Belief About Mandatory School Vaccinations and Vaccination Refusal Among Ohio Appalachian Parents: Do Demographic and Religious Factors, General Health, and Political Affiliation Play a Role?

Abstract

Purpose:

To examine how demographic, general health, religious, and political characteristics influenced beliefs about mandatory school vaccinations and history of vaccination refusal for children among Ohio Appalachian parents.

Methods:

In 2013 and 2014, baseline data were obtained from parents (n = 337) of girls aged 9–17 from 12 counties in rural Ohio Appalachia enrolled in the Community Awareness, Resources and Education (CARE II) Project. Multivariate logistic regression models were used to identify correlates of parental beliefs about mandatory school vaccinations and history of refusing a doctor-recommended vaccine for their child(ren).

Results:

About 47% of parents agreed that parents should have the right to refuse mandatory school vaccinations for their child(ren). Participants who reported their political affiliation as Republican (OR = 2.45, 95% CI: 1.28–4.66) or Independent (OR = 3.31, 95% CI: 1.70–6.44) were more likely to agree that parents should have the right to refuse school-mandated vaccinations than parents who reported their political affiliation as Democrat. Approximately 39% of parents reported ever refusing a vaccine for their child(ren). Participants who were female (OR = 3.90, 95% CI: 1.04–14.58) and believed that parents should have the right to refuse mandatory school vaccinations (OR = 3.27, 95% CI: 1.90–5.62) were more likely to report ever refusing a vaccine for their child(ren).

Conclusion:

The study findings provide information to better understand factors related to vaccination refusal among parents in Appalachia Ohio that can be used to design interventions to improve vaccination uptake.

According to current recommendations by the Advisory Committee on Immunization Practices, adolescents should receive the tetanus–diphtheria toxoid–acellular pertussis vaccine (Tdap), meningococcal vaccine (Men-ACWY), and human papillomavirus (HPV) vaccine at 11–12 years old, and an influenza vaccine every year.¹ Despite their importance, immunization rates for adolescent vaccines lag behind those of childhood vaccines.² While Healthy People 2020 vaccination targets are at 80% for ≥1 Tdap dose and ≥1 MenACWY dose for adolescents aged 13–17 years, overall, vaccination coverage in the United States in 2014 was 87.6% for ≥1 Tdap dose and 79.3% for ≥1 MenACWY dose for adolescents aged 13–17 years. The lowest coverage was observed for HPV vaccination, where 39.7% of females and 21.6% of males aged 13–17 years completed the 3-dose series of the HPV vaccine.²

There are limited reports of the prevalence of vaccination refusal for a child among parents of adolescents. A 2013 study by Gilkey et al³ found 8% of parents from North Carolina refused or delayed a vaccine for their adolescent child(ren). Among those with a history of refusal, parents most commonly reported refusing influenza (26%) and HPV (16%) vaccines for their adolescent child(ren). In a 2016 study, Gilkey et al⁴ found that 24% of a national sample of parents refused any vaccine for their child(ren), with the prevalence of vaccine-specific refusal being 21% for the HPV vaccine (girls only), 5% for the meningococcal vaccine, and 2% for the Tdap vaccine.

Parents do not vaccinate their adolescent children for several reasons including religious beliefs, poor knowledge about the vaccine, and concerns about vaccine safety, necessity, and effectiveness.^5–8 Parental beliefs about vaccinations, including trust in government and opposition to vaccination mandates, have been found to influence parental vaccination decisions for their children (eg, seeking nonmedical exemptions, vaccination refusals).^6,9,10

To help counter these beliefs and improve risk communication about vaccines, there is a need for additional research on the demographic and social determinants of parental vaccination refusal.^11,12 Previous research has found that demographic factors were associated with vaccination refusal but with mixed results.^6,13 Some studies have reported that parents who refused vaccines for their children tended to be white, college-educated, and had higher incomes.^9,14,15 In contrast, living in health professional shortage areas and low socioeconomic areas, a lack of health insurance, problems accessing an immunization clinic, and inadequate support from an immunization clinic are also predictors of parental vaccination refusal for their children.^16,17 Previous studies have also found that other social factors (eg, religious and political affiliation) have been found to influence beliefs about mandatory school vaccinations and vaccination refusal.^6,9,18–20

While there is some conflict over school mandates for vaccination, these mandates may help increase adolescent vaccine coverage, as well as decrease parental refusal to vaccinate their child(ren). Bugenske et al²¹ found that compared to states with no requirements, states that had school vaccination requirements had higher adolescent vaccination rates. Previous studies have found that parents who are non-white, of lower socioeconomic status, and have a larger household size are more likely to oppose mandatory school vaccinations for their child(ren).^6,22 Given the multiple factors that influence vaccination uptake, more research is needed to better understand the social and demographic factors that play a role in opposition to mandatory school vaccinations and refusal to vaccinate a child among parents.

Additional research in vaccination beliefs and refusal is needed among underserved areas of the United States. One area, Ohio Appalachia, a 32-county area, is characterized by lower income, higher prevalence of unemployment, lower level of educational attainment, and numerous health disparities than the United States as a whole.^23–25 Research on vaccination beliefs, refusal, and uptake among the Ohio Appalachian population has primarily focused on HPV vaccination due to the higher cervical cancer incidence within that area compared to non-Appalachian regions of the United States.^25–27 HPV vaccine uptake is low in the United States, compared to other adolescent vaccinations, and this is no exception within Ohio Appalachia.²⁶

Previous research has found lower rates of adolescent vaccinations in rural areas compared to other populations. Vielot et al²⁸ found that rural adolescents were less likely to receive each of the recommended adolescent vaccinations than their urban counterparts in all geographical regions including Appalachia. Reasons for lower vaccination rates in Appalachia and rural areas of the United States are varied and may include socioeconomic status of the area, geographic isolation, fewer medical providers, and a physical environment (eg, unpaved roads) that may make it difficult to adhere to a vaccination schedule.^29–32 Another reason for lower vaccination rates may be the perceptions and attitudes toward vaccinations within this population. For example, Katz et al³⁵ found that Appalachian parents reported government intrusion (vaccine mandates), religiosity, and conservative communities as factors influencing their attitudes and beliefs on HPV vaccines. Another study by Cohen and Head³¹ found rural Appalachian parents’ distrust in the government and lack of knowledge about vaccines as issues regarding adolescent vaccinations (particularly voluntary ones). Furthermore, rural parental beliefs and attitudes regarding adolescent vaccinations were found to be associated with the timely completion of vaccinations.³² However, these limited studies did not take a comprehensive approach to explore the multiple parental factors associated with their vaccine beliefs and refusal for their adolescent child(ren). Thus, this study sought to examine how demographic, general health, religious, and political affiliation are associated with beliefs about mandatory school vaccination and history of vaccination refusal for children among rural Ohio Appalachian parents.

Methods

Study Design

This study used data collected as part of a project of the Ohio State University Center for Population Health and Health Disparities (CPHHD), Community Awareness, Resources and Education (CARE II). This project, also known as the Parents in Appalachia Receive Education Needed for Teens (PARENT) Project, was designed to develop and evaluate a multilevel intervention to increase HPV vaccination rates among young girls and adolescent females (ages 9–17) living in rural Ohio Appalachia. Results of the intervention are reported elsewhere,²⁶ and this paper reports baseline survey data that were collected prior to participants receiving the intervention.

Recruitment

Names of residents in each of the 12 participating counties were randomly selected using a commercial survey company. A master list was first created consisting of all households from the 12 rural counties that had at least 1 female resident aged 9 to 17 years old. A random sample of households was drawn for each county and the names and addresses were given to project staff, who then mailed a recruitment letter and informational sheet introducing the study to the selected households. Rurality was determined by county and ZIP code information of the selected households, operationalized by the rural-urban classifications designated by the Office of Rural Health Policy and the Rural-Urban Commuting Area codes of 4 and above.

At least 5 business days after the letters were mailed, trained interviewers began to contact potential participants by phone. Once a household was reached, the interviewer explained the study and asked to speak to the parent who was the most involved in making health decisions for their daughter. Parents were eligible if they: (1) were 18 years of age and older; (2) were able to speak, read, and write English; (3) were a resident of one of the participating 12 rural Ohio Appalachian counties; (4) were a parent or a legal guardian of a young girl (aged 9 to 17 years; if a parent had more than one daughter, they were asked questions about their eldest daughter); and (5) did not have a child who had received the HPV vaccine. During the initial phone call, the study was described, questions were answered, informed consent was obtained, and the baseline survey was administered.

Interviews were conducted between February 2013 and March 2014. Out of the 4,798 recruitment letters sent to households, 2,168 households were unable to be contacted, 9 parents were deceased, 1,599 were ineligible, 685 refused, and 337 were eligible, consented, and completed the baseline survey.²⁶ The overall cooperate rate was 33.0% (337 of 1,022 eligible parents). Participants received a $10 Wal-Mart gift card after completing the survey. The study was approved by the Institutional Review Board of The Ohio State University.

Measures

Beliefs about the Right to Refuse Mandatory School Vaccinations

To assess beliefs about mandatory school vaccinations, participants were asked to respond to the statement, “Parents should have the right to refuse vaccines that are required for school for any reason.” Responses for this item were measured on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree). Responses were dichotomized into yes (strongly agree, agree, slightly agree) and no (strongly disagree, disagree, slightly disagree, not sure).

History of Vaccine Refusal

Participants were asked (yes/no), “Have you ever refused a vaccine for your child(ren) that a doctor recommended?”

Religious Identity, Religiosity, Religious Attendance, and Place of Worship

Participants were asked, “With what religious family, if any, do you most closely identify?” Responses included all Christian denominational families, nondenominational Christian, no religion, and other. Participants were also asked about their religiosity: “How religious do you consider yourself to be?” Response options included “not at all religious,” “not too religious,” “somewhat religious,” and “very religious.” Participants were asked about their frequency of attendance in religious services: “How of-ten do you attend religious services at a church, mosque, synagogue, or other place of worship?” Response options included “never,” “less than once a year,” “once or twice a year,” “several times a year,” “once a month,” “2–3 times a month,” “about weekly,” “weekly,” and “several times a week.” Last, participants were asked: “By your best guess, how would your current place of worship feel about vaccines?” Response options included “forbids,” “strongly discourages,” “somewhat discourages,” “encourages,” “isn’t concerned,” and “don’t know.” Responses were divided into “forbids/strongly discourages/somewhat discourages” and “encourages/isn’t concerned.” The response, “don’t know,” for this item was excluded from analyses.

Political Affiliation

Participants were asked: “Do you think of yourself as Republican, Democrat, or Independent?” Response options were: “strong Republican,” “moderate Republican,” “leaning Republican,” “Independent,” “leaning Democrat,” “moderate Democrat,” “strong Democrat,” and “other.” Responses were divided into Republican (“strong Republican,” “moderate Republican,” “leaning Republican”), Independent, and Democrat (“leaning Democrat,” “moderate Democrat,” “strong Democrat”). The response “other” for this item was excluded from analyses.

Demographic and Health Characteristics

Participants provided information about their age, gender, race, ethnicity, marital status, education, annual household income, employment status, current health insurance, and smoking status. Annual household income was obtained in ranges of $5,000 for incomes below $20,000 and in ranges of $10,000 for incomes between $20,000 and $100,000 and included a final income category of $100,000 or more. In statistical analyses, we dichotomized income as below $50,000 versus $50,000 or above, or at or below the middle income category versus above the middle income category. General health status (36-item Short Form Health Survey, SF-36³³) was also measured (0 = worst to 100 = best).

Analyses

Univariate logistic regression models were used to examine associations with each potential correlate for 2 outcomes: parental beliefs about mandatory school vaccinations and history of refusing vaccination for their children. Backward elimination was then performed starting with all variables significant at the 0.25 level in the univariate analyses; elimination proceeded until all remaining variables were significant at the 0.1 level. Two-way interactions were explored between variables remaining in the final model and all analyses were conducted using SAS v9.3 (SAS Institute, Cary, North Carolina).

Results

Sample Characteristics

Baseline characteristics of the 337 parents are shown in Table 1. The mean age of the sample was 43.5 years, and the majority of the participants were non-Hispanic white (n = 329, 97.6%) and female (n 311, 92.3%). Most participants reported being married or living as married (n = 301, 89.3%), having more than a high school education (n = 240, 71.2%), being employed less than full-time (n = 188, 56.0%), having a household income >$50,000/year (n = 141, 58.8%), and having current health insurance (n = 306, 91.1%).

Table 1.

Demographic and Health Characteristics of Parents (N = 337)^a

Variable	Total (N = 337) n (%)
Age (mean ± SD)	43.5 ± 6.7
Gender
Male	26 (7.7)
Female	311 (92.3)
Race/ethnicity
Non-Hispanic white	329 (97.6)
Other	8 (2.4)
Education
≤High school	97 (28.8)
>High school	240(71.2)
Marital status
Married/living as married	301 (89.3)
Divorced/separated/widowed/single	36 (10.7)
Annual household income
>$50,000	141 (58.8)
≤$50,000	99 (41.2)
Employment
Full-time	148 (44.0)
Part-time/disabled/unemployed/retired	188 (56.0)
Current health insurance
Yes	306(91.1)
No	30 (8.9)
Smoking status
Never	201 (66.3)
Former/current	102 (33.7)
General health score (mean ± SD)	65.6 ± 22.7

^aTotals may not sum to stated sample size due to missing data.

Correlates of Parental Beliefs About Refusal of Mandatory School Vaccinations

Of the 336 participants (one participant had missing data for this outcome), 158 (47.0%) agreed with the statement that parents should have the right to refuse vaccines that are required for schools for any reason. In univariate analyses, those who were employed full-time were significantly less likely to agree that a parent had the right to refuse mandatory school vaccinations for their child(ren) than participants who did not work full-time (OR = 0.63, 95% CI: 0.41–0.98). Also, participants who identified themselves as an Independent (OR = 3.31, 95% CI: 1.70–6.44) or Republican (OR = 2.45, 95% CI: 1.28–4.66) were significantly more likely to agree that a parent had the right to refuse mandatory school vaccinations for their child(ren) than participants who identified themselves as Democrats (Table 2). At the conclusion of backward elimination, only political affiliation was associated with a parent’s belief in the right to refuse mandatory school vaccinations.

Table 2.

Demographic, Health, Religious, and Political Affiliation Correlates of Parental Belief on Mandatory School Vaccinations

	“Parents Should Have the Right to Refuse Vaccines that are Required for School for any Reason”
Variable	Yes (n = 158) n (%)	No (n = 178) n (%)	Univariate OR (95% CI)a
Age (mean ± SD)	43.5 ± 6.9	43.5 ± 6.5	1.00 (0.97–1.03)b
Gender
Female	143 (46.1)	167 (53.9)	0.63 (0.28–1.41)
Male	15 (57.7)	11 (42.3)	1.00 (referent)
Race/ethnicity
Non-Hispanic white	151 (46.0)	177 (54.0)	n/a
Other	7 (87.5)	1 (12.5)
Education
≤High school	50 (51.6)	47 (48.4)	1.29 (0.80–2.07)
>High school	108 (45.2)	131 (54.8)	1.00 (referent)
Marital status
Married/living as married	142 (48.3)	152 (51.7)	1.52 (0.78–2.95)
Divorced/separated/widowed/single	16 (38.1)	26 (61.9)	1.00 (referent)
Annual household income
>$50,000	67 (47.5)	74 (52.5)	1.18 (0.70–1.98)
≤$50,000	43 (43.4)	56 (56.6)	1.00 (referent)
Employment
Full-time	60 (40.8)	87 (59.2)	0.63 (0.41–0.98)*
Part-time/disabled/unemployed/retired	98 (52.1)	90 (47.9)	1.00 (referent)
Current health insurance
Yes	143 (46.9)	162 (53.1)	1.01 (0.48–2.14)
No	14 (46.7)	16 (53.3)	1.00 (referent)
General health score	67.8 ± 21.1	64.0 ± 23.7	1.01 (0.99–1.02)c
Smoking status
Never	93 (46.5)	107 (53.5)	1.15(0.71–1.85)
Former/current	44 (43.1)	58 (56.9)	1.00 (referent)
Religious family
No religion	15 (55.6)	12 (44.4)	1.58 (0.71–3.50)
Religion	121 (44.2)	153 (55.8)	1.00 (referent)
Religiosity
Very religious	65 (46.8)	74 (53.2)	1.10(0.70–1.74)
Somewhat/not too/ not at all religious	71 (44.4)	89 (55.6)	1.00 (referent)
Religious attendance
≥Weekly	72 (49.3)	74 (50.7)	1.58 (0.99–2.53)
<Weekly	53 (38.1)	86 (61.9)	1.00 (referent)
Place of worship’s opinion on vaccines
Encourages/isn’t concerned	100 (43.5)	130 (56.5)	n/a
Forbids/strongly discourages/somewhat discourages	4 (80.0)	1 (20.0)
Political affiliation
Republican	49 (45.8)	58 (54.2)	2.45 (1.28–4.66)***
Independent	48 (53.3)	42 (46.7)	3.31 (1.70–6.44)***
Democrat	19 (25.7)	55 (74.3)	1.00 (referent)

^aOR and 95% CI not reported if there was an expected cell count less than 5.

^bOR corresponding to 1-year increase.

^cOR corresponding to 1-unit increase.

Totals may not sum to stated sample size due to missing data.

^*P < .05;

^***P < .001.

Correlates of Ever Refusing a Vaccine

Of the 337 participants, 130 (38.6%) reported ever refusing a vaccine for their child(ren) that a doctor had recommended. In univariate analyses, participants who were female (OR = 2.82, 95% CI: 1.04–7.68), very religious (OR = 1.79, 95% CI: 1.11–2.87), attended religious services at least weekly or more (OR = 1.65, 95% CI: 1.02–2.67), or agreed that a parent had the right to refuse vaccines for their child(ren) that are required for schools for any reason (OR = 2.49, 95% CI: 1.59–3.91) were significantly more likely to have ever refused vaccination for their child(ren) (Table 3). In the multivariable model built using backward elimination, participants who were female (OR = 3.90, 95% CI: 1.04–14.58) and agreed that a parent had the right to refuse vaccines for their child(ren) that are required for schools for any reason (OR = 3.27, 95% CI: 1.90–5.62) were significantly more likely to have ever refused a vaccine for their child(ren).

Table 3.

Demographic, Health, Religious, and Political Affiliation Correlates of Parents’ History of Vaccination Refusal for Their Child(ren)

	Ever Refused a Vaccine for Their Children
Variable	Yes (n = 130) n (%)	No (n = 207) n (%)	Univariate OR (95% CI)a	Multivariate OR (95% CI)a
Age (mean ± SD)	42.9 ± 6.5	43.9 ± 6.8	0.98 (0.95–1.01)b
Gender
Female	125 (40.2)	186 (59.8)	2.82 (1.04–7.68)*	3.90(1.04–14.58)*
Male	5 (19.2)	21 (80.8)	1.00 (referent)	1.00 (referent)
Race/ethnicity
Non-Hispanic white	125 (38.0)	204 (62.0)	n/a
Other	5 (63.0)	3 (37.0)
Education
≤High school	39 (40.2)	58 (59.8)	1.10(0.68–1.78)
>High school	91 (37.9)	149 (62.1)	1.00 (referent)
Marital status
Married/living as married	114 (38.6)	181 (61.4)	1.02 (0.53–1.99)
Divorced/separated/widowed/single	16 (38.1)	26 (61.9)	1.00 (referent)
Annual household income
≥$50,000	52 (36.9)	89 (63.1)	0.98 (0.58–1.67)
<$50,000	37 (37.4)	62 (62.6)	1.00 (referent)
Employment
Full-time	51 (34.5)	97 (65.5)	0.38 (0.88–2.15)
Part-time/disabled/unemployed/retired	79 (42.0)	109 (58.0)	1.00 (referent)
Current health insurance
Yes	120 (39.2)	186 (60.8)	1.51 (0.67–3.40)
No	9 (30.0)	21 (70.0)	1.00 (referent)
General health score	65.9 ± 23.1	65.4 ± 22.5	1.00 (0.99–1.01)c
Smoking status
Never	77 (38.3)	124 (61.7)	1.09(0.67–1.79)
Former/current	37 (36.3)	65 (63.7)	1.00 (referent)
Religious identity
No religion	11 (40.7)	16 (59.3)	1.15 (0.51–2.57)
Religion	103 (37.5)	172 (62.5)	1.00 (referent)
Religiosity
Very religious	62 (44.6)	77 (55.4)	1.79(1.11–2.87)*
Somewhat/not too/not at all religious	50 (31.1)	111 (68.9)	1.00 (referent)
Religious attendance
≥Weekly	64 (43.8)	82 (56.2)	1.65 (1.02–2.67)*
<Weekly	45 (32.1)	95 (67.9)	1.00 (referent)
Place of worship’s opinion on vaccines
Encourages/isn’t concerned	85 (37.0)	145 (63.0)	n/a
Forbids/strongly discourages/somewhat discourages	2 (40.0)	3 (60.0)
Political affiliation
Republican	46 (43.0)	61 (57.0)	1.82 (0.97–3.40)
Independent	34 (37.8)	56 (62.2)	1.46 (0.76–2.82)
Democrat	22 (29.3)	53 (70.7)	1.00 (referent)
Belief about the right to refuse mandatory school vaccinations
Yes	79 (50.0)	79 (50.0)	2.49 (1.59–3.91)***	3.27 (1.90–5.62)***
No	51 (28.7)	127 (71.3)	1.00 (referent)	1.00 (referent)

^aOR and 95% CI not reported if there was an expected cell count less than 5.

^bOR corresponding to 1-year increase.

^cOR corresponding to 1-unit increase.

Totals may not sum to stated sample size due to missing data.

^*P < .05;

^***P < .001.

Discussion

This study assessed the demographic, general health, religious, and political affiliation correlates related to beliefs about the right to refuse mandatory school vaccinations for a child and history of vaccination refusal for a child among Ohio Appalachian parents. Previous studies examining social and demographic factors associated with parental beliefs about mandatory school vaccinations and vaccination refusal for a child have found mixed results.^6,13 Therefore, this study sought to provide additional insight into the social and demographic correlates related to beliefs about mandatory school vaccinations and vaccination refusal for a child from the parent perspective.

Approximately 47% of participants agreed with the statement that parents should have the right to refuse vaccines that are required for school for any reason. This percentage is higher than that reported by Kennedy and associates where among over 1,500 parents who participated in a national survey, only 12% stated that they were opposed to mandatory school vaccinations.⁶ Our high percentage of agreement with the parental right to refuse mandatory school vaccinations for a child compared to the Kennedy and associates study may be due to the political and media climate concerning proposed state-mandated HPV vaccinations (eg, Ohio House Bill 81)³⁴ prior to and during the data collection period. Another reason for the high percentage of agreement regarding the parental right to refuse mandatory school vaccinations for a child may be factors associated with HPV vaccine acceptability identified by Ohio Appalachian parents including lack of trust in the medical community and “outsiders,” government intrusion in parental affairs, cultural attitudes, and perceived barriers to vaccination.³⁵

Our analyses found that parents who reported political affiliations of Independent or Republican were more likely to agree with the belief that parents should have the right to refuse mandatory school vaccinations for their child(ren) compared to the political affiliation of Democrat. Our findings are similar to previous research^18,36 which found that certain political affiliations were associated with different vaccination outcomes, with Republicans and Independents less willing than Democrats to receive the H1N1 vaccine for themselves and their children^18,36 as well as HPV vaccine for their adolescent daughters.^19,36 Our findings support the argument that vaccination mandates and refusal have become a political issue.^37–40 Last, agreement with the statement that parents should have the right to refuse mandatory school vaccinations for their child(ren) was associated with vaccination refusal for their child(ren). This finding is consistently supported in the literature^{4,5,7,9,10,18,41} in which individual perceptions (eg, opposition to mandatory vaccinations) influence the likelihood of actions (eg, vaccination refusal).

In this study, 38.6% of participants reported refusing a vaccination for their child(ren) that a doctor recommended. This percentage is higher than that reported by Gilkey et al,⁴ which found 24% of parents had ever refused a vaccine for their child. Another study by Gilkey and associates examined the child’s age at the time of parent vaccination refusal and reported forgone vaccination was more common for young children than for teenagers (16% vs 8%).³ This study and previous studies^3,4 demonstrate that a considerable percentage of parents may be unwilling to vaccinate their child(ren), putting their children and communities at risk of disease outbreaks. Because health care providers are the most common source of information about vaccinations,⁴² physicians are in a position to convey to parents the importance of vaccines to the health of child(ren) and reduce parental vaccination refusal for their child(ren).

Multivariate analyses found that parents who were female were more likely to have refused a vaccine for their child(ren). Previous research found similar results, identifying mothers as more likely to refuse a vaccine for their child(ren) than fathers.³ Also, Rickert et al⁸ reported that mothers were more likely to have negative attitudes regarding vaccination than fathers. The majority of the participants in this study were women, who at recruitment reported that they were the most involved in making health decisions for their daughter. Future research should consider the potential influence of gender on parental immunization beliefs and behavior.

Analyses found that the univariate associations between religiosity and history of vaccination refusal for a child were attenuated once beliefs about school mandates were included in the multivariate model. A possible explanation for this finding is that religious beliefs may affect a parent’s beliefs on whether or not someone has the right to refuse school-mandated vaccinations which, in turn, results in vaccination refusal for their children. Longitudinal research is needed to more fully characterize the associations of parental religious beliefs, beliefs about school-mandated vaccinations, and vaccination refusal for a child from infancy through adolescence.

Parental beliefs about mandatory school vaccinations and refusal of vaccination for a child may be associated with several parental social and demographic factors.^{6,8,9,18–20} To maintain the public health benefit of childhood and adolescent immunizations, continued efforts must be made to educate the public about the need for childhood and adolescent immunizations. There is increasing rhetoric around “patient choice,” and public health agendas have gradually shifted to accommodate the right to refuse vaccination, focusing on making an individual, informed choice.⁴³ Since physicians have an influence on parental health care decisions,⁴⁴ it is important they educate parents and anticipate concerns that parents may have about vaccination in order to minimize refusal and increase vaccination rates.

Strengths/Limitations

Our study has several important strengths including the sample of parents who were from 12 Appalachian Ohio counties, as determined in collaboration with community cancer coalition members, increasing generalizability of the results to many areas of Ohio Appalachia. The study also examined possible correlates of parental beliefs about mandatory school vaccinations and history of vaccination refusal for their child(ren), an area that is not well studied, especially in an Appalachian population. In addition to the cross-sectional nature of the study, there were some limitations. First, the data are based on self-report, and we do not know the specific vaccine(s) the parents had refused for their child(ren). However, given our focus of examining vaccination refusal in general, the data are sufficient. Second, participants were not asked the reason why they had refused a vaccine for their child(ren). Last, most participants were female, white, and living in Ohio Appalachia, and they may not represent the totality of the residents living in these counties. The findings of this study are based on a white, largely rural, North Central Appalachian population and transferability to other groups in the Appalachian region (ie, Northern, Southern, Southern Central, Central) is likely limited. Furthermore, the education and income levels of participants may not reflect the socioeconomic status of the Ohio Appalachian region as a whole. Due to this limited generalizability, more research is warranted to examine the multiple factors associated with parental beliefs about mandatory school vaccinations and history of vaccination refusal for their child(ren) within an Appalachian population.

Conclusions

This study examined demographic, health, religious, and political affiliation factors associated with beliefs about mandatory school vaccinations and history of vaccination refusal for children among parents residing in Ohio Appalachia. Political affiliation was a significant correlate of parental beliefs about the right to refuse mandatory school vaccinations for their child(ren). Also, parental beliefs about the right to refuse mandatory school vaccinations and gender were significant correlates of vaccination refusal for their child(ren). The study findings provide information to better understand factors related to vaccination refusal among parents in Appalachia Ohio that can be used to design interventions to improve vaccination uptake.