1. Vaccine Hesitancy and Confidence: Insights from Recent Communication Research
Glen Nowak, PhD.
Professor, Department of Advertising & Public Relations
Director, Grady Center for Health and Risk Communications
Grady College of Journalism and Mass Communication
University of Georgia
23rd Annual Immunize Georgia Conference,
September 9, 2016

2. I have no relevant financial interests to disclose.
Disclosure Statement
I have no relevant financial interests to disclose.

3. Overview – Highlights from three recent studies
Parents of children 5 years old and younger
How confident are they when comes to a) recommended vaccines, b) the immunization schedule, and c) other health-related products for young children, specifically antibiotics, over-the-counter medicines, and vitamins?
What are some of the relationships that exist between confidence levels and other potentially related to their decision making? How about demographic characteristics?
U.S. measles outbreak and parent beliefs and intentions
Some insights into first-time expectant mothers and their vaccination-related beliefs, confidence, and plans.

4. Parent Variation in Vaccine Attitudes, Beliefs and Behavior – Two Ways to Characterize
Continuum of Acceptance
Refusers (decline many/most/all)
Decline one or two
Hesitant – and delay or space as a result
Hesitant – but don’t delay or space as a result
Accept as recommended, but have many concerns or questions
Accept, and have few concerns or questions
Segmentation approach
Refuser (<2%)
Late or selective vaccinator (2-27%)
The Hesitant (20-30%)
Cautious Acceptor (25-35%)
Unquestioning Acceptor (30-40%)
NOTE: Estimated ranges are based on a literature review in Leask et al. (2012) “Communicating with Parents about Vaccination: A Framework for Health Professionals,” BMC Pediatrics, 12(154).

5. How do parents of young children perceive vaccines relative to antibiotics, over-the-counter medicines, and vitamins for children?

6. Parents’, Recommended Vaccines, and Other Health-related Products for Young Children
Obtain some context for interpreting vaccination behaviors and confidence-related findings -- and examine whether confidence ratings are associated with vaccine-related interest, knowledge, and trust in healthcare providers as well as demographics.
Assess if parents’ confidence ratings differ when it comes to confidence in vaccines versus confidence in the immunization schedule.
Examine whether relationships found between vaccines and confidence ratings are the same or different when it comes to antibiotics, over-the-counter medicines, and children’s vitamins.

7. Research Method: A November 2014 YouGov Online Survey of 1,000 Parents
Nationally representative, online survey
Response rate of 36.3%
Parents with at least one child age 5 or younger
Analysis:
Crosstabs and ANOVAs exploring differences in vaccine confidence based on demographics and other factors

8. Antibiotics for children
Vaccine and Health Product Use: Young Children
Item
Vaccines for children
Antibiotics for children
OTCs for children
Children’s vitamins
Has your youngest child received all, some or none of the recommended vaccines to date?
None
4.6%
n/a
Some
20.6%
All
74.8%
Has your youngest child been given … No
34.7%
19.1%
33.5%
Unsure
5.5%
5.2%
3.7%
Yes
59.8%
75.8%
62.8%

9. Antibiotics for children
Delays and Refusals of a
Recommended Health Product
Item
Vaccines for children
Antibiotics for children
OTCs for children
Children’s vitamins
Have you ever delayed having your child or children get a recommended [TOPIC] for reasons other than illness or allergy? No
69.5%
81.1%
76.5%
78.8%
Unsure
7.2%
7.4%
7.6%
6.8%
Yes
23.3%
11.5%
15.9%
14.4%
Have you ever decided not to have your child or children get a recommended [TOPIC] for reasons other than illness or allergy?
74.2%
82.0%
76.0%
78.3%
6.1%
5.5%
6.7%
6.4%
19.7%
12.5%
17.3%
15.3%

10. Vaccination Compliance to date: Demographic Correlates
Followed the Schedule:
The highest compliance rates were among parents who were White, college-educated, and had household incomes greater than $30K per year
Departed from the Schedule:
Parents most likely to indicate their child received some but not all recommended vaccinations were more likely to be Black or Hispanic, have some college or less education, and household incomes of $30K a year or less

11. Antibiotics for children
Vaccination and Other Health-related Product Intentions
Item
Vaccines for children
Antibiotics for children
OTCs for children
Children’s vitamins
Do you plan or intend to have your child or children get all of the remaining recommended vaccines? No
10.5%
n/a
Unsure
12.8%
Yes
76.7%
If your child will was ill, and your physician recommended [TOPIC] would you have your child take it?
12.1%
16.1%
18.9%
13.4%
11.4%
17.1%
74.5%
72.4%
64.1%

12. Demographic Patterns In Vaccine Compliance:
Associations with Race, Education & Income
Parents who were least likely to delay or decline a recommended health product:
Variable
Vaccines
Antibiotics
OTCs
Vitamins
Race
Black
White & Black
All groups about equally likely
White
Education
All groups about equal
Post-grad.
College or higher
Income
Greater than $70K
Middle income (30K – 69,999)

13. Mean Confidence Scores
Vaccination Confidence – The General Picture
Mean Confidence Scores
Item
Overall
White
Black
Hispanic
The Vaccination Schedule
Recommended childhood vaccination schedule is safe
7.1
7.0
7.7
6.6
Recommended childhood vaccination schedule will protect my child from all the diseases and illnesses
6.9
7.6
My child’s overall health will benefit from getting all the recommended vaccines
7.2
7.3
7.5
The Individual Vaccines in the Schedule
My child won’t have a bad or serious adverse reaction to any of the recommended vaccines
6.5
Each of the recommended vaccines is effective in protecting my child from disease and illness
7.4
My child’s overall health benefits from each one of the vaccines in the recommended schedule

14. Mean Confidence Scores
Vaccine Confidence and Education
Mean Confidence Scores
Item
≤ High school
Some college
College degree
Post-grad.
The Vaccination Schedule
Recommended childhood vaccination schedule is safe
6.9
6.8
7.1
8.3
Recommended childhood vaccination schedule will protect my child from all the diseases and illnesses
6.6
7.2
8.2
My child’s overall health will benefit from getting all the recommended vaccines
7.0
7.3
8.4
The Individual Vaccines in the Schedule
My child won’t have a bad or serious adverse reaction to any of the recommended vaccines
6.4
7.6
Each of the recommended vaccines is effective in protecting my child from disease and illness
8.1
My child’s overall health benefits from each one of the vaccines in the recommended schedule

15. Vaccine Confidence Ratings and Vaccination Behaviors and Intentions
Parents who indicated their child had received all recommended vaccinations to date averaged ~7.5 on confidence-related measures – vs. ~5.5 for parents who said their child had received some of the recommended vaccinations to date – vs. ~3.7 for parents who said “none.”
Parents who indicated they had delayed a recommended vaccination averaged ~6.1 on confidence-related measures (vs. ~7.5 for parents who had not). Among decliners, it was around ~5.6 vs. ~7.5).
With respect to intentions to get future recommended vaccinations, those who said “no” averaged around ~4.7, while those unsure averaged around ~5.4, and those who said “yes” averaged around ~7.2.

16. Confidence Rating and Interest in Vaccines and Other Health-related Products for Children
There was a strong positive correlation between self-reported interest in vaccines and both the vaccine schedule and vaccine confidence items (six items total). For example:
“Very interested” parents had a mean confidence rating of around 7 for each confidence measure (on 0-10 scale), compared to an average rating of around 4.2 for parents who were “not at all interested”
A similar positive correlation was found for antibiotic and OTC medicine confidence ratings and interest levels – though the “not at all interested” confidence ratings were slightly higher (around 5.2 on average).
For vitamins, a positive correlation was found, but even parents who were “not at all interested” were fairly confident in the safety of vitamins.

17. Bad Reactions: Knowledge of and Personal Experience
Yes No
Unsure/DK
Do you know of anyone who has had a bad reaction- outside of general soreness, fever, redness, or swelling at the injection site- a vaccine?
23.5%
65.8%
10.7%
Have any of your children ever had a bad reaction – outside of general soreness, fever, redness, or swelling at the injection site – to a vaccine?
13.4%
78.6%
8.0%
Do you know of anyone who has had a bad reaction to an antibiotic?
33.1%
57.3%
9.6%
Have any of your children ever had a bad reaction to an antibiotic?
14.4%
79.4%
6.2%
Do you know of anyone who has had a bad reaction to an over-the-counter medicine for children?
16.7%
75.1%
8.2%
Have any of your children ever had a bad reaction to an over-the-counter medicine for children?
7.0%
86.1%
Do you know of anyone who has had a bad reaction to a vitamin?
8.7%
85.0%
6.3%
Have any of your children ever had a bad reaction to a vitamin?
5.3%
87.9%
6.7%

18. Vaccine preventable disease outbreaks – do they affect parents’ beliefs and behaviors?

19. THE MEASLES OUTBREAK

20. A “Natural” Experiment surrounding the 2014-2015 outbreak
Data:
Pair of independent, nationally representative, YouGov surveys –
Survey 1: Nov. 3 – Dec. 1, 2014
Survey 2: May 19 – June 19, 2015
Response rates of 36.3% and 32.7%
Parents (N = 1,000 across each survey) with at least one child age 5 or younger
Measured:
Vaccine-related concerns, confidence, beliefs regarding state immunization, mandates, future vaccination intentions
Comparisons involved “no,” “low,” and “high” awareness parents to those in Survey 1

21. Vaccination Behaviors and Intentions

22. Vaccine-related Concerns

23. Vaccine-related confidence

24. Support for Vaccination Mandates

26. Demographics Age Range: 19 to 44 years (M=28 years; SD=5.2) % Race
White/Caucasian
74.6
Black or African American
11.7
American Indian or Alaska Native
1.0
Asian
7.6
Other
5.1
Annual income
Less than $25,000
23.0
$25,000-$74,999 34
$75,000 +
36.5
I did not want to answer question
6.5
77% Married or Partnered
0.5% Divorced
22.5% Single
19% Advanced degree
22.5% 4-yr degree
11% 2-yr degree
29% Some college or technical school
17.5% HS or GED
0.5% Less than HS
0.5% Other
55.8% Employed full-time
15.6% Employed part-time
17.1% Unemployed
6.5% Stay-at-home parent
3.5% Student
1.5% Other
66% Private insurance
31% Medicare/Medicaid
3% None

27. Which of the following best describes your plans for vaccinating your baby?
I plan to have my child receive all of the vaccinations recommended by his/her doctor or nurse as scheduled…………………………………………………75.0% I plan to have my child receive all the vaccinations recommended by his/her doctor or nurse but will space out or delay them………………………………10.5% I have not decided yet about plans for vaccinating my baby………… % I plan to have my child receive some but not all of the vaccinations recommended by his/her doctor or nurse ………………………………………..…4.0% I intend to have my child receive none of the vaccinations recommended by his/her doctor or nurse ………………………………………………………………..……….0%
NOTES for NVAC – responses on this item were used to create groups (variable: P10Q3)
Acceptors (75%)  said their child would receive all as recommended
Delayers/decliners (14.5% -- second statement + fourth statement)  would space our or delay or get some but not all
Undecided (10.5%)  were unsure about their vaccination plans
Complete refusers (0%)  per the inclusion/exclusion criteria of the survey

28. Respondents overall How confident are you… Total % M (SD)
in the effectiveness of routine childhood vaccines?
81.4
4.22 (0.90)
in the value of routine childhood vaccines?
78.4
4.23 (0.94)
in the safety of routine childhood vaccines?
73.5
4.02 (1.02)
How important…
Total %
M (SD)
to you is it that your baby receives all the vaccines recommended for him/her?
86.5
4.47 (0.88)
do you think immunizations are for keeping children healthy?
84.5
4.40 (0.87)
is it to you that your baby receives vaccines according to the recommended schedule?
83.5
4.37 (0.95)
Respondents were asked a series of agree-disagree statements related to the confidence and importance of recommended vaccines.
Scales ranged from 1-5 (higher numbers = higher confidence or importance)
“Total %” column represents responses that were either a “4” or a “5”
“M(SD)” column represents “mean” and “standard deviation”

29. Acceptors (n=150) How confident are you… Total % M (SD)
in the effectiveness of routine childhood vaccines?
90.5
4.45 (0.68)
in the value of routine childhood vaccines?
89.9
4.51 (0.69)
in the safety of routine childhood vaccines?
86.6
4.33 (0.76)
How important…
Total %
M (SD)
to you is it that your baby receives all the vaccines recommended for him/her?
96.0
4.76 (0.51)
do you think immunizations are for keeping children healthy?
95.3
4.69 (0.56)
is it to you that your baby receives vaccines according to the recommended schedule?
96.6
4.71 (0.55)
“Total %” column represents responses that were either a “4” or a “5”
“M(SD)” column represents “mean” and “standard deviation”

30. Delayers/Decliners (n=29)
How confident are you…
Total %
M (SD)
in the effectiveness of routine childhood vaccines?
65.5
3.83 (0.97)
in the value of routine childhood vaccines?
55.1
3.76 (0.87)
in the safety of routine childhood vaccines?
41.4
3.38 (0.98)
How important…
Total %
M (SD)
to you is it that your baby receives all the vaccines recommended for him/her?
62.1
3.72 (1.10)
do you think immunizations are for keeping children healthy?
58.6
3.76 (1.02)
is it to you that your baby receives vaccines according to the recommended schedule?
48.2
3.34 (1.17)
“Total %” column represents responses that were either a “4” or a “5”
“M(SD)” column represents “mean” and “standard deviation”

31. Undecideds (n=21) How confident are you… Total % M (SD)
in the effectiveness of routine childhood vaccines?
38.1
3.10 (1.09)
in the value of routine childhood vaccines?
28.6
2.86 (1.11)
in the safety of routine childhood vaccines?
23.8
2.62 (1.12)
How important…
Total %
M (SD)
to you is it that your baby receives all the vaccines recommended for him/her?
52.3
3.43 (1.21)
do you think immunizations are for keeping children healthy?
42.9
3.19 (0.98)
is it to you that your baby receives vaccines according to the recommended schedule?
38.1
3.29 (1.06)
“Total %” column represents responses that were either a “4” or a “5”
“M(SD)” column represents “mean” and “standard deviation”
Summary across groups on confidence:
Effectiveness
Acceptors high confidence compared with both Delayers/Decliners (M=4.45 vs M=3.83, p <0.001) & with Undecideds (M=4.45 vs M=3.10, p <0.001)
The difference between Delayers/Decliners and Undecideds was also statistically significant
Value and Safety
Acceptors highest levels of confidence in the value & safety of childhood vaccines (M=4.51 for value & M=4.33 for safety) compared with
Delayers/Decliners (M=3.76 for value & M=3.38 for safety)
Undecideds (M=2.86 for value & M=2.62 for safety)  (p < for all comparisons)
Summary across groups on importance – for all three items, Acceptors had the highest importance ratings
Acceptors
M=4.69 for keeping children healthy
M= 4.76 for receiving all recommended vaccines
M=4.71 for receiving them according to the schedule
Undecideds (statistical sig for all three items with Acceptors, p < 0.001)
M=3.19 for keeping children healthy
M= 3.43 for receiving all recommended vaccines
M=3.29 for receiving them according to the schedule
Delayers (statistical sig for all three items with Acceptors, p < 0.001)
M=3.76 for keeping children healthy
M= 3.72 for receiving all recommended vaccines
M=3.34 for receiving them according to the schedule

32. Parents should ask questions about the safety of their child’s immunizations. (%)
Strongly disagree
Somewhat disagree
Neither disagree
nor agree
5.6
Somewhat agree
15.2
Strongly agree
79.3
Parents should ask questions about the importance or value of their child’s vaccinations. (%)
5.5
13.6
80.9

33. Summary and Conclusions
There does appear to a positive association between parents’ self-reported vaccine confidence levels and vaccination compliance.
Overall, parent confidence ratings for the recommended vaccination schedule and the individual vaccines in the schedule were fairly high.
They were as high as those for recommended antibiotics and higher than recommended OTC medicines and children’s vitamins.
Higher SES parents had highest confidence ratings in all categories, while lower SES parents tend to have lowest ratings.
Interest – and vaccination experiences – appear to matter, including with respect to affecting parent confidence levels.
Results support providing parents, especially first-time parents, with information about vaccines, including early on.

34. THANK YOU!
Questions?