Vaccine Attitudes, Concerns, and Information Sources Reported by Parents of Young Children: Results From the 2009 HealthStyles Survey
OBJECTIVE: To describe the vaccine-related attitudes, concerns, and information sources of US parents of young children.
METHODS: We calculated weighted proportions and 95% confidence intervals for vaccine-related attitudes, concerns, and information sources of parents with at least 1 child aged 6 years or younger who participated in the 2009 HealthStyles survey.
RESULTS: The overall response rate for the survey was 65% (4556 of 7004); 475 respondents were parents or guardians (“parents”) of at least 1 child aged 6 years or younger. Among those respondents, nearly all (93.4%) reported that their youngest child had or would receive all recommended vaccines. The majority of parents reported believing that vaccines were important to children's health (79.8%) and that they were either confident or very confident in vaccine safety (79.0%). The vaccine-related concern listed most often by parents was a child's pain from the shots given in 1 visit (44.2%), followed by a child getting too many vaccines at 1 doctor's visit (34.2%). When asked to list their most important sources of information on vaccines, the most common response was a child's doctor or nurse (81.7%).
CONCLUSIONS: To maintain and improve on the success of childhood vaccines in preventing disease, a holistic approach is needed to address parents' concerns in an ongoing manner. Listening and responding in ways and with resources that address specific questions and concerns could help parents make more informed vaccination decisions.
Parental acceptance of routine childhood immunization is essential to protecting children's health, because high vaccination-coverage rates result in decreased rates of vaccine-preventable diseases in the United States. Although concern over the safety or necessity of vaccination is not a new phenomenon,1 the perception among some parents that vaccines are unsafe for their children has been heightened in recent years by several factors including the number of vaccines in the recommended childhood immunization schedule,2 the presence of conflicting vaccine-safety information and misinformation online and elsewhere,3,4 and scientifically refuted yet widely publicized theories that link vaccines to chronic health problems or developmental disabilities such as autism.5 Paradoxically, the overall success of the US childhood vaccination program can help perpetuate these concerns. Because vaccine-preventable disease rates are low in the United States, parents who have no personal experience with vaccine-preventable diseases might focus their attention on the perceived risks of vaccines instead of their well-documented benefits.6
Parents who question the necessity or safety of vaccines for infants may ultimately choose to either decline or delay vaccination, which will leave their children vulnerable to disease. In addition, an unvaccinated child in a community threatens the health protection afforded to those in their community who are too young to be vaccinated and those for whom immunization is contraindicated. Although immunization is compulsory for school entry in the United States, parents in all but 2 states can opt out of some or all vaccines for either religious or personal reasons, depending on state law.7 Furthermore, although school-entry laws act as a “safety net” for immunization of school-aged children, immunization of infants and young children is not compulsory unless a child attends day care, where most states also allow nonmedical exemptions.8
Past research has explored the association between vaccine concerns and exemption to compulsory vaccination for school entry,9,–,12 immunization coverage,13,–,15 and vaccine-preventable disease incidence.7,16,–,19 The vaccine-related attitudes and beliefs of parents are also well documented.2,20,–,25 However, to communicate effectively with parents about vaccines and vaccine-preventable diseases, it is necessary to assess their vaccine-related attitudes and concerns continually. Our objective with this analysis was to describe the vaccine-related attitudes, concerns, and information sources of US parents in 2009.
We used the HealthStyles consumer mail panel survey as the source of information for this study. HealthStyles is part of an annual series of consumer mail surveys. The first in this annual series, ConsumerStyles, was sent to a stratified random sample of 21 420 households that participate in occasional surveys as members of a consumer mail panel. The survey focuses on a wide range of consumer purchasing and media attitudes and behaviors. HealthStyles, which focuses specifically on health-related attitudes and behaviors, was sent to a random sample of 7004 ConsumerStyles respondents as a follow-up survey. The ConsumerStyles and HealthStyles methods are described in greater detail elsewhere, including a discussion of the mail panel survey methodology and the representativeness of HealthStyles data compared with the Behavioral Risk Factor Surveillance System survey, a probability sample survey.26
Questions regarding vaccine-related attitudes, concerns, and information sources were included in the 2009 HealthStyles survey, which was fielded from August through September. Question format varied and included 5- and 10-point Likert-type scale, yes/no, and multiple-choice questions. Participant demographic characteristics were taken from the existing mail panel database and were not included on the survey instrument. The secondary analysis described here was exempt from human subjects review by the Centers for Disease Control and Prevention institutional review board, because the data were nonidentifiable.
We calculated weighted proportions and 95% confidence intervals for demographic characteristics and vaccine-related attitudes, concerns, and information sources of parents with at least 1 child aged 6 years or younger who participated in the 2009 HealthStyles survey. All survey data were weighted by using the Current Population Survey of the US Census to be representative of the US population for gender, age, income, race, and household size. SPSS 14.0 (SPSS Inc, Chicago, IL) was used for all analyses.
Response Rate and Demographic Characteristics of the 2009 HealthStyles Survey
The overall response rate for the 2009 HealthStyles survey was 65% (4556 of 7004). We restricted the analysis to the 475 respondents with at least 1 child aged 6 years or younger (“parents”). The majority of parents surveyed were female (60.2%) and white (59.4%) and reported educational attainment of some college or higher (63.8%) (Table 1). Nearly all parents reported that their youngest child had already received (74.5%) or would receive (18.9%) all recommended vaccines (Table 2).
Vaccine-Related Attitudes and Concerns
Parents reported their attitudes regarding the safety and necessity of vaccines (Tables 2 and 3). The majority of the parents were either confident or very confident in vaccine safety (79.0%) and believed that vaccines are important to children's health (79.8%). Similarly, 73% of the parents somewhat or strongly agreed that the benefits of vaccines outweighed the risks. Most parents (72.7%) were comfortable or very comfortable with the number of vaccines that children receive in their first 2 years of life; however, 21.9% of the parents did somewhat or strongly agree that they were concerned about too many vaccines potentially damaging a child's immune system. When asked how many shots parents were comfortable with their child receiving in 1 doctor's visit, the most common response was 1 to 2 (42.2%), followed by 3 to 4 (33.6%), and “whatever the doctor recommends” (22.5%).
Parents were asked to respond to a series of 11 potential vaccine-related concerns and were also given the option of stating that they had no vaccine-related concerns (Table 4). Just more than one-fifth (20.8%) of the parents reported that none of the 11 issues listed were of concern to them. The most common concern reported by the parents was that it is painful for children to receive multiple shots during 1 doctor's visit (44.2%). Other concerns reported by >25% of the parents included their child receiving too many vaccines in 1 doctor's visit (34.2%), vaccines causing fevers in their child (28.3%), children getting too many vaccines in their first 2 years of life (27.8%), and vaccines causing learning disabilities such as autism (26.2%).
Vaccine-Information Sources and the Role of the Health Care Provider
Parents were asked to name the 3 most important sources that have helped them make decisions about vaccinating their youngest child (Table 5). By far, the most common response was their child's doctor or nurse (81.7%). Parents were also asked several additional questions about the role of their child's health care provider in vaccine communication (Table 6). Most parents (83.3%) somewhat or strongly agreed that their child's health care provider has strongly recommended vaccinating their child, and 86.5% somewhat or strongly agreed that they usually follow the health care provider's advice. The majority of parents (60.7%) said that they usually ask from 1 to 3 questions about vaccines during a routine office visit, and 84.0% somewhat or strongly agreed that they trust the vaccine advice they get from their child's health care provider.
Overall, parents reported positive attitudes about vaccines; most of them felt that vaccines were important to their children's health and were confident in vaccine safety. Although parents reported a variety of different vaccine-related concerns, the most common concern was that vaccines were painful for their children; many of them were also concerned about the number of vaccines that their children receive and about potential short-term (eg, fever, pain) and long-term adverse effects after vaccination. These findings highlight the need to address parents' specific questions and concerns about vaccines, even among parents whose overall confidence in vaccines is high. As in past research, parents in our survey cited health care providers as the most important source of information when making decisions about vaccines.2,11
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.
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.
Our survey revealed that although parental confidence in vaccine safety is high, several vaccine-related concerns, such as pain from vaccine administration, postvaccination fevers, and the number of vaccines given at once, were common among parents of young children. Health care providers continue to be parents' most trusted source of vaccine information and advice. To maintain and improve on the success of childhood vaccines in preventing disease, a holistic approach is needed to address these issues in an ongoing manner. Understanding that parents have different questions, concerns, and information needs is the first step. Listening and responding in ways and with resources that address their specific questions and concerns, along with utilization of comfort measures that can make immunization visits less stressful for both child and parent, might help parents make more informed vaccination decisions.
- Accepted November 29, 2010.
- Address correspondence to Allison Kennedy, MPH, 1600 Clifton Rd NE, Mail Stop E-52, Atlanta, GA 30333. E-mail:
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- Copyright © 2011 by the American Academy of Pediatrics