasons that parents who did not have any of their children immunized indicated to explain their decision. The 3 most commonly reported explanations for not allowing immunization were related to concerns about adverse effects.
Understanding of the Adverse Effects of Immunization
To assess understanding of the risks and benefits of immunization, respondents were asked to select statements from a list with which they agreed (Table 2). Respondents were then asked if they personally knew anyone who had had a “bad side-effect from baby shots.” Of the 359 respondents, 47% replied that they knew someone with a serious adverse effect. More parents aged 40 years or older reported that they knew someone with a serious adverse effect of immunizations than did the younger (<40-year-old) parents (56% vs 44%; P = .04). Table 3 lists the most common types of adverse effects to immunization reported.
Attitudes Regarding the Immunization Schedule
Parents were asked whether giving shots at 2, 4, and 6 months was “too early.” Of the 359 respondents, 47% did not feel that physicians gave shots too early, 35% felt that doctors do give immunizations too early, and 18% were unsure. More parents who reported knowing someone with a serious adverse effect from immunizations replied that giving shots at 2, 4, and 6 months was “too early” compared with parents who did not know someone with a serious adverse effect from immunizations (57% vs 25%; P < .001).
Sources of Information Regarding Vaccines
All the respondents were asked to identify who advised them against infant immunizations. Of the 154 respondents, 38% replied that they had received such advice from their community and friends, 37% from parents/other family members, 16% from books, 19% from articles, 10% from chiropractors, and 6% from their family's doctor/nurse. No respondents reported that their ministers advised against immunization. Parents younger than 40 years were more likely to report having received advice against immunizations from parents/other family members than older parents (45% vs 25%; P = .02).
The respondents were asked to indicate any sources from which they learned about infant immunizations. Of the 327 respondents, 74% wrote that they had learned about immunizations from their doctor/nurse, 64% from their family, 7% in school, 7% from magazines or papers, 5% from their midwife, and 3% from their chiropractor. Parents younger than 40 years were more likely to report that they learned about infant immunizations from their family than were older parents (73% vs 52%; P < .001).
Addressing Spirituality or Faith in Decision-Making Regarding Immunization
Only a small minority of the parents reported that their religious or spiritual beliefs influenced their decisions about immunization. When asked if “giving shots disagrees with your faith or spiritual beliefs in some way,” 63% replied “no,” 4% indicated “yes,” and 30% did not respond to the question.
Addressing Access and Financial Burden of Vaccines
The respondents were asked if they knew that the Holmes County DoH offered immunization clinics throughout the county at convenient times and locations. Of the 49 respondents who had not had any of their children immunized, 20% did not know about the DoH vaccine posts in their county. Of the 304 respondents who had had some or all of their children vaccinated, 11% did not know about the DoH clinics (P = .005). We asked the respondents if they knew that immunizations provided by the DoH could be free of charge. A larger proportion of parents who had not had any of their children immunized were not aware that immunizations could be obtained at no cost (37%) compared with only 11% of the respondents who had had some or all of their children vaccinated (P < .001).
Factors That Would Influence Decision-Making of Exempting Parents
Parents who exempted completely or partially from vaccines were asked to indicate factors that might alter their decision. Of the 95 respondents, 86% stated that they would be more likely to consider having their children immunized if they “knew shots were safe to give,” 20% if “there was a disease outbreak,” 11% if “shots were required by the law/government,” and 10% if their “parents or family encouraged them.” The answers “if the shots were cheaper,” if their “bishop or elder recommended them,” and if “it were easier to get to the doctor's office or clinic” were selected by only 5%, 3%, and 3% of the respondents, respectively.
None of the 10 exempting parents who were not aware of accessible DoH vaccine posts stated that they would consider having their children immunized if the doctor's office were “easier to get to.” Only 2 of the 18 exempting parents who were not aware that DoH vaccines could be free indicated that they would consider having their children immunized if “the shots were cheaper.”
We found that Amish parents in Holmes County generally accept some vaccinations; 85% of them have their children at least partially immunized. Amish parents of unvaccinated children were concerned about adverse effects and the ability of an infant to tolerate vaccines rather than about financial, accessibility, or religious issues. Their concerns about adverse effects and the ability of an infant to tolerate vaccines mirror the concerns of non-Amish parents in the broader American society.
Given the low immunization rates in Holmes County, we were surprised by the high proportion of respondents who had accepted vaccines for some or all of their children. In an effort to keep the survey brief, respondents were not asked to specify which vaccines they accepted. DoH staff reported to us that some Amish parents accept immunizations against poliovirus or H influenzae type b but not those against varicella or Streptococcus pneumoniae. Thus, although the parents had accepted some immunizations, their children would not be “fully immunized” according to Centers for Disease Control and Prevention standards. This finding points to the need to further explore parents' concerns about individual vaccines rather than vaccination as a general practice.
When comparing responses of the parents who exempted completely with those of nonexempting parents, concern regarding potential adverse effects was the major barrier to immunization cited; 82% of the exempting parents stated that they would consider vaccinating their children if “they knew the shots were safe to give,” and only a few exempting parents reported that they would have their children immunized if the shots were cheaper or easier to access. The fact that many parents claimed to know someone who had suffered a “serious adverse effect” from immunization and described many potential adverse effects may reflect the closeness of their community or the incidence of inherited metabolic disorders in the population. However, surveys of the general American public have revealed similar parental misconceptions regarding adverse effects of immunization.13 One study of antivaccination Web sites found content claims that vaccines cause idiopathic illness and erode immunity in 95% of sites analyzed.21 Other concerns of Amish parents about the current immunization schedule, including that it is “too hard on a baby's system” or that infants are “too young to handle shots,” reflect misconceptions about immunizations that are reflected in the views of the mainstream American public.22,23
Similar to our study, a survey of an Arthur, Illinois, Amish population found that parents were most concerned about vaccine safety rather than availability, cost, prioritization, or alignment with religious values.24 Thus, the Amish populations of Holmes County and Arthur seem to differ from the Amish population in Lancaster County, where 51% of parents exempting from vaccines did not consider vaccination a priority compared with other activities of daily life, and 29% of exempting parents felt that it was “too difficult to travel” to places where vaccinations were offered.9
Our study shows that the characterization of religious values in medical decision-making is complex. Amish respondents stressed that individual families were responsible for the decision to vaccinate. Only a few respondents reported that giving shots would conflict with their faith or spiritual beliefs. This result aligns with previous findings that most Amish people do not view vaccination as a religious or spiritual issue. In contrast to the study of the Amish population in Arthur, our study provides further insight into underimmunization in Amish communities by revealing the practice of selective immunization. The reticence of parents to accept immunization against rubella and varicella because of the understanding that the immunizations “come from aborted babies” suggests an ethical if not specifically religious basis for their decision-making. (Rubella and varicella vaccines present concern because the attenuated viruses in the vaccines are propagated by using a human cell line, WI-38, derived in 1961. The cell line was originally prepared from tissues of an aborted fetus.)25 Further investigation is needed to more fully understand the reasons for selective immunization among Amish families.
Understanding separatist groups such as the Amish is crucial for prevention of disease epidemics, because underimmunized populations are proven reservoirs of serious infections.26 We aimed to examine nonquantifiable issues such as parental attitudes, expectations, and beliefs. The survey was designed to systematically gather data that focused on a specific line of inquiry, but given our resources, it was difficult to validate our data with triangulation or respondent validation.27,28 Nevertheless, our findings provide insight for future studies involving the same and comparison populations.
The response rate to our survey was only 37%, which introduces a risk of sampling bias. Survey recipients who view health care providers and vaccinations favorably may have been more likely to complete and return our survey. We speculate that parents who completely exempt from immunization may have been less likely to respond to our survey. Another study that used written surveys of an Amish population about health care issues obtained a similar response rate.10 Those investigators reflected that “the Amish are not often asked to answer written survey questions and may not be familiar with this mode of gathering information.”10 Lack of familiarity with this type of instrument may have contributed to some reticence among Amish parents to respond to our survey. However, other means of assessing parental opinions in the general population (eg, telephone surveys) cannot be used effectively in the Amish community. The issue of nonresponse to the entire survey or to specific questions in the Amish population is difficult to interpret without further and potentially costly investigation.
More Amish parents in Holmes County reported accepting vaccines than we expected, but these Amish families often permit their children to receive only certain vaccines. Although most Amish parents report that decisions about immunization are not influenced by their religious beliefs, many choose to exempt from certain vaccines on the basis of ethical values. The Amish may require different approaches to addressing misconceptions about vaccination than the general population, because the religious principles of the Amish, who value separation from the secular world, prevent exposure to many avenues that are used to educate the public about vaccines, such as television or radio. Because Amish families are less likely to seek preventive health care,29 peer educators within the Amish community who are sensitive to the traditions and culture of the Amish community may be needed to address the common misconceptions about immunizations reported in this study. Our results indicate that concerns about immunization practice among Amish populations are similar to the concerns of mainstream Americans and that concerns about vaccine safety represent the major barrier to immunization. Efforts of health care providers working with Amish families must focus on redirection of parental misconceptions about vaccine safety rather than simply improving access to vaccines.
This research was supported by a grant from the Akron Children's Hospital Foundation.
Special thanks go to Peter Reuman, Jerry Slabaugh, Marla Sabey, Marne Woyat, D. J. McFadden, MD, Akron Children's Hospital Department of Volunteers, and the Holmes County DoH.
- Accepted March 22, 2011.
- Address correspondence to Olivia K. Wenger, MD, Department of Pediatrics, Akron Children's Hospital, 128 E Milltown Rd, Suite 209, Wooster, OH 44691. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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