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The Journal of School Nursing
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The online version of this article can be found at:
DOI: 10.1177/1059840511426578
2012 28: 153 originally published online 10 November 2011The Journal of School Nursing
Karlen E. Luthy, Renea L. Beckstrand, Lynn C. Callister and Spencer Cahoon
Reasons Parents Exempt Children From Receiving Immunizations
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Research Article
Reasons Parents Exempt Children
From Receiving Immunizations
Karlen E. Luthy, DNP, FNP
1
,
Renea L. Beckstrand, RN, PhD, CCRN, CNE
1
,
Lynn C. Callister, RN, PhD, FAAN
1
, and Spencer Cahoon, SN
1
Abstract
School nurses are on the front lines of educational efforts to promote childhood vaccinations. However, some parents still
choose to exempt their children from receiving vaccinations for personal reasons. Studying the beliefs of parents who exempt
vaccinations allows health care workers, including school nurses, to better understand parental concerns which may, in turn,
help prepare school nurses for effective communication with these parents. The objective of the study was to explore
personal beliefs of parents living in Utah, who exempted their children from receiving vaccinations. A cross-sectional, descrip-
tive design was implemented. Data were collected from a convenience sample of 287 parents responding to an open-ended
question about why they exempted their children from receiving at least one vaccination. The qualitative data included
parental comments, concerns, or suggestions regarding childhood vaccinations. Five categories were identified regarding rea-
sons for personal exemptions: parental perceptions, health care systems issues, chronic disease concerns, immune system
concerns, adverse reaction concerns and other reasons not classified. The number of parents refusing childhood vaccinations
remains relatively low; however, despite public health efforts, the percentage increases each year.
Keywords
communicable diseases, environmental health, safety, immunizations, parent, family
Americans enjoy a life relatively free of communicable
diseases that in the past were a source of widespread sick-
ness and economic hardship (Ehreth, 2003). Vaccinations
have played an integral part in reducing the transmission
of diseases that were once highly feared, such as measles
and pertussis. As a result, the once visible manifestations
of these vaccine-preventable diseases have likewise dimin-
ished and, consequently, the number of people choosing to
be exempted from vaccinations has increased (Kennedy,
Brown, & Gust, 2005). Public attention continues to shift
from the monumental achievements of vaccinations in
reducing or eradicating diseases to the potential side effects
and concerns about the efficacy of vaccines (Opel, Diekema,
Lee, & Marcuse, 2009; Thompson et al., 2007).
To ensure public safety, government entities in the
United States (U.S.) have implemented mandatory vaccine
requirements before a child may enter public school (Omer
et al., 2006; Thompson et al., 2007). However, each individ-
ual state allows children with immunodeficiencies, such as
those undergoing chemotherapy or solid organ transplant
recipients, or those children otherwise unable to receive
vaccines due to medical contraindications, to obtain a
medical exemption (Centers for Disease Control and Pre-
vention, 2011a). With the state required medical exemption
in place, these children are able to attend public school. In
addition, 48 states allow exemptions from vaccines based
on religious beliefs (Salmon et al., 2006).
A third type of vaccination exemption, one based on
parents’ personal beliefs, is becoming increasingly prevalent
(Thompson et al., 2007). Currently, 20 states allow for
personal exemptions (Salmon et al., 2006). Many parents
choosing this type of exemption express concerns regarding
the safety of vaccines (Kennedy et al., 2005; Opel et al.,
2009; Salmon et al., 2005, 2009). Furthermore, many
parents seem suspicious that vaccines may directly cause
various chronic diseases (Offit & Hackett, 2003). Addition-
ally, some parents may claim a personal exemption in
response to their disdain for government organizations
and pharmaceutical companies who are perceived as
benefitting financially from mandatory vaccination require-
ments (Cooper, Larson, & Katz, 2008). The reasons for
philosophical exemptions may vary, but interestingly there
seems to be at least one commonality: emotionally based
1
College of Nursing, Brigham Young University, Provo, UT, USA
Corresponding Author:
Karlen E. Luthy, College of Nursing, Brigham Young University, 355 SWKT,
Provo, UT 84602, USA
Email: beth_luthy@byu.edu
The Journal of School Nursing
28(2) 153-160
ªThe Author(s) 2012
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DOI: 10.1177/1059840511426578
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negative conjecture despite overwhelming positive scientific
evidence.
Although the vast majority of U.S. parents continue to
immunize their children, the increasing trend of parents
exempting their children from receiving vaccinations based
on personal beliefs may ultimately result in potentially seri-
ous health and economic consequences (Ehreth, 2003; Zhou
et al., 2005). The unvaccinated child has a much higher risk
of contracting communicable diseases and then spreading
these diseases to children with religious or medical exemp-
tions or to those who are too young to receive vaccinations
(Opel et al., 2009). Furthermore, communities with lower
vaccination rates are at risk for outbreaks of highly virulent
diseases (United States Department of Health and Human
Services [USDHHS], 1994, 1995). Recently, residents of
Utah experienced one such outbreak where 15 cases of measles
were reported during the spring and summer of 2011, all of
whom were school-aged children (Standard Examiner, 2011).
For Utah school nurses, managing vaccination compli-
ance among the students of several schools simultaneously
is challenging (Luthy, Thorpe, Dymock, & Connely,
2011). In Utah, the student-to-nurse ratio is, on average,
1:5,822 (Maughan, 2009), so many school nurses must rely
on school officials, such as secretaries, to collect and con-
duct a cursory review of vaccination records when students
enroll during the school year. However, all vaccination
records are then verified by the school nurse. Utah parents
who are opposed to vaccinations and who cannot provide
proof of their child’s vaccinations are typically contacted,
first by letter and then via telephone, by school nurses.
Telephone contact between parent and school nurse is an
opportune time for nurses to engage in a discussion on par-
ental concerns regarding vaccinations. Parents who cannot
be convinced to vaccinate their children are then referred
to their local Utah health department where exemption
forms are distributed.
In Utah, kindergarten registration usually takes place dur-
ing the spring, enrolling children for the following school
year. The majority of parents attending kindergarten regis-
tration have the child’s vaccination records directly evalu-
ated by the school nurse who can then identify missing
vaccinations and speak with parents about vaccination con-
cerns. Parents enrolling a transfer student during the summer
months are contacted by school nurses, if needed, first by
letter and then by telephone for any additional vaccination
information prior to the beginning of school.
Since 2005, the percentage of vaccination exemptions
among school-age children in Utah, has steadily risen from
2.8%to 3.3%in 2009 (Utah Department of Health, 2011),
which is slightly higher than the national average of 1%to
3%(Council of State Governments, 2007). In order to pro-
mote the overall health and well-being of community mem-
bers it is, therefore, important to identify the major reasons
parents exempt their children from receiving vaccinations.
Accordingly, the objective of this study was to describe the
personal beliefs of Utah parents who exempted their children
from receiving vaccinations.
Research Questions
1. What are the demographics of Utah parents who claim
personal exemptions from childhood vaccinations?
2. What are the common vaccine-related beliefs of Utah
parents who exempt?
Background
In two previous case–control studies, the reasons parents
claimed exemptions from childhood vaccinations were
reviewed in five states: Colorado, Massachusetts, Missouri,
Washington, and Wisconsin (Salmon et al., 2005, 2009). In
these states, parents of children exempted from receiving at
least one vaccination were between the age of 36 and
45 years, the median level of education was at least some
college, and their annual income was between $60,000 and
$69,999. In addition, the majority of the respondents were
Caucasian (Salmon et al., 2005, 2009).
In these five states, varicella and hepatitis B were the
most commonly exempted vaccines. When asked why the
parents chose to exempt their child from vaccines, between
57%and 68.6%stated they believed vaccinations caused
harm. Other reasons for refusing vaccinations included
belief that the vaccination overwhelmed the immune system,
the child was not at risk for the disease, the disease was not
dangerous, it was better to get the disease and then recover
using natural means, concerns regarding the risk of autism,
and safety concerns regarding thimerosal (Salmon et al.,
2005, 2009).
Some similar findings were identified in the 2002
HealthStyles survey. For example, sociodemographic char-
acteristics of parents who exempted their children from
receiving vaccinations in this study also included Caucasian
mothers between the age of 40 and 49 years, with some col-
lege education (Kennedy et al., 2005). However, there were
also differences. For example, most parents responding to
the HealthStyles survey reported a total annual income of
$0–$49,999 (Kennedy et al., 2005). While concerns regard-
ing autism, thimerosal, or overwhelming the immune system
were not specifically measured in the HealthStyles survey,
parents did report they felt the child’s immune system could
fight off disease without vaccinations and that they did not
believe vaccines were an important part of maintaining the
health of their children. (Kennedy et al., 2005).
Method
The questionnaire was finalized after conducting multiple
searches of electronic bibliographic databases to identify
and collect studies related to childhood vaccination exemp-
tions and personal beliefs. Databases utilized in the search
included MEDLINE, MEDLINEPlus, EBSCO, PubMed,
154 The Journal of School Nursing 28(2)
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CINAHL, Web ofScience, Biomedical Reference Collection-
Basic, Health Source-Nursing/Academic Edition, and the
Cochrane Library Online. Search terms included immuniza-
tion,vaccination,exemption,exemption form,philosophical
exemption,parents,philosophical belief,personal belief,
childhood,andpediatrics. Additionally, current guidelines
and recommendations for childhood vaccinations were
collected by conducting an Internet search from the Centers
for Disease Control and Prevention.
Design and Sample
To determine why Utah parents opted to exempt their
children from receiving at least one vaccination, 801 parents
were surveyed. A cross-sectional, descriptive design was uti-
lized. A 16-item questionnaire including fill in the blank,
multiple choice, and open-ended comment sections was
adapted, with permission, from a prior Utah State Depart-
ment of Health (USDOH) exemption questionnaire. The
original USDOH questionnaire was created with a team of
vaccination experts living in various parts of the state. The
USDOH questionnaire was then tested with parents to estab-
lish face validity. Because our questionnaire was adapted
using the USDOH tool that had already been tested with par-
ents, we did not conduct additional parental testing prior to
questionnaire distribution.
After receiving institutional review board approval, the
questionnaire was distributed to all county health depart-
ments in the state of Utah. Utah parents seeking to exempt
a child from vaccinations for personal reasons were required
to first obtain the appropriate documentation from their local
health department prior to attending school. In the school
setting, often school nurses are the point of contact with
exempting parents who wish to enroll their child in public
school. If school nurses are unsuccessful in their efforts to
convince the parent to vaccinate their children, school nurses
then refer these parents to the local health department to
obtain an exemption form. Consequently, the health depart-
ments seemed the ideal setting where exempting parents
could be questioned regarding their vaccination beliefs.
The nurses employed at health departments throughout
the state were responsible for identifying parents who were
seeking to complete the required paperwork for a personal
exemption. Parents were then asked whether they would like
to participate in a study regarding the reasons for a personal
exemption. After obtaining informed consent, the parent
completed the questionnaire, which took approximately
15 min. Upon completion of the questionnaire, a $1 gift
certificate for food was given as compensation for the par-
ent’s time.
Measures
The vaccination exemption questionnaire was developed to
assess parental attitudes and beliefs and identify potential
barriers to those who refuse vaccinations for their children
due to personal beliefs. Questionnaire items were chosen
based on commonly identified parental concerns, expert
opinion, and other perceived barriers published in the litera-
ture, such as negative attitudes about vaccinations and
vaccination safety, low perceived susceptibility to and
severity of vaccine-preventable diseases, and a mistrust of
the government. Before distribution, the questionnaire was
reviewed by a local immunization coalition consisting of
experts in public health, pediatrics, and state and local gov-
ernment agencies to establish face validity. Data collection
took place between August 2007 and May 2008.
The vaccination exemption questionnaire included
seven demographic questions: gender, age, annual income,
education, race, grade of the child for whom the exemption
was sought, and vaccination status of the parent. In addition,
parents were asked to identify why they were claiming a per-
sonal exemption and could choose from a list of 11 choices,
marking all responses that applied. Parents were also asked
about vaccination conversations with their child’s health
care provider and whether they used the Internet to obtain
vaccination information. There were also open-ended
questions regarding reasons for exemption and sources of
obtaining vaccination information. Data reported in this
manuscript focuses on responses to the open-ended question,
‘‘Please share any other comments you feel would be helpful
to understand why you are claiming a personal exemption.’’
In this item, parents wrote comments, concerns, or sugges-
tion they had regarding childhood vaccinations. The remain-
ing data are currently being analyzed and will be published
at a later time.
Analytic Strategies
Of the 801 parents who completed the questionnaire, 287
parents shared comments or explanations as to why they
were claiming a personal exemption to immunizations for
a response rate of 35.8%to this item. Open-texted items
were transcribed and analyzed for themes. To ensure the
trustworthiness of the data, two researchers engaged in
content analysis independently, coding and analyzing each
response. On completion of the coding, the synthesized data
and codes were compared until a consensus was reached.
Another nurse researcher with expertise in qualitative inquiry
then verified the findings by conducting an independent anal-
ysis of data and themes. The themes were compared with
literature on parental concerns regarding pediatric vaccina-
tions. Qualitative results are described as follows, with narra-
tives to illustrate themes.
Results
Demographics
Two hundred eighty-seven parents responded to the
open-ended question. Demographic data are summarized
in Table 1. A comparison between the 287 parents
Luthy et al. 155
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responding to the open-ended question and the 514 parents
who were nonresponders revealed demographic similarities
with one exception. The most commonly listed education
level of the nonresponders was ‘‘some college,’’ whereas the
most commonly listed education level of the responders was
‘‘college graduate.’’
Qualitative Findings
The overarching theme was that parents are concerned about
vaccine safety. Five categories were identified regarding
reasons for personal exemptions: (1) issues regarding paren-
tal perceptions of vaccine harm (28.6%), (2) health care sys-
tems issues (26.1%), (3) chronic disease concerns (16.4%),
(4) immune system concerns (12.5%), (5) adverse reaction
concerns (9.3%), and (6) other (6.9%; see Figure 1). The
most commonly reported concerns regarding vaccine safety
included vaccines being perceived to cause autism and/or
immune system overload. The second most common theme
was related to health care systems issues with over one quar-
ter of parents who filed for a personal exemption citing no
accommodations for lost vaccination records, as the most
prominent reason for requesting a personal exemption.
Parental perceptions. Of the 287 parents responding to the
open-ended question, 82 (28.6%) shared their perceptions
regarding vaccinations. Common parental perceptions
included worry about vaccine safety, the need to reaffirm
parental rights when determining when and how to immu-
nize their children, questions regarding vaccine effective-
ness, and the belief that natural healing methods were
superior to vaccinations. Many parents stated they had
researched vaccine safety, and were confused by seemingly
conflicting information in the media. As expressed by one
mother, ‘‘Please find results [regarding vaccination safety].
I am confused and scared ....’’
Parents also felt their judgment should be respected and
wanted to affirm their parental rights. As expressed by one
parent, ‘‘I am responsible for my child’s health and I would
prefer to take care of him according to my own beliefs and
knowledge.’’ Furthermore, parents often analyzed the risks
and benefits of vaccines, concluding that American children
are not at risk for contracting communicable diseases. One
parent stated, ‘‘I do not feel she is at a high risk at this time’’
and another stated, ‘‘I just do not feel my child is in an at risk
group ... I will administer when we are at risk, such as
traveling.’’
In addition, these parents were not convinced that
vaccines worked, stating ‘‘there is no evidence proving vac-
cine’s effectiveness [as a way to prevent disease]’’ and, ‘‘If
immunizations worked, you wouldn’t have epidemics.’’
Rather, relying on natural immunity was a motivation for
some parents who believed as this parent wrote that, ‘‘All
diseases can be prevented and cured using safe natural
means, without resorting to manufactured chemical pro-
cesses.’’ Parents also believed that if they used natural meth-
ods for boosting the child’s immune system, vaccinations
were not needed. As stated by several parents, ‘‘ ... I believe
[the] body can heal itself’’ and, ‘‘I know there are other
options to prevent disease. I work at a natural health clinic’’
Table 1. Demographics of Parents (n ¼287) Exempting Childhood
Immunizations for Personal Reasons
Question Responders
Gender Female: n¼241 (85.8%)
Male: n¼40 (14.2%)
Age 20–47 years (mean 35 years)
Household
income
Greater than $75,001: n¼77 (28.8%)
$60,001–$75,000: n¼33 (12.4%)
$45,001–$60,000: n¼58 (21.7%)
$30,001–$45,000: n¼33 (12.4%)
$15,001–$30,000: n¼38 (14.2%)
Less than $15,000: n¼28 (10.5%)
Mean income range $45,001–$60,000
Education College graduate: n¼115 (42.6%)
Some college: n¼105 (38.9%)
High school graduate: n¼31 (11.5%)
Some high school: n¼19 (7%)
Race White: n¼252 (94.7%)
American Indian/Alaskan Native: n¼1 (.4%)
Asian: n¼4 (1.5%)
Native Hawaiian/other Pacific Islander: n¼3
(1.1%)
Other race: n¼6 (2.3%)
Parent
vaccination
status
Vaccinated as a child: n¼232 (87.9%)
Not vaccinated as a child: n¼32 (12.1%)
Exempted child’s
grade in school
Pre-school: n¼48 (18.7%)
Kindergarten: n¼105 (40.8%)
Seventh grade: n¼29 (11.3%)
All other grades combined: n¼75 (29.2%)
Geographic area Urban: n¼230 (81%)
Rural: n¼53 (19%)
Figure 1. Reasons parents choose personal exemption from
vaccination.
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and, ‘‘I use homeopathic methods to build up my child’s
immune system (a natural alternative).’’
Health care systems issues. Citing frustration with the
public health system and policies, 75 of 287 or 26.1%of
respondents stated they submitted a personal exemption for
convenience purposes so their child could enroll in school.
For example, almost half of these parents filed for an exemp-
tion because they were unable to locate or access the child’s
vaccination record in a timely manner. These parents were
not opposed to childhood vaccinations but instead requested
the exemption for a variety of reasons such as, ‘‘[I] don’t
have access to [immunization] records today. School starts
today,’’ or, ‘‘My children’s records are in another country,’’
or ‘‘[their] records are in storage.’’
Some parents believed their child qualified for a medical
exemption but did not have the time to obtain the required
health care provider’s signature. Several parents stated their
child was ‘‘allergic’’ to vaccinations, while others reported
that their ‘‘MD recommended against vaccines’’ for various
health-related reasons. Finally, some parents needed more
time to vaccinate because they were waiting for ‘‘[health]
insurance’’ or completion of adoption paperwork, or because
they wanted the child ‘‘to receive immunizations from their
pediatrician [and] he is out of the [vaccine] needed.’’
Chronic disease concerns. Some parents (16.4%) had con-
cerns about the perceived correlation between receiving vac-
cinations and developing a chronic disease. Over half of these
parents in this category (61.7%) cited fear of their children
developing autism as their reason for refusing vaccinations.
The remaining 38.3%of parents with chronic disease con-
cerns specified worry regarding seizures, learning disabil-
ities, or attention deficit with hyperactivity disorder
(ADHD) as the reason for the exemption.
Even after numerous studies have refuted any correlation
between vaccinations and autism (Institute of Medicine,
2008; Kimmel, Burns, Wolfe, & Zimmerman, 2007; Offit,
2011), parents felt as this parent wrote that he ‘‘[felt]
strongly there is a connection [between immunizations and]
with autism’’ or were wary of any possible link and
‘‘[wanted] to do more research regarding vaccines and aut-
ism’’ before vaccinating their children. Almost half of
autism-concerned parents (45%) stated they had another
child diagnosed with autism. They believed vaccines to be
the cause of the autism and were exempting a different child
from receiving vaccinations.
Similar reasoning was present in parents concerned about
vaccines and seizure disorders who stated, ‘‘I have a child
with epilepsy caused by a vaccine reaction ... I am not will-
ing to risk the same reaction in my other children.’’ Other
parents believed vaccinations were correlated with ADHD
or other disabilities stating, ‘‘I have read studies that have
shown that vaccines affect the ‘‘white matter’’ in the
developing brain, blocking connections. I believe that is why
we have so much ... ADHD and other behavioral
problems.’’
Immune system concerns. Concerns regarding vaccination
effects on the immune system were expressed by 12.5%of
the respondents. Almost all of these parents (97.2%) stated
vaccinations overwhelmed the child’s. Developing immune
system. ‘‘We are told that a baby’s immune system is not
strong enough and needs to be protected,’’ wrote one mother.
Like many others, one respondent decided the safest way for
vaccination was, ‘‘one disease at a time and no more than
one vaccination a month.’’ Although most respondents were
parents of grade school age children, some respondents
exempted younger children, most likely to satisfy vaccina-
tion requirements for day care. These parents with younger
children expressed their desire to wait until the child was
older, when they felt the child would have a stronger
immune system. As stated by one parent, ‘‘I prefer to vacci-
nate at age 2,’’ and by another, ‘‘We are waiting until he will
be 5 years old.’’
Adverse reactions. Concerns regarding adverse reactions
were listed by 9.4%of respondents. The majority of these par-
ents (63%) were convinced by a family member or friend
whose child reportedly experienced an adverse reaction that
their children could also experience an adverse event because
of vaccination. For example, one parent stated that ‘‘a friend’s
child was permanently injured via shots,’’ and another respon-
dent mentioned that her ‘‘cousin received [the same] vaccina-
tion and had bad side effects.’’ In addition, some parents had
previously seen reactions in their own children after receiving
a vaccination. ‘‘Overall I think they’re good, but my son had
terrible reactions from them,’’ explained one parent.
Discussion
Educational efforts regarding childhood vaccinations need
to continue, an endeavor where health care workers find
themselves on the front line (Luthy, Beckstrand, & Callister,
2010). While parents may have access to scientific interpre-
tations of vaccination data in research reports, vaccination
information may be more easily understood if synthesized
into layman’s terms (Davis et al., 2006). Parental percep-
tions that vaccines may be harmful to children or to their
immune systems is common (Salmon et al., 2004). To alle-
viate this concern, perhaps parental access to additional
resources, such as reports or data proving otherwise, would
be helpful. In addition, respectful discussion regarding vac-
cine effectiveness and the fact that outbreaks of disease in
communities are not related to the effectiveness of the vac-
cine but rather attributable to the unvaccinated or undervac-
cinated populations within a community may be helpful.
The fact that over 25%of parents claiming a personal
exemption did so because of health care systems issues was
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especially surprising. Implementing and then using state
vaccine registries may help prevent unnecessary exemptions
for reasons of lost or otherwise unavailable records. Also,
accurately assessing a parent’s request for an exemption and
differentiating between the need for a medical, religious, or
personal exemption is needed. While it may seem the
numbers of parents claiming personal exemptions are on the
rise, this may not be the case.
Parents worrying needlessly about a possible correlation
between vaccinations and autism do not understand the
source of this fraudulent claim and should be educated on
the Lancet’s retraction of Wakefield’s 1998 publication pos-
tulating that vaccinations caused autism (Lancet Editors,
2010). Parents should also be made aware that the data in
Wakefield’s study was falsified and that his medical license
was revoked due to his falsification of data (Luthy, Sperhac,
Faux, & Miner, 2010). While eight review panels by the
Institute of Medicine have found absolutely no correlation
between vaccinations and autism (Institute of Medicine,
2008; Kimmel et al., 2007; Offit, 2011), parents may not
be aware of the study findings. Also, because some parents
associate thimerosal (a mercury-based preservative) in vac-
cines with autism (Kirby, 2005), these parents may benefit
from knowing thimerosal was removed from routine infant
vaccinations in 2002 (Centers for Disease Control and
Prevention, 2011b; Luthy et al., 2010).
Lastly, while several parents specifically mentioned their
concern regarding adverse reactions of vaccines, it is not
clear how these parents defined an adverse reaction. It is
possible that what these parents classified as an adverse
reaction, may not be considered an adverse reaction to health
care providers. Also interesting is that many of these parents
refused vaccinations simply because a friend or extended
family member had an adverse reaction. Therefore, it may
be helpful to ask parents to describe their interpretation of
an adverse reaction, allowing for education regarding
common side effects to vaccinations.
Recommendations for School Nurses
Additional support that clarifies misconceptions should be
provided regarding the immune system. While it is true that
children today receive double the number of vaccinations as
compared to children 20 years ago, parents need to know
that the number of immunological components within each
vaccination is fewer (Luthy et al., 2010; Offit, 2011). It may
be helpful for parents to understand that a normal immune
system in an infant or young child could theoretically handle
up to 100,000 vaccinations at the same time (Offit & Bell,
2003). Essentially, a vaccination is just a small drop in the
sea of a baby’s immune system (Children’s Hospital of
Philadelphia [CHOP], 2010). Furthermore, waiting to vacci-
nate until a child is older is especially risky since many of
the vaccinations administered during infancy protect against
the very diseases to which infants are especially susceptible
(CHOP, 2010). Finally, parents should be reassured that
although redness at the injection site or fever are common
side effects of vaccinations, these are not signs that the
child’s immune system has been compromised.
Over a quarter of respondents indicated that they filed for
exemption for convenience purposes so their child could
enroll in school. As a result, those working in school health
may benefit from further training on assessing parents’
requests for exemption forms. Carefully evaluating a par-
ent’s request for an exemption form and then accurately
classifying the request as either medical, religious, or per-
sonal would improve the legitimacy of the exemption rates.
While parents who are behind vaccinating their children
may feel overwhelmed with the number of vaccines needed
and believe completing an exemption form is easier, school
nurses may be able to facilitate vaccination by assisting the
child to achieve a conditional status where he or she receives
only the vaccines needed to gain school admission. School
nurses can then work with the parents on following up with
their health care provider for future vaccinations.
Sometimes, however, parents have specific questions that
cannot be easily and readily answered. As such, it is impor-
tant for school nurses to familiarize themselves with the
common questions, as well as the not-so-common questions,
parents may ask. While resources such as Vaccines and Your
Child: Separating Fact From Fiction by Offit and Moser
and Do Vaccines Cause That’’!A Guide for Evaluating Vac-
cine Safety Concerns by Myers and Pineda are helpful
resources for parents, the information presented in these
books can also help school nurses. Because the books are
written in a question and answer format, the school nurse can
become familiar with numerous parent questions and have
quick access to the answers in layman’s terms. Conse-
quently, school nurses may find the books to be a valuable
resource.
There are a variety of venues during which the school
nurse could engage parents in a discussion regarding vac-
cines. Back-to-school night, school festivals, parent–teacher
conferences, and kindergarten enrollment are just a few
venues the school nurse could use to provide vaccination
education to individual or groups of parents. In addition,
school nurses could utilize already established school–par-
ent communication methods, such as school newsletters or
parent e-mail lists, to share regular and positive vaccination
messages.
Limitations of the Study
The convenience sample was from one state and may not
represent the entire population of parents in the United
States, thus the findings cannot be generalizable to other
populations. Additionally, the questionnaire tool used for
this study was not piloted using parents, although the tool
was an adaptation of another instrument that was validated
with parents.
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Conclusion
The percentage of parents nationwide that refuse childhood
vaccinations remains relatively low when compared to the
number of parents who choose to vaccinate their children.
However, despite educational and public health efforts, this
percentage increases each year. Health care workers, such as
school nurses, are on the front lines of these educational
efforts and play an integral role in increasing immunization
rates and helping parents make decisions based on facts
rather than misconceptions.
Parents seeking personal exemptions from vaccinations
do so for a variety of reasons. Common perceptions of
parents refusing vaccinations include worry about vaccine
safety, the need to reaffirm their parental rights in the deci-
sion of how and when to vaccine their children, questions
regarding vaccine effectiveness, and the belief that natural
healing methods were superior to vaccinations. Some
parents completed the personal exemption form not because
they were opposed to vaccinations, but because they
believed it was the only way to enroll their child in school
while waiting for access to vaccination records. Worry about
vaccinations and a possible correlation with chronic ill-
nesses such as autism and epilepsy continue to proliferate
despite numerous studies refuting these myths. Finally,
parents seeking personal exemptions express concerns
regarding vaccinations overwhelming the child’s immune
system and worry about adverse reactions.
School nurses are instrumental in providing vaccination
education to parents. Providing detailed information
regarding the contents of vaccines, the ability of the immune
system to respond to many vaccinations simultaneously, as
well as sharing the metaphor that a vaccination is just a drop
in the sea of a baby’s immune system may help alleviate
some of these parental concerns. Utilizing understandable
layman’s terms during parent interactions is necessary.
Finally, parents waiting to vaccinate until a child is older
need to understand their decision is especially risky since
many of the vaccinations administered during infancy pro-
tect against the very diseases to which infants are especially
susceptible.
Those working in school health may also benefit from
further training on assessing parents’ requests for exemption
forms. It is important to differentiate between medical,
religious, or personal reasons for exempting children from
vaccinations. Accordingly, parents should be directed to
completing the appropriate exemption form for school entry.
Also, school nurses may be able to facilitate vaccination by
assisting the child to achieve a conditional status where he or
she receives only the vaccines needed to gain school admis-
sion rather than exempting all vaccinations.
Acknowledgements
The authors would like to acknowledge the help of Linda Abel,
BSN, MPA and the Utah Immunization Program, as well as all the
Utah Health Departments for facilitating the distribution and col-
lection of the questionnaires.
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, authorship, and/or publication of this article: This
study was funded by a grant from the Brigham Young University
College of Nursing Research Council.
References
Centers for Disease Control and Prevention. (2011a). Immunization
laws, Retrieved from http://www.hhs.gov/nvpo/law.html
Centers for Disease Control and Prevention. (2011b). Mercury and
vaccines (thimerosal). Retrieved from http://www.cdc.gov/
vaccinesafety/Concerns/thimerosal/index.html
Children’s Hospital of Philadelphia. (2010). Vaccine education
center. Retrieved from http://www.chop.edu/service/vaccine-
education-center/vaccine-safety/
Cooper, L. Z., Larson, H. J., & Katz, S. L. (2008). Protecting public
trust in immunizations. Pediatrics,122, 149-153.
Council of State Governments. (2007). Exemptions from school
immunization requirements. Retrieved from http://www.healthy
states.csg.org
Davis, T. C., Fredrickson, D. D., Kennen, E. M., Humiston, S. G.,
Arnold, C. L., Quinlin, M. S ... Bocchini JA Jr. (2006).
Vaccine risk/benefit communication: Effect of an educational
package for public health nurses. Health Education Behavior,
33, 787-801.
Ehreth, J. (2003). The global value of vaccination. Vaccine,21,
596-600.
Institute of Medicine. (2008). Immunization safety review.
Retrieved from http://www.iom.edu/? ID¼4705
Kennedy, A. M., Brown, C. J., & Gust, D. A. (2005). Vaccine
beliefs of parents who oppose compulsory vaccination. Public
Health Reports,120, 252-258.
Kimmel, S. R., Burns, I. T., Wolfe, R. M., & Zimmerman, R. K.
(2007). Addressing immunization barriers, benefits, and risks.
Journal of Family Practice,56, S61-S69.
Kirby, D. (2005). Evidence of harm: Mercury in vaccines and the
autism epidemic: A medical controversy. New York, NY: St.
Martin’s Press.
Lancet Editors. (2010). Retraction—Ileal-lymphoid-nodular
hyperplasia, non-specific colitis, and pervasive developmental dis-
order in children. Lancet. doi:10.1016/S0140-6736(10)60175-4
Luthy, K. E., Beckstrand, R. L., & Callister, L. C. (2010). Parental
hesitation in immunizing children in Utah. Public Health
Nursing,27, 25-31.
Luthy, K. E., Sperhac, A. M., Faux, S. A., & Miner, J. K. (2010).
Improving immunization rates in your clinic and community.
Contemporary Pediatrics,27, 54-60.
Luthy et al. 159
at BRIGHAM YOUNG UNIV on August 27, 2013jsn.sagepub.comDownloaded from
Luthy, K. E., Thorpe, A., Dymock, L. C., & Connely, S. (2011).
Evaluation of an intervention program to increase immunization
compliance among school children. Journal of School Nursing,
27, 252-257.
Maughan, E. (2009). Part 1–Factors associated with school nurse
ratios: An analysis of state data. Journal of School Nursing,
25, 214-221.
Offit, P. A. (2011). Deadly choices: How the anti-vaccine move-
ment threatens us all. New York, NY: Basic Books.
Offit, P. A., & Bell, L. M. (2003). Vaccines: What you should know
(3rd ed.). Hoboken, NJ: John Wiley.
Offit, P. A., & Hackett, C. J. (2003). Addressing parents’ concerns:
Do vaccines cause allergic or autoimmune diseases? Pediatrics,
111, 653-659.
Omer, S. B., Pan, W. K. Y., Halsey, N. A., Stokley, S., Moulton, L.
H., Navar, A. M., ... Salmon, D. A. (2006). Nonmedical exemp-
tions to school immunization requirements: Secular trends and
association of state policies with pertussis incidence. Journal
of the American Medical Association,296, 1757-1763.
Opel, D. J., Diekema, D. S., Lee, N. R., & Marcuse, E. K.
(2009). Social marketing as a strategy to increase immuniza-
tion rates. Archives of Pediatrics and Adolescent Medicine,
163,432-437.
Salmon, D. A., Moulton, L. H., Omer, S. B., Chace, L. M.,
Klassen, A., Talebian, P., & Halsey, N. A. (2004). Knowledge,
attitudes, and beliefs of school nurses and personnel and
associations with nonmedical immunization exemptions. Pedia-
trics,113, e552-e559.
Salmon,D.A.,Moulton,L.H.,Omer,S.B.,deHart,M.P.,
Stokley, S., & Halsey, N. A. (2005). Factors associated with
refusal of childhood vaccines among parents of school-aged
children. Archives of Pediatrics and Adolescent Medicine,
159,470-476.
Salmon, D. A., Sotir, M. J., Pan, W. K., Berg, J. L., Omer, S. B., &
Stokley, S. & Halsey, N. A. (2009). Parental vaccine refusal in
Wisconsin: A case-control study. Wisconsin Medical Journal,
108, 17-23.
Salmon, D. A., Teret, S. P., MacIntyre, C. R., Salisbury, D.,
Burgess, M. A., & Halsey, N. A. (2006). Compulsory vaccina-
tion and conscientious or philosophical exemptions: Past,
present, and future. Lancet,367, 436-442.
Standard Examiner. (2011, June). Health board reports 15 cases
of measles. Retrieved from http://www.stardard.net/topics/
medical/2011/06/23/health-board-reports-15-cases-measles
Thompson, J. W., Tyson, S., Card-Higginson, P., Jacobs, R. F.,
Wheeler, J. G., Simpson, P., ... Salmon, D. A. (2007). Impact
of addition of philosophical exemptions on childhood immuniza-
tion rates. American Journalof Preventive Medicine,32,194-201.
US Department of Health and Human Services. (1994). Outbreak of
measles among Christian Science students—Missouri and Illi-
nois, 1994. Morbidity and Mortality Weekly Report,43,463-465.
United States Department of Health and Human Services. (1995).
Measles—United States, 1994. Morbidity and Mortality Weekly
Report 44, 493-494.
Utah Department of Health. (2011). Utah healthstatus update: Utah’s
web-based community health assessment tool, Retrieved from
http://health.utah.gov/opha/publications/hsu/11Apr_CHA.pdf
Zhou, F., Santoli, J., Messonnier, M. L., Hussain, R. Y, Shefer, A,
Chu, S. Y., ... Harpaz, R. (2005). Economic evaluation of the
7-vaccine routine childhood immunization schedule in the
United States, 2001. Archives of Pediatrics and Adolescent
Medicine,159, 1136-1144.
Bios
Karlen E. Luthy, DNP, FNP, is an assistant professor at the
College of Nursing, Brigham Young University, Provo, UT, USA.
Renea L. Beckstrand, RN, PhD, CCRN, CNE, is an associate
professor at the College of Nursing, Brigham Young University,
Provo, UT, USA.
Lynn C. Callister, RN, PhD, FAAN, is a professor emerita at
College of Nursing, Brigham Young University, Provo, UT, USA.
Spencer Cahoon, SN, College of Nursing, Brigham Young
University, Provo, UT, USA.
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