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Running head: MMR VACCINATION IN CHILDREN

Final Paper: MMR Vaccination in Children
Monica Bush, Christie Dixon, Jaime Rivera, and Kaitlin Shartle
The Pennsylvania State University

Abstract
Recently, vaccination has decreased among children, due to parents not getting their
children vaccinated. The overall goal of our implementation strategy is to convince Penn State
students to vaccinate their future children. In the past, pamphlets and websites were used, but a
more interactive strategy was needed. We used the Health Belief Model in our campaign to
outline severity and susceptibility.
Our audience members will be exposed to various stimuli messages in a quasi
experiment. The participants will then be asked if they would be willing to sign a pledge to get
their children vaccinated in the future. This strategy was used to open more interactive strategies
to this topic, with the hope that future studies will do the same.

Keywords: mumps, measles , MMR vaccination, health belief model

Problem Statement
Not enough parents are vaccinating their children today. This leads to an increase in
preventable diseases. Although there are many vaccines, the MMR vaccine is important due to its
ability to prevent 3 serious diseases. The MMR vaccine is required for college students attending
Penn State, as well as for the children attending day cares on campus (Penn State, 2015).
Although it is mandatory here, these requirements are not always mandatory or applicable. There
has also been a recent increase in disease outbreaks of diseases that could be prevented through
the MMR vaccine. The MMR vaccine helps to protect against measles, mumps and rubella.
These diseases can be extremely dangerous and sometimes deadly.
According to the CDC, the measles can cause flu-like symptoms and can result in
pneumonia and brain damage. The mumps “can cause fever, headache, muscle aches, tiredness,
loss of appetite, and swollen salivary glands. Complications can include swelling of the testicles
or ovaries, deafness, inflammation of the brain and/or tissue covering the brain and spinal cord
(encephalitis/meningitis) and, rarely, death”. Lastly, rubella, or German measles, is a rash caused
by a virus that slowly covers the entire body. Complications can occur if a woman is pregnant,
resulting in mental retardation and birth defects. Rubella, like measles and mumps is also a very
contagious disease (CDC, Sept 2015). All of these diseases are preventable issues with
vaccinations. Death is not unheard of when it comes to these diseases.
Mumps and the measles spread increasingly fast through saliva and mucus from
coughing, sneezing, and sharing items (CDC, Sept 2015). Getting these diseases immediate

attention, especially in children, is very urgent. When not taken care of in a timely manner, these
diseases can spin out of control. Not only are the consequences bad, but also they can infect
other children before you know it. These symptoms are not easy for children to endure. It will
take a lot out of a child if they were to come down with these symptoms. Children are
vulnerable at a young age and shouldn’t have to deal with these diseases when there is an option
of vaccination, with little to no cost.
Background Information
There have been benefits to preventing these serious illnesses among children. According
to a Macalester College article on the history of the MMR vaccination, “it is estimated that
vaccination against measles has prevented 52 million cases, 5,200 deaths, and 17,400 cases of
mental retardation, achieving a net savings of 5.1 billion dollars.” There are also studies that
show the rate of the measles is almost nonexistent, along with the mumps and rubella because
this vaccination exists. There are minor side effects, just like any other vaccination. Some
common side effects of the MMR vaccination are soreness from the injection site, fever, mild
rash, and temporary stiffness (CDC, Sept 2015).
The current campaign strategy has been using public service announcements,
commercials, and pamphlets. This tactic aims at awareness, instead of prevention. However, this
is a one-way communication style that provides little or no interaction with the audience. With
the increased rise of parents who are not vaccinating their children, a new interactive strategy
needs to be introduced. There have been some implications to the vaccination, and some serious
speculation over the MMR vaccine. There has been debate over whether or not there is a link
between autism and the MMR vaccination, which has caused some reluctance among parents
giving their children the vaccine. However, this research has been shown to be false.

A study done in California by Doctors Loring Dales, Sandro Jo Hammer, and Natalie J.
Smith was done to see if the MMR vaccine increases the chance of autism. The sample size was
conducted on children and the results showed there was no correlation between MMR
immunization among young children and an increase in autism occurrence. The test helped give
light that autism is not completely understood as far as far as in a diagnosis standpoint (Hammer
et al., 2001).
In the United states there are much efforts conducted to fight disease through vaccination.
The division of immunizations works with the Pennsylvania Department of Health to the
prevention of diseases such as hepatitis B, outbreak control interventions and the vaccines for
children program. The division works well with other departments to fulfill their overall goal
such as the department of public welfare, the Pennsylvania chapter of the American Academy of
pediatrics and the Pennsylvania Medical Society. Their mission is to offer immunizations in day
care facilities licensed by DPW. They also work on the general improvement of vaccine
coverage in the private medical sector.
The department also provides education by providing educational materials and training
opportunities to all vaccine providers and they work with the statewide coalition such as the
Pennsylvania Immunization Coalition and the Pennsylvania regional coalitions. Through the use
of vaccines, the department helped in the eradication of most vaccine-preventable diseases. This
control has controlled over the past 5 to 6 years. (PA Commonwealth, n.d.)
The question arises, if there is a relationship between both factors, why is there so much
effort in disease prevention through vaccination? Overall the importance of vaccinations are
needed for all people to fight off diseases and lower chances of epidemics. The government here
in Pennsylvania and the rest of the United States invests time, money and effort to vaccinate

because of the need to lower chances of sickness. There have been studies to disprove that
immunizations such as MMR does not increase the chances of autism. If there were an increasing
chance of autism through vaccinations, the benefits would outweigh the costs.
There have been numerous studies conducted and research continues to show vaccines
are an effective way to prevent serious illness (CDC, Sept 2015). Perhaps this fear of
vaccinations linking to autism is one of the major setbacks of parents not administering these
vaccines for their children. Despite these setbacks, the CDC and FDA continuously monitor the
safety of vaccines after they are approved (CDC, Sept 2015).
Significance
For our intervention proposal, we have decided to use the Health Belief Model (Janz and
Becker, 1984). The Health Belief Model has a variety of characteristics. People are more likely
to engage in a health behavior if they believe they are susceptible to the condition and if the
particular condition has serious consequences which may personally impact them. People are
also more likely to engage in this model if actions are available to prevent the condition, if there
are benefits to taking action, and if the perceived barriers are not strong enough to prevent the
action. This model was developed to explain why medical screening programs were not very
successful. This relates to the topic of vaccines, because even though most insurances cover
vaccines, there are some parents who do not give their children vaccines.
Our proposed strategy would be two phased. The first phase would be to bring the
participants in and have them randomized to a stimuli message. After this, the participants would
walk out of the testing center and be asked if they are willing to sign a pledge and hang up
posters to promote childhood vaccinations. This strategy is more effective than the previous

strategy of pamphlets and websites, because it is more interactive. Also by having people sign a
pledge it makes the person more committed to vaccinating their children in the future.
Evidence
A review of 30 studies between 1990 and 2012 assessed the impact of various
interventions to get parents to vaccinate their children. These studies were analyzed based on
parental attitudes towards vaccines, intent to vaccinate and actual vaccine refusal. Some of these
studies focused on introducing laws at the state and school level. However, a majority of studies
focused on parent-centered information or education. These materials were mostly written
materials, including pamphlets, brochures and posters. Only eight of fifteen educational
interventions showed statistical significant increases in parental attitudes toward vaccination and
five of ten showed statistically significant increases in parental intention to vaccine (Sadaf,
2013).
This review shows that providing parents with education materials about vaccines may
increase positive attitudes and intentions in some cases, but not all. Easy to access and reliable
information regarding vaccines is very important in promoting parents to vaccinate their
children. Parents should be provided with reliable websites regarding parental vaccine concerns.
However, this may promote parents to do their own searches on vaccines and may encounter
misinformation on the internet (Sadaf, 2013). Educating parents about vaccines is important,
therefore messages need to be created to help inform parents about the benefits of vaccinating
their children. In addition, how these messages are delivered to parents is just as important
because it needs to be effective.
In a study by Opel et. al. (2013),they studied how physicians talked to parents about
vaccines. The study found that vaccine resistance increased when physicians used participatory

approaches in discussion about vaccines compared to necessity approaches. For example, in
necessity approaches, physicians would say your “daughter needs to get two shots today” instead
of “do you want your daughter get her shots?” like a participatory approach. Another important
factor was how physicians responded to the parent’s resistance to getting his or her child
vaccination. If physicians continued to insist their recommendation of the vaccine, almost half of
the vaccine hesitant parents eventually accepted the vaccinations for their children (Opel, 2013).
A review of studies have found that evidence-based strategies are lacking in the area of
vaccine coverage. Inventions also need to be formated and changed for each individual family.
However, there are some guidelines in how physicians can promote vaccine coverage, establish
honest and respectful dialogue. Acknowledge that vaccine risks do exist, but balance these
against the risks of the disease. Provide other information sources, such as reputable Internet
sites. Maintain ongoing discussion with vaccine-hesitant families (Healy, 2011).
Parents have also expressed concern over the number of injections given in a single visit.
Meyerhoff and Jacobs found that the increased number of vaccine doses leads to increased
vaccine rejection. However, not all of the vaccines are injections. Therefore a more effective
strategies would be to say “your child needs two injections and a drink” rather than the child
needed “immunization against seven diseases” (Meyerhoff, 2005). By looking at the past
research done, this can provide more insight into the future of research in this area.
There have been multiple interventions implemented to help increase parent compliance
of vaccinations, though most of them are focused on keeping up with the recommended CDC
vaccination schedule as a whole instead of focusing on how important one vaccine, such as
MMR, is to a child’s health. One intervention that was tested focused on tailoring information for
parents and addressing their concerns of the MMR vaccine. In this study, parents were

questioned on how likely they were to allow their child to receive the vaccine. Those parents
who were hesitant were then split into two groups, a control group and an experimental group.
The control group was given generic information on a website about why the vaccine is
important. The experimental group was given a website that was tailored to their ethnicity, the
name of their child, their past experiences with the vaccine, and their reasons for not vaccinating
their child. While the sample size was very small, and the results did end up not being
statistically significant, the study did seem to show that parents who are given access to material
more tailored to their specific concerns of the vaccine were more likely to vaccinate their
children than parents who were just given general information (Gowda, 2013).
Research Plan
The study will be a quasi-experiment with a two by two design. The two factors we are
focusing on are severity and susceptibility. These stimuli messages will be compared against the
previous strategy by using pamphlets and websites. Therefore there will be five groups, one
group for each message, and one other group assigned to this control. The intervention strategies
will then be compared to each other and the control group. Effectiveness will be determined by
how many people sign the pledge and put up the posters on campus.
We are looking to recruit 50 college students for this study. These students would be
around ages 18-22, making sure both genders and all races are represented. College students are
preparing for their future, but most do not have children yet. This is our target audience with the
hope that college students will be persuaded to get their child vaccinated with the MMR vaccine
in the future. These participants will be recruited at the Pennsylvania State University with
various methods, including handing out flyers in the HUB, posting flyers around campus, and
talking in classes.

Stimuli Messages
Our main goal is for the audience members to gain an understanding of the severity and
susceptibility that would potentially apply to their children. If parents do not get their children
vaccinated, then our message design will show how bad the consequences may be if the children
are not vaccinated. The first message will be high in both severity and susceptibility, and we will
do this by stating there is a possibility of death if the child contracts the illness. We will also
specify the statistics, which state the likelihood any child could contract these diseases if they do
not receive the vaccination.
The second message will be low in both categories, which will show the possibilities of
getting these diseases. However, there will not be a fear tactic for scaring the participant for this
specific message. For example, we will mention a few mild symptoms and cases of breakouts in
the United States.
The other two messages will vary with high and low severity and susceptibility. Our
third message will be high in severity and low in susceptibility. The high severity will state the
consequences of contracting any of these diseases, including the unpleasant symptoms
accompanying the illnesses, the possibility of death, and the difficulties prolonging the illness
after the child has contracted the illness. This could include the consequences of the child
missing school, potentially being hospitalization, and the possible struggle to get back into a
normal routine. This will be the only information detailed in the message. Which will be general,
so we do not imply and susceptibility. We want them to feel as if there isn’t a great chance of
contracting the disease, but want them to fear the effects of the disease. We will mention that not
every child gets the disease, but that the possibility of catching the disease is a present threat.

The fourth message will have high susceptibility with low severity. On this message we
will use a fear tactic by showing the amount of children who contracted the diseases throughout
the country who did not receive the vaccine, and contracted the illness. We are using the power
of numbers in this case, and relying on them to convince the participants to vaccinate their future
children. We do not want to draw attention to the symptoms or consequences of the diseases on
this message, because we want to have low severity.
The messages will include the pamphlets specifically outlining the potential effects and
the symptoms felt from these diseases. We will be sure to highlight the potential for death
through theses messages, because we feel as though this could show how severe the diseases can
be if the parents’ children are not vaccinated.
Measures
The measures used in this study are meant to see an overall change in attitude towards
vaccination. We will measure the two following factors: severity and susceptibility. Our
measurements will be based on the pledge they took and the messages our subjects will
participate in. Their attitudes will be measured in the form of a numeric grading system from 1-5
(1 being the weakest and 5 being the strongest). The questions will be similar in context, but will
be tailored towards both severity and susceptibility. This will measure their overall change in
attitude towards the campaign they participated in. The questions will be the following:
Severity

How important would MMR vaccination be for your child?

How serious would it be if your child contracted one of the following diseases (Measles,
Mumps, or Rubella)?

Do the consequences of MMR vaccination outweigh your decision in refusing to get
your child vaccinated?

Do the symptoms and consequences of these diseases alarm you enough to get a MMR
vaccine for your child?

Is contracting the disease as severe as you thought?

Susceptibility

What are the chances of your child contracting a disease like mumps if they get the MMR
vaccine?

What are the chances of your child contracting a disease like mumps if they don’t get the
MMR vaccine?

Do you feel that your child is at a high risk of disease in your area?

In regards to the previous question, is the likelihood of disease important enough to get
the MMR vaccine for your child?

The accumulation of the quantitative data will be illustrated via a Z score. This scale will
measure the change of attitude for severity and susceptibility and will be shown in the form of a
bell curve. Ideally, this scale will range from 1 being the furthest left, 3 being the median, and 5
being the farthest right. We hope that this bell curve will be skewed to the right, meaning that the
majority of the participants found this campaign to be effective in changing their attitude towards
vaccination and will be more inclined to vaccinate their children in the future.
Implementation and Discussion
All of the stimuli messages will be videos averaging at around two minutes per video,
with each person seeing one version of the stimuli message. These videos will be shown in a
laboratory setting.We will have a sign-in sheet for participants, and a proctor to show the

message, to guarantee the participants are watching the videos. The implementation will be
assessed by seeing how many people sign the the pledge and by analyzing the participant's
overall reaction as described in the measures section. The final data will then be put into a bell
graph form via z score. This implementation will give us more insight into the topic of vaccines
and promoting them to get their children vaccinated in the future
If doing this project again we would have the participants be exposed to the stimuli
message not in a laboratory setting, such as outside in the environment. We could also use
different channels of communications besides video, such as posters or videos. Also a survey
would be beneficial to analyze attitudes before and after the message. A limitation of this study is
that the target audience are college students, so thinking about having children may be too far in
the future to start thinking about. Also some of the participants in the study may never have
children. Therefore the actual effects are too far in the future to possibly have an impact, which is
an issue. Considering this factor to be a limitation, the possibility of conducting a cohort study
would seem more suitable. In the future it would be beneficial to choose a new target audience.
Our group was able to communicate well, and even though there were some issues between
group members, the issues were resolved shortly after. Also more in-person group meetings
would have been beneficial.
We hope that this paper will raise awareness and education to Penn State students about
the topic of children vaccination. The intention of this project is to increase MMR vaccination in
Pennsylvania. We hope this campaign would not only leave an impact at the time, but in the
future as well by inspiring others studies. With the hope that we can advance the knowledge of
this topic by drawing ideas from ours for the ongoing debate of vaccination not only statewide,
but nationwide.

References
Gowda, C., Schaffer, S., Kopec, K., Markel, A., & Dempsey, A. (2013). A pilot study on the
effects of individually tailored education for MMR vaccine-hesitant parents on
MMR

vaccination intention. Human Vaccines & Immunotherapeutics, 9(2): 437-445.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859769/

Dales, L., Hammer, S., & Smith, N. (n.d.). Time Trends in Autism and in MMR Immunization
Coverage in California.
Gowda, C., Schaffer, S., Kopec, K., Markel, A., & Dempsey, A. (2013). A pilot study on the
effects of individually tailored education for MMR vaccine-hesitant parents on
MMR

vaccination intention. Human Vaccines & Immunotherapeutics, 9(2): 437-445.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859769/

Healy, C.M. and Pickering, L.K. (2011). How to communicate with vaccine-hesitant parents.
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