Abstract
Objective
To assess the role of maternal attitudes and other factors associated with infant vaccination status.
Study design
Data on reported vaccination status were analyzed from a nationally representative prospective survey of mothers of 2- to 6-month-old infants. Weighted univariate and multiple logistic regression analyses were conducted. Latent profile analysis of mothers reporting nonimmunized infants identified distinct groups,
Results
Of 3268 mothers, 2820 (weighted 86.2%), 311 (9.1%), and 137 (4.7%), respectively, reported their infant had received all, some, or no recommended vaccinations for age. Younger infants and infants with younger mothers were more likely to have received no vaccinations. Mothers with neutral and negative attitudes toward vaccination were >3 (aOR 3.66, 95% CI 1.80–7.46) and 43 times (aOR 43.23, 95% CI 20.28–92.16), respectively, more likely than mothers with positive attitudes to report their infants had received no vaccinations. Two subgroups of mothers reporting that their infants had received no vaccinations were identified: group A (52.5%) had less than positive attitudes and less than positive subjective norms about vaccination (ie, perceived social pressure from others); group B (47.5%) had positive attitudes and positive subjective norms. GroupAmothers were more likely to be white (76.1% vs 48.3%, P = .002), more educated (43.5% vs 35.4% college or higher, P = .02), and to exclusively breastfeed (74.9% vs. 27.3%, P < .001).
Conclusions
Although access barriers can result in nonvaccination, less than positive maternal attitude toward vaccination was the strongest predictor. Strategies to improve vaccination rates must focus on both improved access and better understanding of factors underlying maternal attitudes.
Childhood vaccination is one of the most successful public health interventions of the 20th century.1 Ironically, by eliminating diseases, vaccines may have shifted some toward a decision not to vaccinate. Previous studies have reported factors impacting the decision to vaccinate2–4 and parenting behaviors correlated with the decision not to vaccinate.4,5 The Theory of Planned Behavior (TPB) posits that one’s attitudes toward a behavior, perceived social pressure from valued others (subjective norms), and perceptions about one’s own control over the behavior impact on intention and ultimately the behavior.6 However, not all children who lack vaccines have parents who intended to not vaccinate them. These families may have access difficulties; urban, low-income, and minority children are at greatest risk for undervaccination.7 Although there is a perception that there are these 2 categories of children who have not received recommended vaccinations, no study has documented the relative size and characteristics of these 2 distinct scenarios.
We analyzed data on vaccination status from the Study of Attitudes and Factors Effecting Infant Care (SAFE), a nationally representative study of mothers’ infant care practice choices. The objective of this analysis was to, in this sample of mothers of 2- to 6-month-old infants, assess the role of maternal attitudes and other factors associated with infant vaccination status.
Methods
The SAFE study, conducted in 2011–2014, used a stratified, 2-stage, cluster design, with oversampling of black and Hispanic mothers, to obtain a nationally representative sample of mothers of 2- to 6-month-old infants. Sampling procedures have been previously described.8,9 Briefly, a probability sample of 32 US birth hospitals with >100 births/year, based on the 2010 American Hospital Association annual survey, was selected. Each hospital was assigned enrollment targets so that ~1000 surveys, including >250 each from Hispanic and black mothers, were obtained annually for 3 years. Mothers were eligible if they spoke English or Spanish, lived in the US, and would be caring for their infant by 2–4 months after delivery. Sampling weights were calculated to account for the probability of selection and differential response patterns.
After signing written informed consent, mothers completed an initial interview to collect demographic data and contact information. Once their infants were >60 days old, mothers were asked to complete an online or telephone followup survey. This survey, informed by the TPB,6 included questions regarding current infant care practices (including vaccination status, feeding, sleep position, sleep location) and, for each infant care practice, subjective norms, perceived control, and attitudes. Mothers who reported that their infant received no vaccinations were queried about reasons. Definitions of study measures are shown in Table I (available at www.jpeds.com). All survey questions were piloted and validated with mothers in the target population. Institutional Review Board approval was obtained at all participating hospitals.
Statistical Analyses
All analyses accounted for the 2-stage cluster sample design for both variable estimates and 95% CI using SAS (SAS Institute, Cary, North Carolina)10 methods for complex survey design. Demographic and behavioral characteristics, with weighted percentages, were calculated to obtain prevalence estimates with 95% CI. Weighted univariate and multiple logistic regression analyses, with vaccination status (none vs fully vaccinated, none vs any vaccinations) as the primary outcome, were conducted. Multiple logistic regression analyses first controlled for demographic factors only; a second model included demographic and infant care practice variables, and a third model included all variables (demographic, infant care practices, and TPB domains). A second latent profile analysis, accounting for sampling weights and design, was conducted among the 137 mothers who reported that their infants had received no vaccinations to identify distinct groups, based on maternal race, education, attitudes, subjective norms, and breastfeeding status. Finally, we conducted a systematic coding of all responses regarding reasons for receiving no vaccines.
Results
A total of 3268 mothers (82.0% of those enrolled) responded to the questions required for study analyses. The weighted distribution of maternal and infant characteristics was largely comparable with that of all mothers who gave birth in the US from 2012 to 2013 (Table II).11 Maternal education was comparable with national data for high school graduates and women with some college but in our sample, women with less than high school education were underrepresented (12.7% vs 17.8% national) and women with college or more were overrepresented (33.0% vs 28.0% national). Most (63.1%) infants were 8–11 weeks old, and 89.4% were <20 weeks of age at the followup survey. Feeding and sleep location practices in this population have been previously reported12; 30.3% were exclusively breastfeeding, 77.1% were being placed supine for sleep, and 65.6% were roomsharing without bedsharing (Table III).
Table II.
Characteristics of the SAFE study population, overall and by vaccination status
| Characteristics | Overall (N = 3268) | Weighted percent* | US vital statistics percent* | Fully vaccinated (N = 2820) (86.2%) | Partially vaccinated (N = 311) (9.1%) | Received no vaccinations (N = 137) (4.7%) | Received no vaccinations vs fully vaccinated (demographics only) aOR (95%CI)† | Received no vaccinations vs fully vaccinated (full model) aOR (95%CI)‡ |
|---|---|---|---|---|---|---|---|---|
| Mother’s age, y | ||||||||
| Less than 20 | 270 | 7.4% | 8.1% | 78.5% | 11.8% | 9.7% | 4.76 (2.09, 10.82) | 5.39 (2.33, 12.44) |
| 20 to 29 | 1773 | 52.2% | 51.8% | 87.7% | 8.7% | 3.6% | 0.96 (0.64, 1.45) | 1.09 (0.75, 1.58) |
| 30 or more | 1225 | 40.4% | 40.1% | 85.7% | 9.1% | 5.2% | Reference | Reference |
| Mother’s race | ||||||||
| White | 1267 | 52.4% | 54.1% | 85.4% | 9.0% | 5.7% | Reference | Reference |
| Black | 824 | 13.0% | 14.7% | 85.1% | 11.3% | 3.6% | 0.88 (0.49, 1.57) | 1.31 (0.71, 2.43) |
| Hispanic | 901 | 25.9% | 23.1% | 89.3% | 7.7% | 3.0% | 0.48 (0.22, 1.04) | 0.75 (0.38, 1.50) |
| Other | 275 | 8.7% | NA | 83.8% | 10.5% | 5.7% | 0.89 (0.40, 1.97) | 1.63 (0.72, 3.70) |
| Mother’s education | ||||||||
| Less than HS | 471 | 12.7% | 17.8% | 83.9% | 9.8% | 6.4% | 1.71 (0.94, 3.11) | 2.27 (1.14, 4.53) |
| HS or GED | 822 | 23.4% | 24.1% | 88.2% | 9.3% | 2.5% | 0.56 (0.30, 1.06) | 0.73 (0.39, 1.38) |
| Some college | 1035 | 30.9% | 28.8% | 87.0% | 8.4% | 4.7% | 0.99 (0.64, 1.53) | 0.80 (0.54, 1.19) |
| College or more | 927 | 33.0% | 28.0% | 84.9% | 9.4% | 5.6% | Reference | Reference |
| Mother’s parity | ||||||||
| 1 | 1199 | 37.7% | 39.8% | 85.4% | 10.1% | 4.5% | Reference | Reference |
| 2 | 1087 | 33.7% | NA | 87.0% | 8.0% | 4.9% | 1.34 (0.82, 2.20) | 1.57 (0.86, 2.89) |
| 3 + | 973 | 28.6% | NA | 86.3% | 8.9% | 4.8% | 1.58 (0.97, 2.59) | 1.54 (0.83, 2.85) |
| Household income | ||||||||
| Less than $20 000 | 1143 | 29.3% | 16.2% | 86.8% | 9.2% | 4.0% | 0.53 (0.27, 1.04) | 0.59 (0.30, 1.18) |
| $20 000–49 999 | 829 | 24.7% | 21.1% | 87.1% | 9.2% | 3.7% | 0.72 (0.47, 1.10) | 0.69 (0.45, 1.05) |
| $50 000 or more | 576 | 19.9% | 38.1% | 85.3% | 8.6% | 6.1% | Reference | Reference |
| Unknown | 720 | 26.1% | 24.6% | 85.4% | 9.2% | 5.4% | 0.79 (0.43, 1.44) | 0.84 (0.41, 1.70) |
| Region | ||||||||
| Northeast | 630 | 21.3% | NA | 85.4% | 9.5% | 5.1% | 1.53 (1.02, 2.29) | 1.88 (1.13, 3.14) |
| Midwest | 493 | 12.8% | NA | 87.5% | 7.9% | 4.6% | 1.16 (0.58, 2.31) | 1.37 (0.75, 2.49) |
| South/Southeast | 1371 | 41.4% | NA | 88.7% | 7.8% | 3.5% | Reference | Reference |
| West | 774 | 24.4% | NA | 82.1% | 11.4% | 6.5% | 2.20 (1.06, 4.60) | 1.92 (0.91, 4.06) |
| Infant sex | a | |||||||
| Male | 1668 | 50.6% | 48.8% | 86.5% | 8.9% | 4.5% | 0.99 (0.73, 1.35) | 0.86 (0.57, 1.30) |
| Female | 1596 | 49.4% | 51.2% | 85.9% | 9.2% | 4.9% | Reference | Reference |
| Infant birth weight | ||||||||
| <2500 g | 201 | 5.7% | 8.0% | 88.9% | 9.1% | 2.0% | 0.42 (0.16, 1.10) | 0.58 (0.18, 1.89) |
| 2500+ g | 3048 | 94.3% | 91.9% | 86.1% | 9.1% | 4.8% | Reference | Reference |
| Infant age at survey | ||||||||
| 8–11 wk | 2014 | 63.1% | NA | 84.8% | 9.2% | 6.1% | Reference | Reference |
| 12–15 wk | 559 | 17.0% | NA | 88.9% | 8.0% | 3.2% | 0.47 (0.24, 0.92) | 0.40 (0.20, 0.81) |
| 16–19 wk | 317 | 9.3% | NA | 90.1% | 8.2% | 1.8% | 0.34 (0.11, 1.10) | 0.27 (0.09, 0.78) |
| 20+ wk | 378 | 10.6% | NA | 87.3% | 11.1% | 1.6% | 0.24 (0.10, 0.58) | 0.24 (0.10, 0.56) |
GED, general educational development; HS, high school; NA, not applicable.
The percentages presented in these columns represent column percentages and sum to 100% within each demographic category. All other percentages presented are weighted row percentages and sum to 100% across the 3 vaccination categories.
The ORs were adjusted for all of the demographic variables included in this Table.
Table III.
Associations between infant care practices and vaccination-related TPB domains (perceived social norms, perceived control, and attitudes) and vaccination status
| Characteristics | Overall (N = 3268) | Weighted percent* | Fully vaccinated (N = 2820) (86.2%) | Partially vaccinated (N = 311) (9.1%) | Received no vaccinations (N = 137) (4.7%) | Received no vaccinations vs fully vaccinated (demographics and infant care practices) aOR (95%CI)† | Received no vaccinations vs fully vaccinated (full model) aOR (95%CI)‡ |
|---|---|---|---|---|---|---|---|
| Feeding | |||||||
| Exclusive breastfeeding | 897 | 30.3% | 80.9% | 10.9% | 8.2% | 2.58 (1.68, 3.98) | 1.35 (0.78, 2.34) |
| Partial breastfeeding | 983 | 29.2% | 88.3% | 8.4% | 3.4% | 1.08 (0.70, 1.66) | 0.79 (0.48, 1.32) |
| No breastfeeding | 1379 | 40.5% | 88.6% | 8.3% | 3.1% | Reference | Reference |
| Sleep position | |||||||
| Supine | 2461 | 77.1% | 86.4% | 9.2% | 4.4% | Reference | Reference |
| Side | 486 | 14.0% | 85.8% | 8.0% | 6.2% | 1.66 (0.71, 3.90) | 1.95 (0.80, 4.77) |
| Prone | 281 | 7.7% | 84.7% | 10.4% | 5.0% | 1.12 (0.51, 2.46) | 0.83 (0.32, 2.14) |
| Other | 40 | 1.1% | 89.4% | 6.2% | 4.3% | 0.85 (0.09, 7.86) | 0.49 (0.12, 2.11) |
| Sleep location | |||||||
| Roomsharing without bedsharing | 2162 | 65.6% | 87.7% | 8.5% | 3.8% | Reference | Reference |
| Separate room | 381 | 13.7% | 88.8% | 7.2% | 4.0% | 0.97 (0.43, 2.19) | 1.16 (0.52, 2.59) |
| Bedsharing (whole or part of the night) | 688 | 20.7% | 80.6% | 12.0% | 7.4% | 1.71 (1.12, 2.60) | 1.33 (0.81, 2.21) |
| Perceived social norm | |||||||
| Positive toward vaccination | 3003 | 91.0% | 88.8% | 8.4% | 2.8% | Reference | |
| Not positive toward vaccination | 263 | 9.0% | 59.7% | 16.2% | 24.1% | 3.06 (1.80, 5.22) | |
| Perceived control of vaccination | |||||||
| Yes | 2883 | 87.0% | 86.7% | 8.9% | 4.4% | Reference | |
| No | 384 | 13.0% | 82.7% | 10.5% | 6.8% | 0.99 (0.49, 1.99) | |
| Attitude about vaccination | |||||||
| Positive | 2934 | 88.4% | 90.7% | 7.0% | 2.3% | Reference | |
| Neutral | 220 | 7.7% | 65.0% | 25.3% | 9.8% | 3.66 (1.80, 7.46) | |
| Negative | 114 | 3.9% | 26.8% | 25.0% | 48.2% | 43.23 (20.28, 92.16) | |
The percentages presented in this column represent weighted column percentages and sum to 100% within each variable category. All other percentages presented are weighted row percentages and sum to 100% across the 3 vaccination categories.
ORs in this column are adjusted for all demographic variables shown in Table I, as well as for feeding, sleep position, and sleep location.
Prevalence of Vaccination Status and Demographic Characteristics
Of 3268 infants, 2820 (86.3%) were fully vaccinated for age, 311 (9.1%) were partially vaccinated, and 137 (4.7%) were reported as having received no vaccines. In a model that controlled for demographic factors only, younger mothers and mothers living in the Northeast or West were more likely to report that their infants had received no vaccinations, and older infants were less likely to be reported as having received no vaccinations (Table II).
Association between Vaccination Status and Infant Care Practices, Maternal Attitudes, and Subjective Norms
In a model that controlled for demographics and infant care practices, infants who were exclusively breastfed or who bedshared for part or all of the night were more likely to be reported as receiving no vaccinations (Table III). Infant sleep position was not associated with vaccination status. In this model, compared with the one that controlled for demographic factors only, mothers <20 years of age and with lower educational status were more likely to report that their infants had received no vaccinations.
When the model was adjusted to include demographics, infant care practices, and TPB domains, young mothers and those with lower educational status continued to be more likely to report their infants had received no vaccinations (Table II). However, feeding mode and sleep location were no longer associated with vaccination status. In this model, mothers who perceived subjective norms to be not positive toward vaccination were >3 times as likely to report their infants as receiving no vaccinations. Compared with mothers with positive attitudes about vaccination, those with neutral attitudes were >3 times more likely, and those with negative attitudes were 43 times more likely, to report that their infant had received no vaccinations (Table III).
Characteristics of 2 Groups of Mothers of Infants Who Received No Vaccinations
Latent Profile Analysis identified 2 distinct subgroups of mothers who reported their infants as having received no vaccinations (entropy 0.86, Vuong-Lo-Mendell-Rubin test of 2 vs 1 group; P = .054): group A (weighted 52.5%), who generally (74.5%) had negative attitudes toward vaccination, and group B (weighted 47.5%), who generally (87.2%) had positive attitudes toward vaccination (Table IV). Group A mothers were more likely to be white (P = .002), better educated (P = .02), and to exclusively breastfeed (P < .001). The 2 subgroups also had very different perceptions about subjective norms regarding vaccination. Although 98.4% of group B mothers perceived subjective norms about vaccination to be positive, 86% of group A mothers perceived these subjective norms to be not positive toward vaccination.
Table IV.
Characteristics of 2 groups of mothers of infants who have received no vaccinations, based on latent profile analysis*
| Characteristics | All nonvaccinated (N = 137) | Received no vaccinations Group A† (N = 61) 52.5% | Received no vaccinations Group B‡ (N = 76) 47.5% | P value |
|---|---|---|---|---|
| Race | .002 | |||
| White | 62.9% | 76.1% | 48.3% | |
| Black | 9.9% | 4.4% | 15.9% | |
| Hispanic | 16.7% | 13.1% | 20.7% | |
| Other | 10.6% | 6.3% | 15.2% | |
| Mother’s education | .020 | |||
| Less than HS | 17.2% | 7.2% | 28.2% | |
| HS or GED | 12.3% | 10.0% | 14.8% | |
| Some college | 30.8% | 39.3% | 21.6% | |
| College or more | 39.6% | 43.5% | 35.4% | |
| Feeding | <.001 | |||
| Exclusive breastfeeding | 52.3% | 74.9% | 27.3% | |
| Partial breastfeeding | 20.8% | 16.6% | 25.6% | |
| No breastfeeding | 26.8% | 8.5% | 47.1% | |
| Perceived social norm | <.001 | |||
| Positive toward vaccination | 54.0% | 14.0% | 98.4% | |
| Not positive toward vaccination | 46.0% | 86.0% | 1.6% | |
| Attitude about vaccination | <.001 | |||
| Positive | 44.1% | 5.3% | 87.2% | |
| Neutral | 16.0% | 20.3% | 11.2% | |
| Negative | 39.9% | 74.5% | 1.6% |
All percentages are weighted and are column percentages that sum to 100% within each variable category.
Group A: mothers with less than positive attitudes toward vaccination.
Group B: mothers with positive attitudes toward vaccination.
Reasons for receiving no vaccinations also were identified. More than one-half (55.7%) of group A mothers did not provide a response, 31% identified maternal choice, and 13% cited scheduling. Scheduling (63%) was the most commonly cited reason among group B mothers, followed by transportation problems or lack of insurance (25%), maternal choice (7%), and no response (5%) (Figure). Mean infant age was 8.9 weeks for those in either group who cited scheduling.
Figure.
Mothers’ stated reasons for infants not being fully vaccinated. Mothers in group A had less than positive attitudes toward vaccination, and mothers in group B had positive attitudes.
Discussion
In this nationally representative study, maternal attitudes and subjective norms toward vaccination were important predictors of infant nonvaccination, and the risk increased as maternal attitudes toward vaccination became more negative. Compared with mothers with positive attitudes, those with neutral and negative attitudes were >3 and 43 times, respectively, more likely to report that their infant had received no vaccinations. Similarly, mothers who perceived the opinions of others toward vaccination to be negative were more likely to report that their infants had received no vaccinations. In addition, although exclusive breastfeeding and bedsharing were associated with not having received vaccinations in a model that included just demographics and infant care practices, these associations were no longer significant when maternal attitudes and subjective norms were included in the model. Further, we identified 2 distinct, approximately equal in size, groups of mothers reporting that their infants had received no vaccines. Approximately one-half of these mothers had neutral or negative attitudes and less than positive subjective norms about vaccination; these mothers were more likely to be older, white, more highly educated and to exclusively breastfeed their infants. The other one-half had positive attitudes and positive subjective norms about vaccination.
A large proportion of the subgroup of mothers who reported that their infants had received no vaccines and who had neutral or negative attitudes toward vaccination cited maternal choice as the reason for nonvaccination; 70% of mothers who responded provided this reason. However, this may be an underestimate, as 56% did not respond to this question, perhaps reflecting a reluctance to admit a voluntary decision to not vaccinate. Infants in this subgroup also were more likely to be exclusively breastfed. Previous studies have shown an association between breastfeeding and the decision not to vaccinate.4,5 Mothers who exclusively breastfeed may be more likely to believe that a naturalistic approach to health is desirable and may have more negative attitudes about vaccination as being “unnatural.” There also may be a belief that vaccinations are not necessary because breast milk is protective against some infectious diseases. These beliefs should be specifically addressed by providers. The American Academy of Pediatrics has outlined strategies for addressing vaccine hesitancy,13 but admittedly, efficacy data for these strategies are limited.14 Further study is needed to better understand how and why mothers form their attitudes toward vaccination. The mothers who reported their infants had received no vaccinations and had negative attitudes also were more educated. Prior SAFE analyses have found that higher education generally is correlated with higher levels of trust in physicians.8 However, maternal trust in physicians may vary depending on the infant care practice.3 Although physicians are trusted sources of advice for other infant care practices, parents who refuse vaccines may not trust the physician to provide balanced advice about vaccination.15 Further, there are other sources of information, including family, friends, and media, that may influence maternal decision-making about vaccination.16
Nearly one-half of the infants who had received no vaccinations had mothers with positive attitudes and subjective norms regarding vaccination. These mothers were more likely to be non-white, have a high school diploma or less, and to formula feed exclusively. These mothers also were more likely to cite issues with access, including scheduling (63%), and transportation problems or lack of insurance (25%). Infants whose mothers cited scheduling had a mean age of 8.9 weeks. Although it is not unreasonable for infants to receive their first set of vaccinations between 2 and 3 months, difficulty in scheduling appointments may reflect access barriers for these families. Other studies also have found that issues with vaccination access can impact vaccination status.17–20
We found that mothers living in the Northeast and West US were more likely to report that their infants were not fully vaccinated. This has not been found in national immunization surveys21 but may reflect regional differences in maternal attitudes toward vaccination or in hospital policies regarding newborn hepatitis B vaccination. This finding warrants further investigation.
There are several limitations to this study. First, vaccination status was determined by maternal report, rather than objective verification. This contrasts with the Centers for Disease Control and Prevention’s National Immunization Survey, which verifies vaccination status by provider questionnaire.21 Although accuracy rates with maternal report of vaccinations in other populations have been high,22 some mothers may have been less than forthcoming about their infant’s vaccination status if they believed it to be a nonfavored response or may have recalled information inaccurately. Based on our survey questions, we cannot know whether partial immunization reported by the mothers was accurate as some mothers may not be fully aware of the immunization schedule. In addition, it is possible that partial immunization is related to the healthcare system, similar to missed vaccines during the postpartum period, rather than the preference of the mother. Further, many mothers responded to the survey when infants were 8–9 weeks of age, when the first vaccination visit still may not have been scheduled, and, therefore, some of our no-vaccination group may ultimately reflect only delayed vaccination. Because this mainly occurred in the positive attitudes group, we believe that this likely represents an important observation, reflecting a barrier to on-time vaccination. However, it is possible that some mothers with less than positive attitudes may have merely delayed vaccines and not permanently refused them. Finally, although this study was designed to achieve a nationally representative sample of mothers and their infants and the sample was weighted to improve generalizability, mothers without a high school diploma were underrepresented. Thus, we may have underestimated the proportion of mothers with positive attitudes who reported that their infants had received no vaccinations. Because of all of these limitations, our data should not be used to define prevalence of a particular vaccination status. However, we believe that our data are relevant for understanding factors associated with vaccination status.
Acknowledgments
Funded by National Institute of Child Health and Human Development (NICHD) (U10 HD059207). The authors declare no conflicts of interest.
Glossary
- SAFE
Study of Attitudes and Factors Effecting Infant Care
- TPB
Theory of Planned Behavior
Appendix
The 32 participating hospitals involved in recruitment and data collection included:
Baylor University Medical Center, TX; Baystate Medical Center, MA: Ben Taub General Hospital, TX, Bethesda Memorial Hospital, FL; Brookdale Hospital and Medical Center, NY; Camden Clark Medical Center, WV; Delaware County Memorial Hospital, PA; Geisinger Regional Medical Center, PA; Genesys Regional Medical Center, MI; Hamilton Medical Center, GA; Jersey Shore University Medical Center, NJ; Johns Hopkins Hospital and Medical Center, MD; Kaweah Delta Health Care District, CA; Lake Charles Memorial Hospital, LA; Medical Center of Arlington, TX; Moreno Valley Community Hospital, CA; Mount Carmel, OH; Natchitoches Regional medical Center, LA; Nashville General Hospital, TN; Northcrest Medical Center, TN; Riverside County Regional Medical Center, CA; Riverside Regional Medical Center, VA; Rush-Copley Medical Center, IL; Saint Francis Hospital and Medical Center, CT; Saint Joseph Hospital, CA; Saint Mary’s Health Care, MI; Socorro General Hospital, NM; Sutter Roseville Medical Center, CA: Tacoma General Hospital, WA; Texas Health Presbyterian Hospital, Plano, TX; University of California, Davis Medical Center, CA; and Wheaton Franciscan Healthcare, WI., Texas Health Presbyterian Hospital, Plano, TX, University of California, Davis Medical Center, CA, and Wheaton Franciscan Healthcare, WI
Table I.
Definitions of study measures
| Measures (and survey questions) | Maternal response in survey | Classification of response in analysis |
|---|---|---|
| Vaccination status: Has your baby gotten all recommended vaccines? | All | Fully vaccinated |
| Some | Partially vaccinated | |
| None | Received no vaccines | |
| Reasons for not being fully vaccinated | Choice | Maternal choice |
| Dangerous | ||
| Delay | ||
| Autism | ||
| Spacing | ||
| Lack of need | ||
| Unsure about risk/benefit | ||
| Insurance problems | Transportation problems or lack of insurance | |
| Logistics of transportation | ||
| Appointment in future | Scheduling | |
| Scheduling problems | ||
| Breastfeeding: What has your baby been drinking in the last 2 wk? | Only breast milk | Exclusive breastfeeding |
| Mostly breast milk | Partial breastfeeding | |
| Equally breast milk and formula | ||
| Mostly formula | ||
| Only formula | No breastfeeding | |
| Other | ||
| Infant sleep position: What position did you usually place your baby to sleep in the last 2 wk? | On the back | Supine |
| On the stomach | Prone | |
| On the side | Side | |
| Infant sleep location: Where did you usually place your baby to sleep in the last 2 wk? | In a parent’s (or other adult’s) room in his/her own crib | Roomsharing without bedsharing |
| In a parent’s (or other adult’s) bed for part of the night | Bedsharing | |
| In a parent’s (or other adult’s) bed for the whole night | ||
| In another child’s bed for part of the night | ||
| In another child’s bed for the whole night | ||
| Alone in his/her own room/In another child’s room in his/her own crib or bed | Separate room | |
| Subjective norms: Please rate how you feel about this statement (scale of 1–7): “The people who are most important to me think that I should get my baby all of the doctor recommended baby shots (vaccinations).” | Score 5–7 | Positive subjective norms |
| Score <5 | Less than positive subjective norms | |
| Perceived parental control: Please rate how you feel about this statement (scale of 1–7): “Choosing to get my baby all of the doctor recommended baby shots (vaccinations) is mostly up to me.” | Score 5–7 | Perceived control |
| Score <5 | No perceived control | |
| Attitudes: Please rate how you feel about these statements (scale of 1–7): | Mean weighted response 6.9 | Positive |
| Mean weighted response 4.7 | Neutral | |
| (1) I think getting all of the doctor recommended baby shots (vaccinations) would be healthy for my baby. | Mean weighted response 1.7 | Negative |
| (2) I think getting all of the doctor recommended baby shots (vaccinations) would be good for my baby. | ||
| (3) I think getting all of the doctor recommended baby shots (vaccinations) would make my baby safer. |
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