Evidence Based Practice & Policy

The Journal of School Nursing

29(2) 95-103
Common Perceptions of Parents ª The Author(s) 2012
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DOI: 10.1177/1059840512455365
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Vaccination

Karlen E. Luthy, DNP, FNP1,

Renea L. Beckstrand, PhD, RN, CCRN, CNE1, and
Carly J. H. Meyers, BS, RN2

Abstract
School nurses, as vaccination advocates, need to be aware of parents’ common concerns regarding vaccines, so the nurse can
develop strategies to communicate with parents. The purpose of this cross-sectional, descriptive study was to identify
common reasons parents in Utah seek exempting rather than vaccinating their children. Data were collected from a
convenience sample of 801 parents responding to a 16-item questionnaire about why they exempted their children from
receiving vaccinations. The most commonly reported reason for seeking a personal exemption included vaccines conflicting
with philosophical beliefs. Parents exempting from one vaccine most commonly exempted the hepatitis series. Most parents
communicated their vaccine concerns with their health care provider prior to seeking exemption. The majority of exempting
parents did not use the Internet when researching vaccines even though they had Internet access. Considering the common
vaccine-related perceptions of parents may be helpful when developing strategies to overcome these barriers to vaccination.

Keywords
immunizations, health/wellness, health education, communicable diseases

Since the beginning of the 19th century, vaccinations have
saved millions of lives (Calandrillo, 2004). Now implemen-
ted worldwide, vaccination is regarded as one of the most
important life-saving measures of all time (Public Health
Agency of Canada, 2009). In U.S. history, vaccinations
became common with the mandate of the small pox vaccine
in 1827 (Hinman, Orenstein, Williamson, & Darrington,
2002; Kennedy, Brown, & Gust, 2005). Since then, laws
have continued mandatory school vaccinations to prevent
outbreaks of communicable diseases (Hinman et al., 2002;
Omer et al., 2006). However, an unforeseen consequence
of successful vaccinations has been that most people lack
firsthand experience with serious communicable diseases
(Salmon et al., 1999). Lack of experience with vaccine
preventable diseases (VPD) has led to parents focusing less
on the overwhelming benefits of vaccinations and more on
possible adverse events (AEs) (Gust et al., 2009; Opel,
Diekema, Lee, & Marcuse, 2009). For these parents, the risk
of AEs from vaccinations is more worrisome than their child
contracting a VPD (Gust et al., 2009; Opel et al., 2009).
As the perceived benefits of vaccines decrease, parental
requests for school vaccination exemptions increase (Sal-
mon et al., 2005a). All states in the United States allow
parents to claim medical exemptions from school vaccina-
tions while 48 states allow exemptions for religious reasons
(Kennedy et al., 2005; Salmon et al., 1999), and 20 states,
like Utah, allow parents to exempt any or all vaccinations
based on their personal beliefs (Berlinger, 2011; National
Conference of State Legislatures [NCSL], 2011b; Salmon
et al., 2006). Consequently, high immunization rates which
lead to fewer community VPD outbreaks have been compro-
mised in Utah communities, resulting in outbreaks of
measles and pertussis (Stewart, 2011; Utah Department of
Health, 2001).
Background
School vaccination requirements, while individually defined
by each state, are largely based on the recommendations of
the U.S. Department of Health and Human Services Advi-
sory Committee on Immunization Practices (Centers for
Disease Control and Prevention [CDC], 2011a; Kroger,
1
Brigham Young University, Provo, UT, USA
2
Cardiac Progressive Care Unit, Utah Valley Regional Medical Center,
Provo, UT, USA
Corresponding Author:
Karlen E. Luthy, Brigham Young University, 355 SWKT, Provo, UT, USA.
Email: beth_luthy@byu.edu

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96
Sumaya, Pickering, & Atkinson, 2011; NCSL, 2011a).
Because school-age children typically have the highest rates
of VPDs, it is important that parents vaccinate them on time
in order to promote optimum immunity against these
diseases (American Academy of Pediatrics, 2008; CDC,
2011b).
The issue of parents refusing childhood vaccinations may
be more prominent than one might think. Nationwide, state
vaccination exemption rates for Kindergarteners range from
<1% to 6.2% (CDC, 2011c). However, during 2010, 12% of
American parents were reported as refusing at least one vac-
cine for their child (Asaithambi, 2012). This discrepancy
between the two groups may be attributable to differences
in state requirements for school vaccines, as well as not
accounting for parents who initially refuse a vaccine for their
child, yet tend to allow their child to receive the same vac-
cine, just later in life. Regardless, vaccination exemptions
are on the rise, doubling in states like California over the last
two decades from <1% in 1990 to 2.3% in 2010 (Crowe,
2011). In fact, more than half of the states have seen an
increase in exemption rates over the past 5 years (Stobbe,
2011). With this rise in exemption rates, the integrity of the
herd effect has been compromised, especially when
considering that highly virulent diseases, such as measles
and pertussis, require a 95% vaccination rate in order for the
herd effect to work (Offit, 2011).
In states that allow vaccination exemptions for nonmedi-
cal reasons, exemption rates increase. For example, in one
Arkansas school district that implemented a nonmedical
exemption process in 2003, nonmedical exemptions steadily
increased over the following 4 years. By the fourth year,
nonmedical exemptions constituted 95% of exemptions
granted in the year (Thompson et al., 2007). In addition, the
rate of vaccination exemption for Kindergarteners in states
such as Mississippi, which does not allow for religious or
philosophical exemptions, is less than 1%. In contrast, the
vaccination exemption rate among Kindergarteners in
Washington State, where both religious and philosophical
exemptions are allowed, is more than 6 times higher, at
6.2% (Asaithambi, 2012). Concurrently, an increase in non-
medical exemptions results in an increase in VPD outbreaks,
such as measles or pertussis, which are commonly observed
in geographically clustered areas of exemption (Rota et al.,
2001). Without question, low vaccination rates increase the
risk for a VPD outbreak (Cochran, Smith, Reid, Morrow, &
Ramirez, 2003; Luman, Barker, McCauley, & Drews-
Botsch, 2005), thus jeopardizing the health and welfare of
both individuals and the public as a whole (Hinman et al.,
2002; Omer et al., 2008).
Why Parents Exempt
Parents exempting children from vaccinations for personal
reasons do so because they have concerns regarding vaccine
safety, have a preference for natural immunity, or because of
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The Journal of School Nursing 29(2)
the ease of the exemption process (Fredrickson et al., 2004;
Kennedy et al., 2005; Salmon et al., 2005a, 2005b; Thomp-
son et al., 2007; Wharton, Hogan, & Segal-Freeman, 2005).
Generally, the most common concern of vaccine-hesitant
parents is vaccine safety (Dempsey et al., 2011; Luthy,
Beckstrand, & Peterson, 2009; Smith, Chu, & Barker,
2004). One of the main safety concerns is that vaccine-
hesitant parents believe vaccinations overload their child’s
immune system, especially when they are infants (Luthy
et al., 2009; Salmon et al., 2004). As such, these parents
exempt vaccinations while their children are younger, but
later consent to vaccination after the child reaches school
age. Sometimes vaccine-hesitant parents can be convinced
to consent to childhood vaccinations for school entry, but
then request alternative vaccination schedules such as those
recommended by Dr. Bob Sears, author of The Vaccine
Book: Making the Right Decision for Your Child, or instead
request the administration of only one shot per month to give
their child’s immune system time to ‘‘adapt.’’ Unfortunately,
children whose vaccinations are perpetually delayed or
refused present a health risk to other children at school
(Salmon et al., 2005b).
Parents with vaccination safety concerns also express a
strong distrust of the government and vaccine manufacturers
which may then equate to a distrust of conventional preven-
tative medicine (Offit, 2011; Salmon et al., 2005a) and tend
to seek medical advice from homeopathic practitioners and
use complementary alternative medicine (Gust et al., 2005;
Salmon et al., 2009). These parents even believe that vaccine
companies and government agencies only promote vaccina-
tion to make a profit on vaccines sales and do not, necessa-
rily, care for the safety of their children (Salmon et al.,
2009).
Preference for Natural Immunity
Sometimes parents vaccinate for some diseases and yet
exempt from others. These parents express a strong
preference for their children to develop natural immunity
from the various diseases rather than active immunity from
vaccinations (Offit, 2011). For example, parents may refuse
varicella vaccine because they believe having chicken pox
provides lifelong protection whereas the vaccine’s immunity
wanes with time (Immunization Action Coalition, 2010).
Generally speaking, the immune response following a single
natural infection is more effective than protection provided
with vaccines; however, immunity resulting from a natural
infection of the chicken pox places a child at an unnecessary
risk for a myriad of disease-related complications such as
encephalitis, pneumonia, meningitis, and necrotizing fascii-
tis (Offit & Moser, 2011). Furthermore, the vaccine is
extremely effective, providing immunity in 97% of young
children following a single dose (Immunization Action
Coalition, 2010). In addition, the chance of a vaccinated
child suffering a shingles outbreak later in life is much lower
Luthy et al.
in vaccinated children rather than after natural chicken pox
infection (Offit & Moser, 2011).
Ease of Exemption Process
Currently, 20 states allow exemptions to school-required
vaccines for reasons other than those contraindicated for
medical reasons or religious observances (Berlinger, 2011;
Salmon et al., 2006). There is a direct and positive correla-
tion between the ease of the personal exemption process and
the request for vaccine exemptions (Hinman et al., 2002;
Omer et al., 2006). Mean exemption rates increased approx-
imately 6% per year in states that easily allowed personal
belief exemptions (Omer et al., 2006). In contrast, states that
had a difficult exemption process, such as intricate paper-
work and extensive administrative processes, or offered reli-
gious exemptions only saw no statistically significant
change in exemption rates (Omer et al., 2006).
Exemptions and School Nurses
As some states allow personal exemptions from vaccines, it
is important to understand why parents choose personal
exemptions, thus preparing health care providers with the
ability to anticipate common parental concerns and to
address these concerns with parents (Gust et al., 2009). In
particular, school nurses need to be aware of a parent’s
common concerns so they can develop appropriate commu-
nication and educational strategies (Luthy, Beckstrand, Cal-
lister, & Cahoon, 2011). As providers of health care services
to children, school nurses have important roles in obtaining
and maintaining vaccination compliance among children
from prekindergarten to high school (Luthy, Thorpe,
Dymock, & Connely, 2010). Accordingly, the purpose of
this study was to identify reasons parents in Utah requested
a personal exemption from childhood vaccinations.
Research Question
What are the vaccine-related perceptions of Utah parents
who choose to exempt vaccination of their children for
personal reasons?
Method
Following institutional board approval, a review of the
literature was conducted searching the databases:
MEDLINE, MEDLINEPlus, CINAHL, EBSCO, PubMed,
Web of Science, Biomedical Reference Collection-Basic,
Health Source-Nursing/Academic Edition, and the Cochrane
Library online. Search terms included immunization,
vaccination, exemption, exemption form, philosophical
exemption, parents, philosophical belief, personal belief,
childhood, and pediatrics. In addition, current recommenda-
tions and guidelines regarding childhood vaccination and
exemptions were obtained from the Centers for Disease
Control and Prevention website.
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97
Design and Sample
To assess why parents refused to give their child at least one
vaccination, a 16-item questionnaire was adapted, with
permission, from a previously distributed Utah State Depart-
ment of Health (USDOH) exemption questionnaire. The
16-item questionnaire included multiple choice, fill in the
blank, and open-ended comment sections. The original
USDOH questionnaire was developed with a team of vacci-
nation experts and then piloted with parents to establish face
validity. Prior to distribution of the updated version, experts
including school nurses, public health nurses, members of
local and state agencies, health care providers specializing
in pediatrics, and members of a local immunization coalition
reviewed the adapted questionnaire for face validity.
The questionnaire was distributed to all county health
departments in Utah. Using a descriptive, cross-sectional
mixed-method study design, parents seeking to exempt their
children from vaccinations were identified as subjects. In
Utah, exemption forms can only be obtained from
vaccination clinics at local health departments and are
required to be turned into the school nurse before children
without vaccinations can attend public school. As such,
health department vaccination clinics seemed an appropriate
location to question exempting parents regarding their per-
sonal vaccination perceptions.
County health department nurses working in the vaccina-
tion clinics were responsible for identifying eligible partici-
pants. To be eligible, parents needed to request and complete
an exemption form for at least one child in the family. Par-
ents seeking a vaccination exemption form were given an
informed consent document for review and asked if they
would like to participate in the study. Upon agreeing to
participate, most parents took about 15 minutes to complete
the questionnaire. A $1 gift certificate for food was given to
parents as compensation for their time.
Instrument
The Vaccination Exemption Questionnaire was developed to
identify attitudes and perceptions of parents seeking a per-
sonal exemption for their children. The questionnaire
included a question about why the parent was seeking a per-
sonal exemption for their child. Participants could choose
from 10 listed items and were directed to choose all items
that applied. Additionally, parents were asked whether they
had discussed vaccinations with their child’s health care
provider, if they were only exempting their child from one
vaccine, if they had access to the Internet and if they used
the Internet to obtain information on immunizations.
Open-ended questions regarding which vaccine was
exempted and why, specific concerns about vaccine safety,
and websites utilized for obtaining vaccination information
were included. Parents could also share any other comments
on why they claimed a personal exemption. There were
seven demographic questions: age, gender, annual income,
98 The Journal of School Nursing 29(2)

education, race, vaccination status of parent, and grade of Table 1. Demographics.

the child for whom the exemption was sought.
Frequency (%)

Male 129 (16.6)

Data Analysis Female 646 (83.4)
Responses were entered into an SPSS database (SPSS, Inc., 20–25 65 (9.1)
Chicago, IL). The accuracy of data was confirmed by two 26–30 164 (23.1)
31–35 171 (24.2)
researchers. When there was a question about a marked
36–40 160 (22.6)
response, the primary investigator personally examined the 41–45 87 (12.3)
item to determine the correct response to enter. Frequencies 46–50 39 (5.5)
and measures of central tendency were calculated for all 50þ 21 (2.9)
items. Open-ended item responses were transcribed and ana- Some high school 65 (9.1)
lyzed for themes. A nurse researcher with expertise in qua- High school 102 (14.3)
litative inquiry then verified the findings by conducting an Some college 277 (38.7)
College graduate 271 (37.9)
independent analysis of data and generated themes. Both
Less than $15,000 77 (10.8)
quantitative and qualitative results are presented. $15,001–$30,000 118 (16.5)
$30,001–$45,000 96 (13.5)
$45,001–$60,000 135 (18.9)
Results $60,001–$75,000 92 (12.9)
The sample consisted of 801 parents with 646 (83.4%) Greater than $75,001 195 (27.3)
females and 129 (16.6%) males. Age ranges were offered Hispanic or Latino 37 (11.3)
Not Hispanic or Latino 291 (88.7)
rather than asking for exact age of the parent; the majority
White 698 (94.8)
of the sample (70%) ranged from 26 to 40 years. The remain- Black/African American 6 (0.8)
ing demographic data including education, household American Indian/Alaskan Native 7 (1)
income, ethnicity, and race is included on Table 1. Asian 7 (1)
Parents were first asked why they were seeking a personal Native Hawaiian/Other Pacific Islander 11 (1.5)
exemption for their child and could check any or all of the 10 Other 7 (1)
listed choices that related to seeking an exemption. The 801
parents selected a total of 1,203 choices. The most frequently
chosen response was that vaccinations conflicted with their Table 2. Common Reasons for Claiming a Personal Exemption.
philosophical beliefs (n ¼ 303, 25.2%; see Table 2). Parents
Selected Parental Response Frequency (%)
also cited concern about overloading or weakening their chil-
dren’s immune systems (n ¼ 269, 22.3%), while another 176 Requirements conflict with n ¼ 303 (25.2)
parents (14.6%) reported they had heard vaccines could cause philosophical beliefs
chronic diseases such as Autism. Other reasons for seeking Concern about overloading n ¼ 269 (22.3)
exemption were concerns that the vaccine caused the illness or weakening child’s
it was supposed to prevent (n ¼ 150, 12.5%) or the possibility immune system
Heard that vaccines can n ¼ 176 (14.6)
of a recurrence of an adverse reaction similar to that of a cause chronic diseases
previous vaccination (n ¼ 141, 11.7%). A few participants Concern that the vaccine may n ¼ 150 (12.5)
reported other, less common, reasons for seeking a personal cause the illness it is supposed
exemption, such as losing the vaccination record and not to prevent
wanting to repeat any vaccinations, reporting a lack of health Child had a reaction to a n ¼ 141 (11.7)
insurance, declining vaccinations because of any associated vaccine in the past
cost, and stating the lack of convenient access to vaccination All other responses combined n ¼ 164 (13.6)
clinics (n ¼ 164, 13.6%).
Many parents (n ¼ 122) reported they were requesting a
personal exemption from only one vaccine with 74 identifying common theme. One parent, exempting her child from
the vaccine (see Table 3). Hepatitis A and B was the most com- receiving the Hepatitis B vaccination stated, ‘‘[It] starts too
monly exempted vaccine (32.4%). Parents also exempted their young. Hep B is usually contracted due to a person’s life-
children from Tetanus (27.0%); Measles, Mumps, and Rubella style choices. I believe we all should live a drug free life and
(MMR; 17.6%), Varicella (13.5%), Polio (6.7%), and have only one sexual partner, to whom we are married.’’
Hemophilus influenza type B (HIB; 2.7%) vaccinations. Another parent exempting her child from receiving varicella
Ninety-one parents wrote comments regarding why they vaccination said, ‘‘I would prefer she build her immunity
were asking for an exemption from one specific vaccine (see naturally.’’ Other reasons for refusing a specific vaccination
Table 4). Not believing in the vaccine (35.2%) was the most included parents wanting a longer period of time over which

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Luthy et al.
Table 3. Vaccine Most Commonly Exempted.
Selected Parental Response Frequency (%)
Hepatitis Series n¼ 24 (32.4)
Tetanus n¼ 20 (27.0)
MMR n¼ 13 (17.6)
Varicella n¼ 10 (13.5)
Polio n¼ 5 (6.7)
HIB n¼ 2 (2.7)
to vaccinate their children (19.8%), having an adverse reac-
tion to the same vaccination given previously (13.2%), not
wanting to repeat a vaccination series (11%), worrying that
the vaccination may cause Autism (11%), and following the
counsel of their health care provider (9.8%).
Many parents stated they had communicated their
concerns with their health care provider prior to seeking a
personal exemption from vaccination. When questioned
about whether they had specific concerns regarding vaccine
safety, 404 (60.3%) had no concerns while 261 (39.2%)
affirmed they did have vaccine safety concerns. Of those
reporting safety concerns, 159 parents wrote comments
about their specific safety concerns. Danger of vaccine
ingredients was the most commonly listed concern
(n ¼ 34, 21.3%; see Table 5). As expressed by one parent,
‘‘I’m concerned that [vaccines] contain mercury, neurotox-
ins, and other harmful substances.’’ Others expressed
concern that vaccinations could cause chronic diseases, such
as Autism or diabetes. Ethical concerns regarding vaccina-
tions were expressed by 22 parents as shown by one parent
who wrote, ‘‘Some [vaccines] are cultured/produced with
the bio material of fetuses.’’ Also listed as vaccine safety
concerns were parental perceived reactions to a previous
vaccine (10%), distrust of government and vaccine manufac-
turers (5.6%), and general information issues (2.5%).
Internet access availability was reported by 693 (91%)
parents. When asked whether or not they used the Internet
to obtain information on vaccinations, 413 (57%) responded
no. The remaining parents (43%) utilized the Internet as a
resource when investigating vaccines with the most com-
monly reported websites being government-based and
health-related websites such as cdc.gov and webmd.com
(see Table 6). Some parents reported that they consulted
specific vaccine websites, although follow-up revealed these
websites contained anti-vaccine messages. A few parents
stated they utilized alternate sources such as online books
and magazine articles, search engines, or parenting websites.
Discussion
The demographic findings in this study are consistent with
similar studies regarding parents who exempt vaccinations
(National Network for Immunization Information [NNII],
2010). Indeed, parents who exempt their children from
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99
Table 4. Why Parents Exempted From Only One Vaccine.
Identified Themes Frequency (%)
Parental beliefs n ¼ 32 (35.2)
Needs more time n ¼ 18 (19.8)
Reactions in the past n ¼ 12 (13.2)
Repeat of Prior Shot n ¼ 10 (11)
Worry about autism n ¼ 10 (11)
Health care provider counsel n ¼ 9 (9.8)
receiving vaccinations are primarily White females, have
some college or are a college graduate, and have an annual
household income of over $75,000 (NNII, 2010).
Conflict with parents’ philosophical beliefs was the most
common reason parents exempted their children. Philosophi-
cal/parental beliefs is a broad category, especially considering
that these parents were available as subjects specifically
because they were seeking an exemption from vaccinations for
personal reasons. Most of the parents who cite philosophical
objection to compulsory vaccination, however, also often
express secondary concerns, some of which may actually be
the root of the philosophical belief. As such, some parents
should be asked additional questions to elicit very specific vac-
cination concerns. For example, a parent reporting a philoso-
phical objection to vaccinations may, in all actuality, have
more specific concerns directly related to vaccine ingredients
or a lack of understanding regarding the need for a specific vac-
cination. Once the specific concern is identified, the school
nurse can inform and then direct the parent to the appropriate
resource, thus taking a more effective and targeted approach
to vaccine education (Luthy, Sperhac, Faux, & Miner, 2010).
It was interesting to note that when parents exempted only
one vaccine, most often they exempted the hepatitis vaccines.
The majority of these parents also directly related Hepatitis A
and B infections with lifestyle choices such as number of sex-
ual partners, mistakenly believing that exposure to these
viruses can be avoided by observing abstinence from sexual
contact. Because of these specific parental beliefs, the parents
did not understand the need for children, who were not sexually
active, to be vaccinated against hepatitis infections. Similarly,
parents who exempted their child from tetanus vaccine
believed that it was only necessary following an injury.
Because none of these parents mentioned the pertussis compo-
nent of the diphtheria, tetanus, and pertussis (DTaP) vaccine
when exempting from tetanus, they may not have been aware
of the prevalence of pertussis disease in the community or the
health risks associated with this potentially devastating dis-
ease. For hepatitis and tetanus vaccinations, additional infor-
mation regarding transmission of these diseases as well as
the incidence of these diseases in the community may help par-
ents understand the importance of these vaccinations and
encourage parents to vaccinate their children.
As the third most common vaccine exemption in this
study, MMR vaccine was still exempted because of concern
regarding a possible link between vaccinations and Autism.
100
Table 5. Specific Concerns About the Safety of Vaccines.
Identified Theme Number of Respondents (%)
Vaccine ingredients n¼ 34 (21.3)
Chronic diseases n¼ 25 (15.7)
Parental beliefs n¼ 22 (13.8)
Vaccine safety n¼ 20 (12.5)
Parental perceived reaction n¼ 16 (10)
Distrust n¼ 9 (5.6)
Information issues n¼ 4 (2.5)
This myth continues to perpetuate despite eight review
panels by the Institute of Medicine conclusively disproving
any such link (Immunization Safety Review Committee,
2004; Kimmel, Burns, Wolfe, & Zimmerman, 2007). Often,
parents base their Autism-vaccination beliefs upon personal
advice or recommendations from friends or family members
(Sporton & Francis, 2001), never fully realizing the history
behind this erroneous connection. The school nurse may want
to summarize the history regarding Wakefield’s (Wakefield et
al., 1998) infamous study for these parents. For example, the
school nurse could communicate facts such as (1) the tiny
sample size of Wakefield’s 1998 study wherein he reported
a correlation between MMR vaccine and Autism which has
been disproven in multiple subsequent studies with thousands
of subjects; (2) Wakefield’s publication was officially
retracted from the Lancet in 2010; (3) Wakefield received
payments (about $750,000) from an attorney who intended
to sue the MMR vaccine manufacturer; (4) Wakefield
patented a new vaccine as a competitor to MMR hoping to
profit, given he could establish the original MMR vaccine
as unsafe; and (5) Wakefield’s involvement in the study was
deemed unethical, dishonest, and he was found guilty of abus-
ing developmentally challenged children which directly
resulted in the revocation of his medical license in 2010
(Deer, 2011; Myers & Pineda, 2008; Offit, 2008, 2011).
When asked, exempting parents stated they had specific
concerns relating to vaccine safety. Of these parents, vaccine
ingredients, namely mercury, was the most commonly cited
concern regarding vaccine safety. With the exception of
some flu vaccine, mercury-containing preservatives were
removed from all vaccines in 2001, although parental worry
regarding this ingredient continues (Offit, 2011; Offit &
Moser, 2011), a concern that has been further propagated
by Dr. Bob Sears in his book The Vaccine Book: Making the
Right Decision for Your Child and numerous anti-
vaccination websites. School nurses need to become familiar
with common vaccine ingredient concerns so as to provide
honest responses to these parents. Furthermore, school
nurses may want to refer the parents requesting Dr. Sears’
alternate vaccine schedule to the article, The Problem with
Dr. Bob’s Alternative Vaccine Schedule or a few selected
websites, such as chop.edu, to assist in vaccine ingredient
conversations with parents.
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The Journal of School Nursing 29(2)
Table 6. Internet Websites Visited for Vaccine Information.
Identified Theme Frequency (%)
Government and science n¼ 18 (23)
Anti-vaccine n¼ 12 (15.3)
Alternate sources n¼ 7 (8.9)
Search engines n¼ 5 (6.4)
Parenting website n¼ 1 (1.2)
Reliance upon the Internet for health-related information
has become a global phenomenon (West & Miller, 2009).
With this in mind, it was surprising to find that more than
half of our participants reported not using the Internet to
obtain vaccination information. It is unclear which
vaccination resources these parents are utilizing, although
possibilities may include health care providers, books, and
family members or friends. Our sample did report Internet
use to acquire vaccination information from government-
based and health-related websites, so, it is a bit perplexing
that reputable websites were accessed for vaccine informa-
tion and yet some of these parents still sought exemptions.
Perhaps the effectiveness of vaccine information should be
further researched among exempting parents to measure the
saliency of individual messages.
The majority of parents stated they had communicated
with their health care provider prior to seeking a personal
exemption yet, apparently, that communication was ineffec-
tive in overcoming the parent’s concerns. There is evidence
that the time a health care provider can spend discussing
vaccination concerns with parents may be severely limited
due to rigorous clinic schedules (Luthy et al., 2009; Luthy
et al., 2010). Nevertheless, contact between health care
providers and parents has been believed to be the single-
most important opportunity to convince exempting parents
they need to vaccinate their children (Luthy et al., 2010).
School nurses have a crucial role in serving as the liaison
between the health care provider and the family (National
Association of School Nurses [NASN], 2011) and provide
‘‘promotion of health education’’ (NASN, 2011, {1).
Consequently, the school nurse may be in a unique position
to further address parental vaccination concerns that the
health care provider did not have time to address.
While it is true that most childhood vaccinations are
administered in the first 2 years of life (United States
Department of Health and Human Services, n.d.), school
nurses still have an active role when interacting with
exempting parents. During admission to the school system,
parents must provide proof of their child’s vaccinations
(CDC, 2012) which, for some parents, is the first time they
have been required to prove vaccination status. Thus, the
vaccine conversation with the school nurse may be the first
communication regarding required vaccines. Additionally,
while it is ideal that all children have access to the health
care system, unfortunately this may not be the case. There
Luthy et al.
were, in fact, 7.3 million children in the United States with
no health insurance in 2010 (DeNavas-Walt, Proctor, &
Smith, 2011), which could pose a formidable barrier to reg-
ular interactions with a health care provider and access to
vaccines. Finally, even children covered by health insurance
may not be adequately vaccinated, especially if the child
changes health care providers frequently or if the vaccina-
tion record is lost.
Recommendations for Future Research
Parents who exempt their children from receiving vaccina-
tions have many questions regarding product safety, ratio-
nale for administering vaccinations at specified intervals,
vaccine ingredients, and vaccines and Autism. With an iden-
tifiable knowledge gap in these areas, effective communica-
tion regarding vaccinations with these parents is imperative.
However, to date, it is unknown as to which educational stra-
tegies are most effective with this group of parents. As such,
it is recommended that future research evaluate the effec-
tiveness of educational materials with this specific
population.
Limitations of the Study
The convenience sample was from one state and may not be
representative of other populations of parents residing in a
different location in the United States. Findings of this study
cannot be generalized to other populations. Moreover, the
questionnaire utilized to collect data was not piloted using
parents, although the tool was an adaptation of another sim-
ilar tool that was validated with parents prior to distribution.
Conclusion and Recommendations
As one of the most important life-saving measures of all
time, vaccines have proven to be successful in reducing the
incidence of VPDs. However, with the lack of experience
with VPDs has come the unintended consequence of a lower
perceived need for vaccines by some parents. For these
exempting parents, the potential for vaccine AEs outweighs
the perceived risk for VPDs. As the perceived benefits of
vaccines decrease, parental requests for personal exemption
from school-required vaccines may continue to increase.
Parents identify specific reasons for requesting personal
exemption from vaccinations and need to be questioned as
to the root cause of this type of request. Such questioning
may reveal identifiable knowledge gaps that the school
nurse can then address with focused educational messages.
For example, parents who exempt hepatitis vaccines may not
understand the need for such vaccinations in children if they
also believe these diseases are only spread by sexual contact.
Additionally, parents exempting tetanus unless the child has
sustained an injury may not be aware that the tetanus vaccine
is combined with pertussis vaccine, a potentially devastating
disease that is prevalent in many communities.
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101
It is disappointing to note that parental concern regarding
a possible link between MMR vaccinations and Autism con-
tinues to negatively affect compulsory vaccination. Further
circulating among exempting parents is worry there is a cor-
relation between mercury-based preservatives in vaccines
and Autism. However, it is important for school nurses to
participate in education efforts to inform parents on the truth
of the MMR vaccine–Autism debate. Additionally, parents
should be informed that mercury-based preservatives are
no longer used in childhood vaccines, with the exception
of flu, as well as the reasons for the removal of this ingredi-
ent from vaccines.
Parents are concerned about vaccine ingredients. There-
fore, it would be helpful for school nurses to become famil-
iar with common ingredient concerns so as to provide an
appropriate response to these parents. In preparation for vac-
cine ingredient discussions, school nurses may want to
review available resources found in print, as well as online.
While the majority of parents do not obtain their vaccina-
tion information from the Internet, those who do commonly
visit government-based and health-related websites. As a
result, it may be helpful to further research the saliency of
various vaccination messages with parents who sought a per-
sonal exemption despite their review of vaccination infor-
mation on reliable websites. Also concerning is the fact
that the vast majority of exempting parents reported they had
communicated with their health care provider prior to seek-
ing a personal exemption. While the health care provider
may not have the time to adequately address the vaccination
concerns of these parents, the school nurse may play a pivo-
tal role in providing additional vaccination information to
these parents and in answering their questions.
Acknowledgment
The authors wish to express their appreciation to Linda Able, BSN,
MPA at the Utah Immunization Program and to all the county
health department nurses who assisted in making this study
possible.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research and/or authorship of this article: Funding was
received from the Brigham Young University College of Nursing
Research and Scholarship Council.
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Author Biographies
Karlen E. Luthy, DNP, FNP, is an assistant professor at Brigham
Young University, Provo, UT, USA
Renea L. Beckstrand, PhD, RN, CCRN, CNE, is a professor at
Brigham Young University, Provo, UT, USA
Carly J. H. Meyers, BS, RN, is a nurse on the Cardiac Progressive
Care Unit, Utah Valley Regional Medical Center, Provo, UT, USA.