Utilization of a mobile panel to assess attitudes and behaviors towards childhood immunization

1. Childhood Immunization Attitudes and Behavior:
National Survey of Parents using a Mobile Panel
John Boyle PhD, ICF
Lewis Berman PhD MS, ICF
Glen Nowak, PhD, University of Georgia
James Dayton, MBA, ICF
Ronaldo Iachan, PhD, ICF
Deirdre Middleton, MPH ICF
2017 Federal CASIC Workshops April 11, 2017

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The Childhood Immunization Attitudes and Behavior Survey: Background
 Childhood Immunization rates are a priority public health issue
 National Immunization Survey (NIS) is primary tool for monitoring these rates
– Dual frame RDD sampling methodology to screen for children aged 19-35 months of age
– Household eligibility rate: 1.5% for landline, 3.3% for cell phone
 NIS Challenges
– Low incidence population+ lack of targeted frame → Large sample needs to be screened
– Estimates needed for more than 50 geographic areas → Larger sample needed
– Immunization estimates based on provider records for children → Larger sample needed
– Declining response rates → Larger sample needed
 The current methodology requires 7.5 million telephone numbers dialed to obtain 24,000 completed
interviews with parents of age-eligible children, to get 15,000 cases with adequate provider data
 Since NIS cannot cover all public health issues associated with childhood immunization, such as vaccine
hesitancy, and resources are limited, alternative methods are needed to supplement it in a timely and cost-
efficient manner

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What Are the Alternatives for Large Samples of Low Incidence Populations?
 Web
– The fastest and least expensive mode of data collection
 Email addresses
– No national population based frame exists
 Non-probability Web Panels
– Large enough (<1,000,000) to generate national samples of low incidence populations
– Have member profiles with characteristics (e.g., children in HH) that can reduce screening costs and time
 Mobile panels
– Particularly appropriate in terms of coverage and use for web surveys of young adults --- 85% smart phone
ownership among 18-29 year olds, 79% among 30-49 year olds (PEW 2014)

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What Should I Know about Non-Probability Samples?
• Non-probability samples are not based on statistical models that allow us to estimate
sampling variability and calculate confidence limits about sample estimates
• However, they are not necessarily subject to other sources of total survey error to a
greater degree than probability samples (i.e., point estimate may be accurate even if
confidence interval cannot be calculated)
• AAPOR acknowledges that non-probability samples may be “fit for purpose” for certain
populations or study objectives
• CDC already uses non-probability samples to track immunization rates among key
populations at the beginning and end of flu season
• This study explores using a national mobile web panel as a particularly appropriate
method for exploring factors affecting childhood immunization in the population

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Methodology for 2016 ChIMPS
National sample drawn from national mobile panel with one million + members
Invitations were sent to adults with children in household from panel profile
Interviews conducted in English only
Interview length: 10.1 minutes (average)
10,000 invitations sent to households with children
1029 completed interviews with adults with children aged 19-35 months
All 50 states and District of Columbia represented in completed sample
Field period 12/16/16 to 12/21/16

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Relationship of Respondent to Target Child:
1st Child 19 – 35 Months (Base: All respondents)
What is your relationship to {S5}?
Code Option CHIMPS % NIS %
1 Mother (step, foster, adoptive) or female guardian 63.3% 69.0%
2 Father (step, foster, adoptive) or male guardian 29.3% 23.4%
3 Grandparent 2.5% 5.9%
7 Other family member or friend 4.9% 1.7%

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Age Group of Eligible Child
29.5%
43.6%
26.9%
29.5% 30.0%
40.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
19-23 months 24-29 months 30-35 months
CHIMPS NIS
S3: Please tell me the month, day, and year of birth of the (FIRST/NEXT) child in your household who is
between 19-35 months old. (Converted to months of age.) N=1099 age-eligible children

8. 8
Gender of Eligible Child
51.8%
48.2%
51.4%
48.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Male Female
CHIMPS NIS
S4. Is the child born on (date) male or female? N=1099 age-eligible children

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Race/Ethnicity of Respondent
65.1%
9.7%
15.6%
5.2% 4.4%
0%
10%
20%
30%
40%
50%
60%
70%
Caucasian African-American Hispanic Asian Other
9
Base: All respondents: n=1029

10. 10
Vaccine Attitudes and Behaviors

11. 11
Child Received All Recommended Vaccines
CBF01 - (Has your child / have all of your children) received all of the vaccines that are
recommended for children up to his / her age? (Base: All respondents: n=1029)
95.7% 96.0% 96.3% 96.2% 97.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian (n=670) African-American (n=100) Hispanic (n=161) Asian (n=53) Other (n=45)
Yes

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Child had Flu Vaccine Since July 1, 2016
BBX. Since July 1, 2016 has (S5) had a flu vaccination? There are two types of flu vaccinations. One is a
shot and the other is a spray, mist, or drop in the nose. (Base: All respondents: n=1029)
61.8%
67.0% 67.1%
81.1%
75.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian (n=670) African-American (n=100) Hispanic (n=161) Asian (n=53) Other (n=45)
Yes

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Ever Delayed Recommended Vaccine for Child
A1: Have you ever delayed having your child or children get a recommended vaccine for reasons other than illness or
allergy? By delayed we mean put off, but ultimately ended up having it done. (Base: All respondents: n=1029)
20.3%
25.0% 24.2% 22.6%
37.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Caucasian (n=670) African-American (n=100) Hispanic (n=161) Asian (n=53) Other (n=45)
Yes

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Ever Decided Not to Give Vaccine to Child
B2: Have you ever decided not to have your child or children get a recommended vaccine for reasons other than
illness or allergy? (Base: Never delayed a recommended vaccine: n=800)
3.6%
8.0%
4.9% 4.9%
14.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian (n=524) African-American (n=75) Hispanic (n=122) Asian (n=41) Other (n=28)
Yes

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Plan for Child to Get All Remaining Vaccines
B3: Do you plan or intend to have your child or children get all the remaining recommended vaccines?
(Base: All respondents: n=1029)
97.2%
94.0%
96.9% 100.0%
91.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian (n=670) African-American (n=100) Hispanic (n=161) Asian (n=53) Other (n=45)
Yes

16. 16
Painful for Children to Get So Many Shots: Agree
Att1: Please indicate how much you would agree or disagree with the following statement. It is painful for children to receive so many
shots during one doctor visit. (Base: All respondents: n=1029)
26%
39% 38% 34% 32%
48%
44% 47%
47%
41%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Children Receive too Many Vaccines in one Doctor’s Visit : Agree
Att2: Please indicate how much you would agree or disagree with the following statement. Children receive too many vaccines in one
doctor's visit. (Base: All respondents: n=1029)
20%
25% 25%
19% 16%
31%
35%
39%
45%
42%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Too Many Vaccines in the First 3-years of life: Agree
Att3: Please indicate how much you would agree or disagree with the following statement. Children get too many vaccines during the
first three years of life. (Base: All respondents: n=1029)
17%
29% 29% 29%
16%
22%
25%
30%
37%
36%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Vaccines May Cause Learning Disabilities, Such as Autism: Agree
Att4: Please indicate how much you would agree or disagree with the following statement. Vaccines may cause learning disabilities,
such as autism. (Base: All respondents: n=1029)
8%
21%
12%
5%
10%
12%
18%
15%
14%
21%
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

20. 20
Some Vaccines Have Unsafe Ingredients: Agree
Att5: Please indicate how much you would agree or disagree with the following statement. Some vaccines have ingredients that are
unsafe. (Base: All respondents: n=1029)
13%
27%
14%
8%
13%
27%
41%
30%
35%
37%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Some Vaccines Prevent Unlikely Diseases: Agree
Att6: Please indicate how much you would agree or disagree with the following statement. Some vaccines are given to children to
prevent diseases they are not likely to get. (Base: All respondents: n=1029)
.
15%
30%
20%
16%
22%
31%
36%
29%
27%
42%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Some Vaccines Prevent Non-Serious Diseases: Agree
Att7: Please indicate how much you would agree or disagree with the following statement. Some vaccines are given to children to
prevent diseases that are not serious. (Base: All respondents: n=1029)
.
10%
19%
13%
16%
23%
21%
23%
23%
30%
23%
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Vaccines are Important to My Child’s Health: Agree
Att8: Please indicate how much you would agree or disagree with the following statement. Childhood vaccines are important for my
child's health. (Base: All respondents: n=1029)
.
75%
63% 67% 68% 69%
20%
32% 27%
30% 31%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

24. 24
Childhood Vaccines are Effective: Agree
Att9: Please indicate how much you would agree or disagree with the following statement: Childhood vaccines are effective.
(Base: All respondents: n=1029)
70%
46%
58% 62% 61%
25%
42%
37%
37% 37%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

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Vaccination is Important to Community Health : Agree
Att10: Please indicate how much you would agree or disagree with the following statement: Having my child vaccinated is important for
the health of others in my community. (Base: All respondents: n=1029)
77%
63%
70%
65% 62%
17%
27%
24% 33%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

26. 26
Vaccine Information from the Government is Reliable and Trustworthy: Agree
Att11: Please indicate how much you would agree or disagree with the following statement: The information I receive about vaccines
from the government is reliable and trustworthy. (Base: All respondents: n=1029)
37%
29%
35%
46% 49%
46%
44%
44%
50%
39%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Caucasian African-American Hispanic Asian Other
Strongly Somewhat

27. 27
Correlations between Vaccine Attitudes and Behavior
Had Flu
Vaccination
Plan to Have
Remaining Vaccines
Ever Delayed
Vaccination
Ever Decided Not to
Vaccinate
Too Painful -.082** -.111** .278** .120**
Too many in one visit -.139** -.171** .344** .182**
Too many in first 3 years -.113** -.199** .334** .211**
May cause learning disabilities -.074 -.250** .338** .289**
Have unsafe ingredients -.103** -.239** .361** .241**
Prevent unlikely diseases -.063 -.181** .250** .155**
Prevent diseases not serious -.079 -.203** .251** .202**
Important for my child’s health .185** .404** -.167** -.350**
Are effective .151** .375** -.177** -.312**
Important to health of others .203** .402** -.156** -.351**
Government information on
vaccines is reliable/trustworthy
.270** .315** -.140** -.235**
Pearson correlation. **Significant at .01 (two-tailed)

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Discussion
 Mobile panel is an efficient and low cost approach for vaccination estimates in NIS age eligible children
 Child gender matches NIS, however, NIS has a somewhat higher percentage of children in the 30-35 month old group. This could affect vaccine compliance.
 For seasonal flu vaccination, minorities report higher rates of childhood vaccinations than do white parents, which is consistent with the CDC reports.
 96% of parents report their children received their recommended vaccinations. While some children have had delays in getting vaccinations, few decided not to
immunize their children and most expect to get the remaining shots.
 Nonetheless, there is concern among parents about the age children receive shots, number of shots, and associated perceived pain. And, there remains concern
about Autism. Most of these concerns are substantially higher among minorities than among white parents.
 At the same time, there is agreement that vaccinations are effective and important to children and communities. And, the government can be trusted regarding
vaccine information. However, these positive attitudes are held by somewhat fewer minority parents than white parents.
 There is a positive correlation between beliefs in the effectiveness and importance of vaccination and trust in government information, and immunization
behavior among parents of young children. Conversely, there is a positive correlation between concerns about pain and vaccine safety, and immunization delay
and avoidance among parents.
 The public health education model posits a causal relationship between knowledge, attitudes, beliefs and behavior, which would make attitudes and beliefs
precursors of public health related behaviors.
 At the present time, there is no ongoing surveillance system for immunization knowledge, attitudes and beliefs that might predict challenges and changes to
immunization behavior. A properly designed non-probability panel might represent an alternative to measuring such trends in the target population.

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