Running head: PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 1

A Study of Parental Resistance to Childhood Vaccination Within the United States Using Data

from the Behavioral Risk Factor Surveillance System (BRFSS)

Allison Culp

Emily Hopkins

Katelyn Thompson

The University of Tennessee at Chattanooga

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 2

ABSTRACT

Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we will investigate

why the national rate for child vaccination coverage in 2015 is relatively low at 72.2%. The

aversion to vaccinations by parents for their children seems to have been on the rise in recent

years though it is of extreme importance to the health of adolescents. Furthermore, we will look

at why there was a serious drop in the percentage of children vaccinated in 2009 at about 44.3%

of children nationally. We will explore what factors are turning parents away from vaccination

and what can be done to increase the number of people vaccinated. Through our research we

hope to show how the percentage of vaccinated individuals benefits the health of our nation or

even of our world.

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 3

INTRODUCTION:

The Behavioral Risk Factor Surveillance System (BRFSS) will be the main source of our data.

The Centers for Disease Control and Prevention (CDC) defines the BRFSS as

“the nation's premier system of health-related telephone surveys that collect state data

about U.S. residents regarding their health-related risk behaviors, chronic health

conditions, and use of preventive services. Established in 1984 with 15 states, BRFSS

now collects data in all 50 states as well as the District of Columbia and three U.S.

territories. BRFSS completes more than 400,000 adult interviews each year, making it the

largest continuously conducted health survey system in the world.”

For this study we will primarily be analyzing the rate of child vaccination coverage

between the years 2007 to 2015 with particular interest in the drop seen in the data collected in

2009. The line chart below shows this sharp decline in vaccination coverage in 2009 and one of

the goals of this paper is to identify the causes for this drop.

Data from the BRFSS

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 4

Additionally, this study is aimed at a discussion that asks why the rate of coverage is only

around 72% though vaccination is vital to the health and safety of an individual. We will also be

using data from the BRFSS about influenza vaccination coverage and related studies because it

offers more insight into why people choose not to vaccinate their children. It is also not a

required vaccination, giving the parents full discretion over whether or not they want to

vaccinate their child, unlike those required for school by law.

LITERATURE REVIEW:

Some previous research has been completed on our topic. One study in particular used

information from the BRFSS to look at the relationship between healthcare access and state-level

vaccination rates across the United States. It was found to have a positive correlation suggesting

the need for wider access to healthcare by making it more financially available and attainable to

communities in need of it (Chiu, A. P., Dushoff, J., Yu, D., & He, D. 2017). Without easy access

to health care, people are generally less likely to get the vaccinations that could improve their

quality of life. When referring to accessibility most often this means affordability. In recent years

the prices have skyrocketed not only for consumers, but for health care practices as well, and

many practices have struggled to stock enough vaccines for their regular and walk in patients.

A study in 2008 the American Academy of Family Physicians conducted a survey of

2,000 random practices to find how many provided vaccines on site, how many referred their

patients elsewhere, and how many neither provided the vaccine nor referred the patients

elsewhere. Over 700 questionnaires were completed and submitted. The survey showed that

while a majority of practices can afford to provide most childhood vaccines, there were several

practices that had to refer their patients elsewhere because they could not afford to stock enough
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 5

vaccinations for all of their patients. One half of the practices who refered patients elsewhere

listed concern about payment for vaccines and associated costs as the reason for their referral.

The survey also found that, “Family physicians may be affected more by the costs of newer

vaccines because of the wide age range of patients they serve along with the larger number of

vaccine products that need to be stocked to serve all age-groups.” (Campos-Outcalt, D., Jeffcott-

Pera, M., Carter-Smith, P., Schoof, B. K., & Young, H. F. (2010, November 8). This

demonstrated that one very important contribution to the decreased childhood vaccination rate in

2009 was the difficulty family practices had maintaining their vaccination stock.

Another study analyzed the rate of vaccination among high-risk individuals using data

from the 2012-2013 BRFSS data. These high-risk individuals included those with pulmonary

disease, diabetes, or heart disease, which can often lower immunity to influenza and if infected

may cause serious and potentially deadly consequences. It was found that approximately 45.4%

of adults aged 18-64 years old with a high-risk condition received an influenza vaccination in the

2012-2013 period (O’Halloran, A. C., Lu, P., Williams, W. W., Bridges, C. B., & Singleton, J.

A. 2016). This is slightly higher than the percentage of vaccinated no-risk individuals. While this

is an encouraging number, it is not ideal and suggests that something must be done to raise this

rate of vaccination among people that are in most need of it. It again makes one consider the

factors that deter an individual from receiving a vaccine: socioeconomic status, availability of

health care, religious objections, and lack of information about the benefits are just a few

examples.

To look further into the reasons why parents chose not to vaccinate their children, one

research team studied the influenza vaccination rate and reasons for vaccination rate in children

with cardiac disease. Out of 186 children with cardiac disease only 36% were vaccinated for the
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 6

previous flu season (Livni, G., Wainstein, A., Birk, E., Chodick, G., & Levy, I. 2017). This was

due to the beliefs and conceptions parents had about the vaccine and whether or not it was safe

and effective. To raise the number of vaccinated children, steps must be taken to inform parents

about the benefits of the vaccination and to make it accessible and affordable. The

misconceptions about vaccinations and particularly the effectiveness of the influenza vaccination

seem to deter many parents away from it. Many people hear about the low rate of effectiveness

of the influenza vaccine every year, and, because the virus tends to change so quickly, it is

difficult to predict and mass produce the correct strain. They think “Vaccines don't really work

anyway—look at last year's flu vaccine.” However, the majority of vaccines are 85-95%

effective at preventing harmful diseases. According to the CDC the flu shot reduces the risk of

contracting the flu by 40-60%. Even though the flu shot might not be as effective as other

vaccines, it still prevents hundreds of thousands of cases of the flu every year. “The bottom line

is that vaccines have meant far fewer deaths, hospitalizations, and disabilities than at any other

time in history.” (Haelle, 2017)

One of the factors that may deter parents from having their children vaccinated it the cost.

Affordable health care has been a leading issue in the United States for many years and is a

major concern for parents in the nation due to the required vaccinations for their children to

attend public school. Before discussing the costs of these vaccinations, it is important to first

identify why these requirements are put in place. These are not government-imposed stipulations

– the individual states choose and enforce that students are vaccinated for certain diseases. This

is to prevent serious outbreak of major diseases that could be detrimental to the community. The

CDC identifies that for students in grades other than kindergarten in Tennessee, the following

vaccines are required: Hepatitis B (HBV), Diphtheria-Tetanus-Pertussis (DTaP), Poliomyelitis

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 7

(IPV), Measles, Mumps, and Rubella, and Varicella. In an attempt to determine if there was a

significant increase in the price of these required vaccines in 2009, the total cost of the required

vaccinations for children in grades other that kindergarten was summed for 2008, 2009, and

2017. This allows one to identify if there was a significant change between 2008 and 2009 that

may have contributed to the 2009 drop in vaccination coverage and how the cost has changed

today. All of this information was acquired from the CDC and is the private sector cost to

maintain consistency. The goal in this test was to see if the prices for required vaccinations could

reflect upon other non-required vaccinations. That is, if the cost of required vaccines was

extremely high in 2009, this may be a cause for the steep decline in overall child vaccination

coverage that can be seen in the BRFSS data.

Row Labels Sum of 2008 Sum of 2009 Sum of 2017

DTaP 22.04 23.03 29.2

HEP B 23.2 23.2 23.2

IPV 26.34 27.62 31.06

MMR 46.54 48.31 67.03

VARICELLA 77.51 64.53 115.16

Grand Total 195.63 186.69 265.65

From this data, it shows that there was not a significant increase in the overall cost of

required vaccinations between 2008 and 2009 – in fact the total slightly decreased. This,

however, is not to say that the cost of other vaccinations did not increase. It is also important to

note that many other factors at this time contributed to the fall in childhood vaccination coverage

and therefore could not be identified by a single aspect. Additionally, these are required for
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 8

children to attend school, unless the parents claim religious or medical exemption in which case

the child is subject to being “prohibited from attending classes if there is an outbreak of a

vaccine-preventable disease at their school or in their community” (Centers for Disease Control

and Prevention 2017). The child vaccination coverage data from the BRFSS is only for children

19 to 35 months, at which time it is still optional to vaccinate. Nonetheless this test did offer

alternative insight: the total cost for Tennessee-required vaccinations has increased dramatically

from 2009 to 2017. This identifies an issue with affordable health care and the need to make

these required vaccinations more readily available not only to protect the child, but to protect the

entire community in which they live.

Health care is extremely expensive in the United States. Since the U.S does not have

socialized health care like many other major countries, the citizens are left to cover the cost of

their health care. There is a large group of people that cannot afford the health insurance they

need nor the health care they need, to guarantee a healthy life. If an individual does not have

health insurance, and they are not covered by Medicare or Medicaid, they have to pay for their

health care needs out of pocket. Vaccines are costly. For example, if an individual goes to

Walgreens to get the Gardasil vaccine they will pay $249.99 for the first dose and $214.99 for

the next two doses. If someone can’t afford health insurance then they most likely don’t have the

money to pay out of pocket for the vaccines they need. At that point vaccines that can protect

individuals from harmful diseases become a privilege. The cost of vaccines is definitely a factor

that causes people to not vaccinate.

With the passing of the Affordable Care Act, many health insurance companies were

required to provide coverage for a majority of vaccines. However, there were also many

insurance companies that were “grandfathered” with the enactment of ACA. This means that if a
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 9

health insurance company has not changed to drastically cut benefits or increase the cost for plan

holders, has notified the plan holders that they now had a grandfathered plan, and they have

continuously covered at least one person since March 23, 2010 then that company is not required

to provide full coverage for preventative care. Families and individuals now have to handle the

cost of vaccination as well as the increasing cost of simply having a health care plan. In 2008 the

average insurance premium for a family insurance plan cost $369 and the deductible cost $2,760.

By early 2017 the average cost for a family premium was $1,021 and the deductible was $8,352

(How Much Does Obamacare Cost in 2017? (2017, January 23). The increase in prices as well

as the potential lack of coverage from the grandfathered insurance plans may have played a

significant role in the drop in vaccination rates in 2009.

Now, the country is faced with the decision whether it is against someone’s rights to

force them to vaccinate. Should the government have the power to force its citizens to get

vaccinated or should it remain a personal choice? As mentioned, there are already vaccination

requirements that must be satisfied to attend certain schools, daycares, etc. that vary from state to

state. “They [the required vaccines] protect the small percentage of children who may have a

compromised immune system or for whom vaccines may not work.” (Haelle, 2017). Every state

allows an exception for children who have medical reasons for not vaccinating. Most states allow

a personal exemption (except for California, Mississippi, and West Virginia.) Having vaccine

requirements is not about forcing someone to do something against their will. It’s about creating

a healthy and safe environment for everyone. "The overwhelming picture," summarizes Dr.

Halsey, "is that vaccines are beneficial and keep children healthy. And that's exactly what all of

us want—parents, health-care providers, and the people who make the vaccines.” (Haelle, 2017).
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 10

People are also scared about the potential risks that are involved from vaccinations. They

question whether the risks outweigh the benefits. In 1998, there was a fraudulent paper published

called the Lancet that linked the MMR vaccine (combined measles, mumps and rubella vaccine)

to colitis and autism spectrum disorders. This led to lower vaccination rates and higher rates of

measles and mumps. The CDC, the Institute of Medicine, the American Academy of Pediatrics,

and many other big name researchers reviewed the evidence and found no link between the

vaccination and autism. It was later found out that the author of this paper had many conflicts of

interest. Parts of the Lancet were withdrawn in 2004. By 2010 the paper was completely

retracted and deemed fraudulent. “Wakefield's paper was described as "perhaps, the most

damaging medical hoax of the last 100 years"”. (MMR vaccine controversy, 2017). This

fraudulent paper was responsible for many deaths and permanent illnesses due to people not

vaccinating in the fear their child would develop autism.

According to the BRFSS in 2009 there was a huge drop in childhood vaccinations. In

2008, the national average for vaccinated children was 68.4%. In 2009 it dropped to 44.3%. It is

unknown why the there was such a significant drop. It could have been influenced by the autism

scare or the recession happening during that time. However, what is known is that having a lower

rate of vaccinations caused major health problems. According to NBC news, “In 2006 and 2009,

there were outbreaks of mumps that sickened thousands in the Midwest and East Coast,

respectively.” (Nixon, 2010) In 2008 (year of normal coverage) there were about five hundred

cases of mumps while in 2009 (year of low coverage) there was roughly 2,000. Even though

vaccines are not 100% effective, they do significantly lower the amount of people affected by

various diseases.

METHODOLOGY:
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 11

All of the data that was analyzed below was gathered using the BRFSS and the archives

of vaccine cost from the CDC. Once the data was collected scatter plots were made using Excel

to see the trend lines in the data.

Bivariate regressions were constructed in Excel using the same data that created the

scatter plots. The regression was used to predict the national average of vaccine coverage, the

cost of a vaccine for the CDC, and the cost of a vaccine from a private sector in the year 2025.

For the national average of vaccine coverage the equation y= -1178.0851+(0.6202*X) was used

to predict the national average in 2025. To calculate the prediction 2025 was substituted for X.

The equation used to predict the cost for the CDC cost was y= -576.29+(0.296*X); the equation

used to predict the the cost for the private sector was y= -3439.2879+(1.736*X). For both of the

equations 2025 was substituted for X to predict the costs. After the scatter plots and predictions

were made, conclusions were able to be drawn about the data.

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 12

DATA AND RESULTS:

Below is a scatter plot of the data collected from the BRFSS about the national average of

childhood vaccinations. Even though there is the outlier of 2009, it is clear by the trend line that

the rate of vaccinations in the U.S. is increasing.

If a bivariate regression is conducted using the data from the graph above we can predict that by

2025 77.8% of children will be vaccinated. Although the average will never reach 100% due to

people that are medically unable to vaccinate, it is a good sign that the vaccination rate is

increasing.

The cost of healthcare is on the rise in the U.S and vaccinations are no exception. The

cost of the MMR vaccine was analyzed because it is required for schools by the state of

Tennessee. Below are scatter plots of the cost of this vaccine for the CDC and for private sectors.

The data was gathered from the CDC archived vaccine price lists. If you look at the trend lines

for the scatter plots below it shows an increase in price of the vaccine between 2007 and 2015.
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 13

By using a bivariate regression we can predict by 2025 that the cost for the CDC will rise to

$23.11 and the private sector cost will rise to $75.44. Based off of the trend lines on the cost

scatter plots and the predictions made using the bivariate regression, it is safe to say vaccination

prices will continue to climb unless the government begins to control the price of vaccines. Even
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 14

though the vaccination rate seems to be on the rise, this could be threatened by the increasing

cost of vaccinations.

CONCLUSION & IMPLICATIONS:

It has been recognized in this paper that the cost of health care is a significant factor in

the parents’ decision to vaccinate their child. Ways to reduce the cost include reconstructing the

healthcare system and its flaws to create affordable and accessible health care to everyone in the

United States. While this may be expensive it is arguably worthwhile to prevent major outbreaks

of serious diseases that pose a threat to the safety of everyone in this nation. Other, smaller

improvements include setting up low-cost clinics that provide vaccines such as influenza. As

shown in Pivot Table 1, the cost of required vaccinations has skyrocketed in recent years, which

may deter parents from additional, optional vaccinations because they cannot afford it (especially

if they have multiple children). The mounting cost of simply having health insurance, coupled

with the increasing cost of vaccines, also contributed to the vaccination rate drop in 2009 and

2010. To reiterate, the cost of the average family health insurance premium from 2008 to 2010

increased by $652 and the cost of the deductible increased by $5,592 (How Much Does

Obamacare Cost in 2017, 2017). To aid in this issue, a federally-funded program called The

Vaccines for Children (VCF) has been created. The CDC buys and distributes vaccines to state

health departments and public health agencies to be offered for a reduced cost or for free

(Centers for Disease Control and Prevention 2017). This is particularly helpful to those with

multiple children, those with a healthcare plan that does not cover the cost adequately, and those

who do not have readily available and accessible health care.

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 15

The pieces are still being put together as to why there was a major drop in the national

vaccination rate in 2009 and 2010. Even though there is not statistical evidence to look at

through the articles we have read, it is possible that the autism scare among other factors played

a role in the decreased rates. In 2010, the paper claiming autism and vaccinations were linked

was deemed fraudulent which led to media coverage. Even though the paper was deemed

fraudulent, it still put the idea in people’s heads that vaccinations might cause autism spectrum

disorders. To this day even though there is no proof that autism is caused by vaccinations there

are still many people that believe it is. The increase in media coverage of the topic could play a

part in why parents delayed or refused vaccinations for their children between 2009 and 2010. To

counter these misconceptions about vaccination, the CDC has released a “Parent’s Guide to

Childhood Immunizations”. This booklet provides a simple description of how the immune

system works, how vaccines help the immune system, the risks and benefits of vaccines, and a

summary of childhood vaccine-preventable diseases. It is a great tool for parents because there is

a tendency for patients to feel that doctors are talking over their heads about medical

information. In order to fix this problem there must be a push for physicians to educate parents

on the benefits of vaccines in terms that are easy to understand. This guide is a good start to

better vaccine education which will hopefully increase the national average of vaccine coverage.

To conclude, the rate of child vaccination coverage is still relatively low at 72.2% in

2015 and will only increase with improvements in the healthcare system by making plans more

accessible and affordable and by offering more education about the benefits of vaccinations. The

misconceptions about the efficacy and pathophysiology of vaccinations in addition to the

financial limitations discussed in this paper may be the greatest contributing factors to the fall of

vaccination coverage in 2009. Factoring in those who object to vaccination due to religious or
PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 16

medical reasons, the percentage of people in the United States who are covered will never reach

100%; but for the sake of the health of the nation, it is important to continue working to raise that

percentage and inform the public about the ways in which it will improve their health and their

communities’ quality of life.

PARENTAL RESISTANCE TO CHILDHOOD VACCINATION 17

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