title: Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study.
abstract: BACKGROUND
  The rate of nonmedical exemptions to school immunization requirements has been increasing, and children with exemptions have contributed to outbreaks of vaccine-preventable diseases.
  
  
  OBJECTIVE
  To determine why parents claim nonmedical exemptions and to explore differences in perceptions of vaccines and vaccine information sources between parents of exempt and fully vaccinated children.
  
  
  METHODS
  Case-control study.
  
  
  METHODS
  Colorado, Massachusetts, Missouri, and Washington.
  
  
  METHODS
  Surveys were mailed to the parents of 815 exempt children (cases) and 1630 fully vaccinated children (controls randomly selected from the same grade and school) recruited from 112 private and public elementary schools. Surveys were completed by 2435 parents (56.1%).
  
  
  METHODS
  Parental reports.
  
  
  RESULTS
  Most children (209 [75.5%] of 277) with nonmedical exemptions received at least some vaccines. The most common vaccine not received was varicella (147 [53.1%] of 277 exempt children). The most common reason stated for requesting exemptions (190 [69%] of 277) was concern that the vaccines might cause harm. Parents of exempt children were significantly more likely than parents of vaccinated children to report low perceived vaccine safety and efficacy, a low level of trust in the government, and low perceived susceptibility to and severity of vaccine-preventable diseases. Parents of exempt children were significantly less likely to report confidence in medical, public health, and government sources for vaccine information and were more likely to report confidence in alternative medicine professionals than parents of vaccinated children.
  
  
  CONCLUSIONS
  Continued efforts must be made to educate parents about the utility and safety of vaccines, especially parents requesting nonmedical exemptions to school immunization requirements.
authors.affiliation: Institute for Vaccine Safety, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Rm. E5543, Baltimore, MD 21205, USA. dsalmon@jhsph.edu
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Salmon
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Moulton
authors.forename: Saad B
authors.initials: SB
authors.lastname: Omer
authors.forename: M Patricia
authors.initials: MP
authors.lastname: DeHart
authors.forename: Shannon
authors.initials: S
authors.lastname: Stokley
authors.forename: Neal A
authors.initials: NA
authors.lastname: Halsey
mesh_terms: D000328:Adult; D001294:Attitude to Health; D016022:Case-Control Studies; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D033282:Parental Consent / Q000523:psychology* / Q000706:statistics & numerical data; D010290:Parents / Q000523:psychology*; D045808:Refusal to Participate / Q000523:psychology* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014481:United States; D014611:Vaccination / Q000009:adverse effects / Q000523:psychology*