Vaccination Paper

Running Header: VACCINATION ATTITUDES, BELIEFS, AND
RATES
Vaccination Attitudes, Beliefs, and Rates Among the Homeschooling Population:
A Cross-Sectional Study In Washington State
Danika Troupe, Elin McWilliams, Molly Carroll, Paige Swift
Western Washington University
Community Health
March 2016

VACCINATION ATTITUDES, BELIEFS, AND
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TABLE OF CONTENTS
Abstract……………………………………………………………………………………………2
Introduction………………………………………………………………………………………..3
Vaccinations and Exemptions………………………………………...………………….. 3
Homeschooling and Vaccinations…………………………………………………………5
Washington State Homeschoolers and Vaccinations……………………………………...6
Purpose and Objectives……………………………………………………………………...…….8
Methods……………………………………………………………………………………………9
Participants………………………………………………………………………………...9
Instrument Design…………………………………………………………………………9
Procedure…………………………………………………………………………...……13
Data Analysis……………………………………………………………………..……..13
Results……………………………………………………………………………………………15
Response Rate and Demographic Characteristics………………………………………..15
Vaccination Rates………………………………………………………………………..16
Perceived Susceptibility………………………………………………………………….16
Perceived Severity……………………………………………………………………….16
Perceived Barriers………………………………………………………………………..17
Perceived Benefits……………………………………………………………………….18
Government’s Role………………………………………………………………………18
Vaccination Mandates and Homeschooling……………………………………………..19
Discussion……………………………………………………………………………………… 19
Limitations……………………………………………………………………………….24
Application and Implication……………………………………………………………………25
References………………………………………………………………………………………26
Tables……………………………………………………………………………………………30
Appendix A: Survey First Draft…………………………………………………………………41
Appendix B: Informed Consent………………………………………………………………….45
Appendix C: Final Qualtrics Survey……………………………………………………………..46
Appendix D: Scoring Guidelines………………………………………………………………...52

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Abstract
Background: School vaccination laws have played a critical role in ensuring the success of the
United States' immunization policy. Recent outbreaks of vaccine preventable diseases (VPDs) in
homeschooling populations have raised concern that homeschoolers are under-vaccinated. Little
vaccination related research has been done among the homeschooling population. To fill the void
of the literature, this study was designed to examine homeschooling parents' opinions regarding
vaccination and to explore the vaccination rates of their children.
Methods: A cross-sectional on-line survey with 29 questions was adopted for this study. A
convenience sample of homeschooling parents in Washington State was contacted for
participation. A majority of the participants were Caucasian with Bachelor's degrees or higher.
Results: Only about half of the participants believed that vaccines are safe (55.6%) and the
majority believed that government should grant vaccine exemptions for personal beliefs (88%)
and 94% believed the government has no right to mandate vaccinations. In addition, data
indicated that participants had a low perceived susceptibility and severity of acquiring VPDs if
unvaccinated, and further, only 23% of their children were fully vaccinated. Parents of
unvaccinated children expressed significantly lower perceived benefits of vaccination, and
significantly higher perceived severity and barriers to vaccination than their partially and fully
vaccinated counterparts.
Conclusions: Homeschoolers in Washington are under-vaccinated, and homeschooling parents
have negative views of childhood vaccines. A closer examination of the vaccine exemption
policy is necessary. Further, education on the benefits of vaccination as well as the severity of
VPDs may be necessary to increase vaccination rates.
Key Words: vaccine, vaccination rates, homeschool, Health Belief Model, survey

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Introduction
Vaccinations and Exemptions
Healthy People 2020 set a goal of 90% coverage for most vaccines in order to reduce
morbidity and mortality rates of vaccine-preventable diseases (VPDs; U. S. Department of
Health and Human Services, 2014). However, some parents delay or refuse childhood
immunizations, which compromises the achievement of this HP 2020 goal, and leaves their
children unprotected. According to Smith and colleagues (2011), parents’ hesitancy towards
vaccines is largely centered on fears of safety of vaccines, a belief that vaccinations are not
necessary to protect a child’s health, and a belief that their child is at low risk of contracting
VPDs if unvaccinated. Therefore, parental hesitancy towards vaccinations is a barrier to reaching
the nation’s vaccination goals.
Remaining unvaccinated can pose health risks for all people, especially children. Feikin
and colleagues (2000) found that unvaccinated children between the ages of 3-18 years old were
22 times more likely to get measles, and had a six times greater chance of acquiring pertussis
compared to those who were fully vaccinated. The risks are even higher for younger children.
Unimmunized children ages 3-10 years old experience a 60-fold increase risk of contracting
measles, and a 16-fold increase risk of contracting pertussis compared to children who were
immunized (Feikin, 2000).
When an individual is unvaccinated, it also poses a risk to people around them by
negatively affecting herd immunity. Herd immunity is the concept that if a sufficient proportion
of individuals in a community become immunized for a disease, the disease will not be easily
introduced in that population, and in addition, will not spread due to the low number of

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susceptible individuals. Herd immunity is important as it protects those who cannot get
vaccinated due to medical reasons (i.e., those who have allergies to ingredients in the vaccine,
those who are severely immunocompromised, or are too young to be vaccinated), those who
choose to not become vaccinated, and those who received a vaccine but the immunity was not
acquired (Diekema, 2014).
Herd immunity is largely established within a community through schools, which require
children to have been immunized in order to enroll (Orenstein, & Hinman, 1999; Khalili, &
Caplan, 2007). Studies have found that enforcing school vaccination laws have played a critical
role in ensuring the success of the United States’ immunization policy (Orenstein, & Hinman,
1999). For example, within two years of states mandating measles vaccinations for school entry,
those that strictly enforced the laws experienced less than 1/10th of the incidence rates of
measles when compared to states that did not strictly enforce the laws (Orenstein, & Hinman,
1999). Thus, strict laws requiring vaccinations for school entry result in decreased incidence of
VPDs in the entire state. Therefore, states requiring immunization for school entry are a critical
component to achieving herd immunity in the population.
Although all states have immunization requirements for children to enter school, states
vary in their stringency of vaccination requirements and exemption laws. All states allow
exemptions for medical reasons, however most states also allow exemptions for nonmedical
reasons (religious and philosophical). Exemptions for religious reasons are available in 47 states,
and 20 states have philosophical exemptions based on personal, moral, or other beliefs (“States
with religious and philosophical...”, 2016).
The stringency by which a state makes nonmedical immunization exemptions available
for school entry has an effect on the overall vaccination rate. Blank, Caplan, and Constable

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(2013) found that states with more rigorous exemption policies (e.g., states that allow only
medical exemptions) had exemption rates that were two times lower than states with exemptions
that were easier to obtain. Similarly, states with policies that allowed a philosophical exemption
experienced exemption rates that were over two and a half times greater than states that only
permitted religious and medical exemptions (Omer, Richards, Ward, & Bednarczyk, 2012).
These findings demonstrate that when exemptions are easily obtained, exemption rates increase.
This is significant as schools that had VPD outbreaks had higher exemption rates (Feikin et al.
2000). Thus, in order to prevent VPD outbreaks in schools, nonmedical exemptions should be
carefully implemented.
Homeschooling and Vaccinations
States vary in their immunization requirements for homeschooled children.
Homeschooled children do not fall under the same immunization requirements as children who
attend public or private schools. According to the Coalition for Responsible Home Education
(2015), only four states (Minnesota, North Dakota, Pennsylvania, and Tennessee) require proof
of immunization for homeschooled children. Other states require immunizations, but do not
require proof of those immunizations, and a total of 25 states do not require homeschoolers to be
immunized (Coalition for Responsible Home Education, 2015).
A growing concern is that the lack of vaccination requirements for homeschoolers have
contributed to recent outbreaks of VPDs in the homeschooled population. A study by Parker and
colleagues (2006) on a 2005 measles outbreak in Indiana found that 94% of the confirmed cases
were unvaccinated, and 71% were homeschooled. Parents of unvaccinated children cited
concerns of safety of the measles, mumps, and rubella (MMR) vaccine as the primary reason
they refused vaccination. These reasons provide evidence that personal refusal of vaccinations,

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as opposed to lack of access to immunization services, was the primary reason patients were
unvaccinated. Similarly, in Oklahoma there were only two reported cases of tetanus in 2012, and
both cases were homeschooled children who had no record of vaccination (Johnson et al., 2013).
Further, a pilot study using email surveys of homeschooled parents in Western Pennsylvania,
researchers found that only 38% of homeschooling families were fully vaccinated (Thorpe et al.,
2012) which is well below the level necessary to achieve herd immunity (Diekema, 2014).
Therefore, there is concern for the safety of homeschooling students if they are unvaccinated, as
this leaves them susceptible to contracting and spreading VPDs.
Compounding the issue is the fact that there is very little research on homeschoolers’
vaccination rates. However, some of the studies that have been done suggest that the homeschool
population is undervaccinated. Kennedy and Gust (2005) investigated homeschooling parents’
attitudes and beliefs about vaccines and compared them to parents who have their children in
public and private school. Kennedy and Gust found that compared to public and private school
parents, homeschooling parents were more concerned that childhood vaccines are not safe. In
addition, they found that homeschooling parents were less likely to believe vaccines were
important and necessary. In other words, in comparison to public and private school parents,
homeschooling parents demonstrated more negative views of vaccinations. This furthers the
concern that homeschoolers may be chronically under-vaccinated and therefore, at risk to
contract and spread VPDs.
Washington State Homeschoolers and Vaccinations
In order to enroll a child in public or private schools in Washington State, proof of
immunization status or proof of exemption needs to be provided (RCW § 28A.210.080).
However, Washington State currently only requires homeschooling parents to keep

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immunization records for their children, but does not require them to provide proof of
immunization, or of exemption (State of Washington, Office of Superintendent of Public
Instruction [OSPI], 2014). Because there is no requirement to report homeschool students’
vaccination status, there is no official tracking system of vaccination compliance among
homeschooling students, leaving their vaccination rates unknown. In addition, the homeschool
population is growing within Washington State. According to an annual report, there are 20,921
children in Washington homeschooling for the 2015-2016 school year, up from 15,406 in 2010-
2011 (OSPI, 2015). Furthermore, due to the fact that school immunization mandates play such a
significant role in increasing and maintaining immunization rates (Orenstein & Hinman, 1999),
there is concern that Washington State’s homeschool population is undervaccinated as they are
not required to be vaccinated.
The dangers of an undervaccinated homeschooling population are compounded by the
fact that many homeschooling students are regularly gathering together in support groups and
homeschool cooperatives (“Regional Support”, n.d.). These groups often take place at local
churches and community centers, and consist of activities and classes intended to enrich the
home-based education experience. Although the exact number of these cooperatives is unknown,
it is likely in the hundreds as Washington Homeschool Organization lists 11 regions in
Washington, with over 70 groups listed in King County (Region 7) alone (“Regional Support”,
n.d.). These cooperatives are not required by law to mandate immunizations because they do not
carry the legal definition of a school. In Washington, the immunization law defines school as
only those that are endorsed by the state board of education (RCW 28A.210070). These
homeschool groups do not carry this endorsement, and therefore do not need to require
immunizations. Studies have already recognized that unvaccinated groups within states should be

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monitored closely (Omer et al., 2008). Therefore, research within Washington State is necessary
to determine if homeschoolers are undervaccinated, as this could threaten the safety of
homeschoolers and their communities.
Due to the many gaps in the information on homeschoolers’ immunizations, the lack of
vaccine requirements, the increase in popularity of homeschooling, and the recent outbreaks of
VPDs in homeschooling communities, the need for information on homeschoolers’ vaccination
decisions and rates in Washington State is becoming increasingly important. In this study,
researchers hope to discover the immunization rates of homeschoolers within Washington State,
and examine attitudes, beliefs, and values of homeschooling parents in regards to immunizations,
and identify whether or not mandates for public and private schools play a role in the decision to
homeschool.
Purpose and Objectives
Purpose: To explore immunization status and vaccination determinants in the
homeschool population.
Objectives:
1. Determine vaccination rates of homeschool children
2. Determine vaccination practices of homeschool parents
3. Identify homeschooling parents’ perceived susceptibility of their children to vaccine
preventable diseases (VPDs)
4. Identify homeschooling parents’ perceived severity of VPDs
5. Identify homeschooling parents’ perceived barriers to their children becoming
immunized
6. Identify homeschooling parents’ perceived benefits of vaccinating their children

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7. Determine if immunization requirements for public/private schools play a role in the
decision to homeschool children
8. Identify homeschooling parents’ beliefs regarding vaccine exemptions
9. Identify homeschooling parents’ beliefs regarding vaccine policy
10. Identify significant differences in beliefs between fully vaccinated, partially
vaccinated, and non-vaccinated groups
Methods
Participants
Subjects were parents who were homeschooling in Washington State during the 2015-
2016 school year. A previous study by Thorpe and colleagues (2012) identified that the most
efficient way to reach homeschoolers was through email. Due to the fact that there is no state
registry for homeschoolers, this study was based upon a convenience sample. Researchers
contacted homeschooling parents via the internet (e.g. over Facebook and email) and asked for
their voluntary participation in the survey. Participants received the link to the survey, and their
responses were anonymous.
Instrument Design
In order to examine homeschooling parents’ attitudes, beliefs, and values surrounding
immunizations for their children, researchers created an online survey that was modeled after
questions that had been used in similar studies (Smith et al., 2011; Gerend, & Shepherd, 2012,
Kennedy & Gust, 2005; Thorpe et al., 2010). Survey questions were grouped into four sections,
based off of the constructs of the Health Belief Model (HBM; Champion & Skinner, 2008). The
HBM is used to better understand reasons that homeschooling parents may accept, delay, or

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refuse vaccines. The four constructs of the HBM used for the survey explored the individual’s
perceived susceptibility to VPDs if unvaccinated, perceived severity of VPDs, perceived benefits
of vaccination, and perceived barriers to vaccination. Additional sections contained questions
written by the researchers that were specific to the homeschooling population within Washington
State. These questions explored participants’ demographics, their beliefs in governmental
intervention and policy regarding vaccines, the role of vaccine mandates in parents’ decisions to
homeschool their children, and vaccination status of the participants’ children.
The first construct, perceived susceptibility to VPDs, explored whether or not individuals
believed their child(ren) were susceptible to contracting a vaccine-preventable disease. This
construct asked participants to indicate (using a Likert scale) how much they agreed or disagreed
to certain statements, such as: “Most of the diseases that the vaccines are designed to prevent are
rare,” or “If there is a vaccine available for a disease and my child is not vaccinated for that
disease, my child's chance of catching that disease is low.” Participants who scored high in this
area had a high perceived susceptibility.
The second construct, perceived severity of VPDs, asked participants about their
perceptions regarding the severity of the outcomes if their child did not get a vaccine, but
developed a VPD. Participants were asked to indicate how much they agreed to certain
statements, such as: “If my child got a disease vaccines are designed to prevent, it could be
deadly,” or “If my child got a disease vaccines are designed to prevent, he/she/zie could be
physically disabled.” Again, participants who scored higher in this construct had a higher
perceived severity of the VPDs if their children were not vaccinated.
The third construct, perceived benefits of vaccination, measured participants perceptions
about the benefits of having their children vaccinated. Participants were asked to indicate their

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agreement towards statements such as: “Vaccinations are important for keeping children
healthy,” or, “Vaccines do a good job [of] preventing disease.” Participants who scored higher in
this construct had a higher belief in the potential benefits of vaccination.
The fourth construct, perceived barriers to vaccination measured participants’ perceptions
of the safety of vaccines. Again, participants were asked to rate their level of agreement with
statements such as: “Childhood vaccines are safe,” and “Too many vaccines given at one time
can overwhelm a child's immune system.” Participants who scored higher in this section had
lower perceived barriers in regards to child immunizations.
The original drafts of the survey may be found in Appendix A. Drafts of the survey
underwent extensive revisions so as to eliminate participants’ response set bias, to provide clarity
within the questions, to ensure proper formatting of questions. In addition, our survey was sent to
3 professors to establish face validity. Researchers sought to eliminate response bias by wording
questions neutrally. That is, questions that seemed judgmental, or that posed the threat of guiding
respondents to answer in one way or another, were rephrased. For example, researchers opted out
of using the label “vaccine preventable diseases” due to concern that respondents might not
believe in the prevention-abilities of vaccines. In other words, the term “vaccine preventable
diseases” implies that vaccines are effective. However respondents may not believe in their
effectiveness and may be dissuaded from continuing the survey if they feel that the survey is
biased. Researchers believed that by saying, “diseases that vaccines are designed to prevent”
would make the survey more open to multiple beliefs of vaccine effectiveness.
Researchers sought to provide clarity for questions by making them more specific. For
example, the question, “Are you concerned that ingredients of immunizations are unsafe?” was
changed into two questions to provide more clarity for respondents and more informative

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answers for researchers. In the final draft of the survey, this original question appeared as two
separate questions, which asked respondents about their perceived safety of thimerosal (a
mercury-based preservative) in the vaccines.
Researchers reformatted questions so that responses for each question were uniform. In
the original draft, each question varied in its answer options, which proved to be problematic for
analysis. For example, one question stated, “Do you believe that childhood vaccines are: Very
safe, Safe, Somewhat safe, Not safe” while another question stated, “Are you concerned that
vaccinations might cause learning disabilities? Very concerned, Concerned, Somewhat
concerned, Not concerned”. By the final draft, all questions had been reformatted so that each
could offer the same set of answers: “Strongly agree, Agree, Somewhat agree, Somewhat
disagree, Disagree, Strongly disagree”. By reformatting these questions, researchers were able
to ensure that different questions within constructs could be summed together.
Following several revisions by the researchers, drafts were reviewed by three professors,
experienced in conducting research. Changes in wording were requested, and most were adapted.
One such change involved the inclusion of the pronoun “zie” when referring to non-binary
genders of individuals (“she/he/zie,” instead of “she/he” or “they”). Further, in the draft of the
instrument submitted for review, researchers had specifically chosen the word “catch” versus
“acquire” to describe a child’s acquisition of a VPD (i.e., “if there is a vaccine available for a
disease and my child is not vaccinated, they are at high risk of catching the disease”). This
decision was made due to the concern that the word “acquire” was of a higher reading level than
desired. Ultimately, researchers chose the word “get” rather than “acquire” or “catch”.
In the original draft of the survey, researchers asked questions about each specific
required vaccine, and each child’s status on said vaccine. However, feedback from professors

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indicated concern of the survey being too lengthy, resulting in participant fatigue, and thus
yielding a low response rate. In the final draft of the survey instrument, these rate-related
questions were compiled into a table, which asked participants to disclose ages, homeschooling
status, vaccination status (Up-to-date, Some, but not all, None, and Don’t know), participation in
school sponsored programs, and attendance in a homeschooling program that is part of a larger
school district.
After final changes had been made to the instrument, researchers uploaded the survey to
Qualtrics, a confidential, anonymous online survey system. (The final, electronic version of the
survey may be found in Appendix C). Included in the electronic version of the instrument was an
informed consent form (Appendix B) which participants had to read and agree to before they
could move on to the rest of the survey. Included in the informed consent was an estimate of the
amount of time expected for the completion of the survey, the length of the survey, a disclosure
about confidentiality and anonymity, and contact information if any concerns were to arise.
Procedure
Homeschool parents were contacted via the Internet and asked to volunteer to fill out the
survey. They were provided with the link to the Qualtrics survey. The survey link was available
from February 21, 2016 - March 4, 2016. No names or emails were connected with the survey
responses and no incentives were provided for participation in the study. The study was
approved by the Western Washington Institutional Review Board on February 19, 2016.
Data analysis
Raw data were imported into the IBM SPSS Statistics Version 23 software for coding and
analysis. At the time of data collection, there were 29 responses to the survey. However, three
responses were discarded because they had not consented to the survey, and another was

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removed because they were not currently homeschooling in Washington State. Additionally, two
more responses were removed because the participants did not respond to any of the questions on
the survey. This left researchers with 23 usable survey responses. Researchers also removed data
of four children that were in public school and eight children who were not old enough to be in
school, as indicated by their parents. After these children were removed, there were 50 children
represented in the study.
The questions in the survey were arranged based on the constructs of the Health Belief
Model. These groups were based on perceived susceptibility of VPDs, perceived barriers to
vaccination, perceived benefits of vaccinations. Additionally, there were groups of questions
about beliefs surrounding government’s role in vaccination, and whether or not vaccination
mandates had affected their decision to homeschool. Each response was given a value (e.g.
“strongly agree” is worth +5 points), and the responses were totalled for each section. Some
questions needed to be reverse coded so the construct could be properly summed. For example,
for perceived barriers, the statement, “Childhood vaccinations are safe”, strongly agree was
coded for +5, and strongly disagree was coded for 0. In the same construct, “Vaccines might
cause learning disabilities”, strongly agree was coded 0, and strongly disagree was coded +5.
Thus, when the constructs were totaled, higher scores reflected lower perceived barriers. (For a
complete scoring guide to all responses see Appendix D). After the responses were totaled, they
were divided by the number of questions in that section in order to obtain an overall average
perception for each construct.
Respondents were then sorted based on the vaccination status of their children, either as
“up-to-date”, “some, but not all”, or “none”. The “up-to-date” group indicated that their children
were fully vaccinated at the time of the survey. Those in the “some, but not all” group had

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children who had received some vaccinations, but not all of the required vaccinations for
children their age. Finally, those in the “none” group had children who had received no
vaccinations at all, but were old enough to have been vaccinated. If a respondent had a young
child who was not up to date on vaccinations, but had an older child that was up to date, it was
assumed that the younger child would eventually be fully vaccinated, and the respondent was
placed in the “up-to-date” category.
Once the data was cleaned and the participants were categorized, researchers ran a one-
way ANOVA test to determine if there were significant differences between the perceptions of
the three groups. If there were differences, a Tukey post-hoc test was run to determine what the
differences between groups were, using a significance of p < .05.
Results
Response Rate and Demographics Characteristics
Due to the design of the study, where researchers sent the survey link to acquaintances
who then sent the survey to their acquaintances, it is impossible to know the response rate of the
survey. That is, researchers do not know how many people received the survey and chose not to
respond.
Of the 23 usable responses (Table 1), the highest percentage of respondents had a
bachelor’s degree (61%), while the lowest percentage was those who had a junior college degree
(9%). It was also found that most of the participants (57%) had an annual household income of
$50,00-$100,000, and only one participant made less than $50,000. Demographic data showed
that 13 of the participants were in the 31-40 year old age range, one participant was in the 18-30
range, and nine participants were in the 41+ age range. Ethnically, most of the participants
identified as White (78%), with Asian being the next highest represented ethnic group (9%).

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Vaccination Rates
When results were organized by respondent (Table 2), there were nine participants in the
“up-to-date” group (39%), twelve participants in the “some, but not all” group (52%), and two
participants in the “none” group (9%). When organized by children, 16 children, representing
32% of the sample were fully vaccinated, 27 children, representing 52% of the sample, had some
vaccines, but not all, and 7 children, representing 14% of the sample had no vaccinations at all.
Perceived Susceptibility
Perceived susceptibility was measured by summing the Likert-scale responses and
dividing by the number of questions in the construct. The higher the score (maximum possible
score = 5), the higher the perceived susceptibility to vaccinations. Overall, parental beliefs of
perceived susceptibility was low, with an average summed score of 1.94 out of 5 (Table 4).
Although the mean perceived susceptibility averages were different between groups (up-to-date
= 2.15, some = 1.97, none = .83), there were no statistically significant differences across the
groups in this construct (p > .05; Table 5). More than half of all respondents (73.9%) believed
that the chance of their child catching a VPD was low, and nearly all (87.0%) did not agree that
their child would catch the disease if unvaccinated, and over half (56.5%) believed that VPDs are
rare (Table 3).
Perceived Severity
Perceived severity was measured by summing the 6-point Likert-scale responses and
score = 5), the higher the perceived severity to VPDs. Overall, the average score was 3.47 out of
5, indicating relatively high perceived severity of all respondents. Nearly all respondents (91.3%)

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agreed that VPDs could be deadly, however 100% of parents whose children had no vaccines
disagreed. Nearly all (91.3%) agreed that VPDs could make their child very sick, 87.0% believed
that VPDs could leave their child physically disabled, 73.9% believed VPDs could cause their
child mental disability, 82.6% agreed it would be expensive, and 95.7% agreed it would be
stressful (Table 6). Parents whose children had all or some vaccinations had a significantly
higher perceived severity of VPDs than those whose children did not have any vaccinations ( p <
.05; Table 9). There were no statistically significant results between those whose children were
fully vaccinated, and those who had some, but not all vaccines (p = .995; Table 9).
Perceived Barriers
Perceived barriers were measured by summing the 6-point Likert-scale responses and
score = 5), the lower the perceived barriers to vaccination. Overall the average perceived barriers
score was 2.12 out of 5, indicating relatively high perceived barriers. However, 65.2% agreed
that childhood vaccinations are safe. Responses were split regarding whether vaccines might
cause learning disabilities with 43.5% agreeing, and 56.5% disagreeing. This was not a barrier
for the unvaccinated group, as all (100%) disagreed that vaccines might cause learning
disabilities. Although 72.7% disagreed that vaccines containing thimerosal were safe, 81.8%
thought that vaccines that did not contain thimerosal were safe. Nearly all (87.0%) agreed that
vaccines may cause uncomfortable side-effects. Furthermore, 87.0% believed that too many
vaccines given to a child at once may overwhelm a child’s immune system, and 82.6% believed
that children under two receive too many vaccines. The average score for perceived barriers were
2.75 for “up-to-date”, 1.81 for “some”, and 1.14 for “none” (Table 11). Although ANOVA

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detected a significant difference between groups (p < .035; Table 12), Tukey HSD did not
indicate where the difference occurred (Table 13).
Perceived Benefits
Perceived benefits were measured by summing the 6-point Likert-scale responses and
score = 5), the higher the perceived benefits to vaccination. The overall score for benefits was
3.16 out of 5, however it is interesting to note that the “none” group collectively reported no
perceived benefits to vaccines (Table 15). Tukey HSD showed that there was a significant
difference between groups; specifically between the “up-to-date” group and the “none” group,
and the “some, but not all” group and the none group (p < .05, Table 17). For the variable,
“Vaccines are important for keeping children healthy”, 82.6% of respondents agreed with this
statement. However, 0% of the “none” group agreed. For the variable, “Vaccines do a good job
[of] preventing disease”, 91.4% of respondents agreed. Interesting, this number comprised all of
the participants in the “up-to-date” and “some, but not all” groups, however, neither of the
participants in the “none” group agreed. Finally, for the variable that the human body can
naturally fight disease, the results were split, as 65.3% of respondents believed this to be true.
However, all of the “none” group believe this is true, while the other two groups had mixed
opinions (Table 14).
Government’s Role
Attitudes about the government’s role in vaccination mandates were measured by
summing the Likert-scale responses and dividing by the number of questions in the construct.
The higher the score (maximum possible score = 5), the stronger the belief in strict governmental
regulation of vaccinations. Overall, the average score was 1.04 out of 5, indicating a very low

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belief in strict governmental regulations. In fact, 91.4% believed that states should grant religious
and personal immunization exemptions. Only 4.3% believed it is the government’s right to
mandate vaccines, and 21.7% believed it is the government’s obligation to mandate vaccines.
ANOVA detected significant difference between groups (p < .05; Table 20; up-to-date = 1.64,
some = .73, none = .25), however Tukey HSD did not detect where the difference occurred
(Table 21).
Vaccination Mandates and Homeschooling
Attitudes about the vaccination mandates and homeschooling were measured by
summing the Likert-scale responses and dividing by the number of questions in the construct. A
high score (maximum possible score = 5), indicates a more positive reception to vaccine
mandates. The average for this construct was 3.02 out of 5, but the results for the two variables
conflicted. Most (78.2%) indicated that vaccination mandates in public schools did not play a
role in their decision to homeschool, however, 56.5% would seek an exemption if vaccines were
mandated for homeschoolers. Those who were fully vaccinated were significantly less likely to
seek an exemption and indicated that public and private school mandates played a role in their
decision to homeschool when compared to those who were not vaccinated (p > .05; Table 25).
Discussion
Income and educational level were not significantly associated with vaccination status (p
> .05). However, all of the respondents whose children had no vaccinations reported an annual
income of over $100,000. This furthers the evidence that lack of vaccinations are not due to
access issues, but rather beliefs in their safety and efficacy (Parker et. al, 2006).
The preliminary results of vaccination status are alarming, as only 32% of children were
fully vaccinated. Although the sample is relatively small (n =50), it is a stark comparison to the

RATES 20
rates in public school, where 82.8% are complete for all recommended vaccinations (DOH,
2015). Those who had some vaccinations represented the largest proportion of the sample (52%).
Due to the limitations of the study, researchers are unable to know how many, and which
vaccines parents are opting out of for their children. For example, this category could include
children who have completed series for all the vaccine but are just behind schedule on one
vaccine, or children who have only received one vaccination. More research on the specific types
of vaccines that are refused or delayed, as well as the vaccination status of children in the series
is needed to fully understand the scope of the problem.
Although there were no statistically significant differences between groups within the
perceived susceptibility construct, all groups had low perceived susceptibility to VPDs if
unvaccinated, with over half (56.5%) believing that VPDs are rare. In contrast, participants
demonstrated relatively high perceived severity if their child was to catch a VPD. That is, they
may think that they are not susceptible to VPDs, even though they believe that VPDs are serious
diseases. However, parents whose children had no vaccinations had significantly lower perceived
severity of VPDs than those whose children had some or all vaccinations. For example, parents
of children who had no vaccinations did not believe that VPDs could be deadly to their children,
and that if their child caught a VPD it would not be expensive. In contrast, 100% of the
respondents whose children were fully vaccinated, believed that VPDs could be deadly, and that
it would be expensive. This indicates an area where education on the severity of VPDs may be
necessary in order to increase vaccination rates.
For all groups, a significant barrier to vaccination was the belief that too many vaccines
given at one time can overwhelm a child’s immune system, with 87% of respondents agreeing
with this statement. Therefore, the dangers of delaying vaccination, and the safety of multi-dose

RATES 21
vaccinations need to be more clearly communicated. Overall, perceived barriers were high for all
groups. For the non-vaccinated group, they, overwhelmingly, did not believe that childhood
vaccinations were safe. In order to investigate the safety barriers further, researches designed
questions about the preservatives of vaccinations which has been identified as a perceived safety
barrier (Gerber & Offit, 2009). Thimerosal-containing vaccines were perceived to be unsafe by
all groups, but a vast majority (81.8%) agreed that vaccines that do not contain thimerosal were
safe. However, for the non-vaccinated group, it did not matter if the vaccine contained
thimerosal or not, as both were perceived to be unsafe. A significant difference was found
between those who had all or some vaccinations and those who had none regarding the safety of
non-thimerosal-containing vaccinations (p < .05). This demonstrates that more efforts should be
made to educate parents on the fact that most of the routinely recommended childhood vaccines
are thimerosal-free (U.S. Department of Health and Human Services, Food and Drug
Administration, 2015).
A surprising finding of the study was that the unvaccinated group disagreed that vaccines
may cause learning disabilities. This is contrary to much of anti-vaccination rhetoric to date
(Gerber & Offit, 2009). Nearly half of the respondents (43.5%) agreed that vaccines might cause
learning disabilities, in spite of the fact that no one in the non-vaccinated group agreed with this
statement. This indicates that the belief that vaccines cause learning disabilities is not a barrier
for those who do not receive vaccines, but may be a barrier to those who had received at least
some vaccinations. More research is needed to investigate this conflict in the data.
The perceived benefits to vaccination demonstrated the most significant difference
between those who had some or all vaccinations and those who had no vaccinations (p > .001).
The average scores of the perceived benefits construct among the “up-to-date” and “some, but

RATES 22
not all” groups were 3.67 and 3.31, respectively, which indicate high perceived benefits.
However, those with no vaccinations had an average score of zero for the perceived benefits
construct. It stands to reason that if an individual does not believe that vaccines have any
benefits, then they will not vaccinate their children. The difference between the partially and
fully vaccinated groups was stark; all of the respondents except those who had no vaccinations
believed that vaccines do a good job of preventing disease. This indicates that understanding and
believing in the benefits of vaccinations may be what makes the difference between
homeschooling parents vaccinating or not vaccinating children. However, upon exploring the
benefits of vaccines further, 65.3% of all respondents agreed that our bodies are able to naturally
fight VPDs. This indicates homeschooling parents may believe, overall, that vaccines do a good
job in preventing a disease, but our bodies may be able to naturally fight the disease if they
acquired a VPD. The results of this construct demonstrates an area of massive improvement on
the education of the benefits of vaccines.
Researchers also investigated homeschooling parent’s beliefs on governmental
requirements for vaccines. The results were alarming, as 91.4% believed states should grant non-
medical exemptions, and even more alarming were the results that only 4.3% said it was the
government’s right to mandate vaccinations. These results indicate that changing vaccination
policy to eliminate some non-medical exemptions and to require vaccinations for homeschoolers
would likely face significant pushback. However, an interesting result of the study was while
only 4.3% agreed it was the government’s right to mandate vaccines, 21.7% agreed that it was
the government’s obligation. In other words, some respondents did not believe that the
government had a right to mandate vaccines, but still felt that the government should mandate
vaccines. It is possible that there was confusion in the wording of the question, leading to this

RATES 23
seemingly conflicting response. However, an alternative explanation is that homeschooling
parents may experience cognitive dissonance that should be explored in further research.
Researchers were also surprised to find that vaccination mandates in public schools
played a small role in the decision to homeschool. However, vaccination mandates in public and
private schools were found to play a significant role in the non-vaccinated group’s decision to
homeschool. Although mandates played little overall role in the decision to homeschool, over
half (56%) of all respondents would seek an exemption if vaccinations were mandatory for
homeschoolers, indicating that even if mandates were extended to homeschoolers,
homeschoolers would likely seek out exemptions at higher rates than public and private schools,
as less than 10% of public and private school students have exemptions (DOH, 2015a). Hence,
mandating vaccines for homeschoolers may be insufficient to achieve similar vaccination rates of
public and private school children.
Overall, education on the safety of vaccines, the susceptibility of children to VPDs, and
the benefits of vaccinations needs to be better communicated to the homeschool population. It is
likely that the historical success of vaccinations preventing diseases has kept many individuals
unaware of the seriousness of VPDs, and the benefits of routine vaccines. Because people are
unexposed to the complications of many VPDs, they may be more likely to question the safety of
vaccination, and weigh it against the chance that they will get the VPD. The findings of this
study indicate that the construct that is most critical to communicate to homeschooling families
is the benefits of vaccination, as those who believed in the benefits were more likely to be
vaccinated than those who did not believe in the benefits. However, the non vaccinated group
also expressed a significantly higher perceived severity of VPDs and higher perceived barriers to

RATES 24
vaccination than the partially and fully vaccinated groups. Thus, these addressing these
constructs in patient education may also be necessary to achieve higher vaccination rates.
Making vaccination mandates the same for homeschooled children as they are for public
and private school children would likely face a significant push-back from the homeschooling
community as governmental vaccination mandates were viewed very negatively by every group
in the survey, even those who had fully vaccinated children. Further, if vaccinations were
mandated, over half stated they would seek an exemption.
Limitations
There were several limitations to this study. First, the sample obtained was a
convenience sample, which means that these results are not able to be generalized to the
homeschooling population, as it was not a random sample. Because no registry exists for
homeschoolers, a random sample was impossible. Thus, researchers reached out to individuals
within the population that were personal contacts. In addition, only a small sample of the
population was obtained, as the study was intended to be a pilot test of the instrument. Further
responses need to be collected in order to make claims about this population with confidence.
Another limitation is the lack of a comparison group. Although there is public record of
the percentages of children in public and private schools who are vaccinated, there is not a study
to show how those parents feel about vaccinations. In further research, a comparison group will
be established to see if there is a difference in beliefs about vaccinations between homeschooling
parents and parents who are not homeschooling. An additional limitation is that two participants
had children with different vaccination statuses. For the purpose of data analysis, researchers
assumed that the younger child would eventually be fully vaccinated if the older child had

RATES 25
already been fully vaccinated. However, this may not be true, as the parents’ opinions of
vaccinations may have changed since the oldest child was vaccinated.
Another limitation of the study was that participants were self-reporting on the
vaccination status of their children, which could be influenced by recall bias. The last limitation
that researchers found was that all the vaccines were combined in the survey questions. This
means that if participants had differing opinions on various vaccines, there was no way for them
to express this to researchers. Additionally, when reporting vaccination status there was no way
to know what vaccinations had or had not been received by the children in the “some, but not
all” group leading to a potentially huge range of vaccination statuses in this group.
Application and Implication
Because of the success that vaccination mandates in public and private schools have
played in reducing VPDs in a community (Orenstein, & Hinman, 1999; Khalili, & Caplan,
2007), vaccination policy should be changed for homeschoolers. Vaccination mandates in
Washington State should be extended to the homeschooling population in order to protect
homeschoolers, and their surrounding communities from VPDs. Furthermore, education
campaigns that target the benefits of vaccination, as well as the susceptibility to VPDs, if
remaining unvaccinated, should be conducted in homeschool groups and cooperatives
throughout Washington. The survey designed by researchers could be used to measure how
attitudes and vaccination rates change as a result of the policy and educational interventions.

RATES 26
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RATES 31
Tables
Table 1
Respondent’s demographics
Variable
Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)
Level of Educational Attainment
High School Diploma 2 (22) 1 (8) 1 (50) 4 (17)
Junior College Degree 1 (11) 1 (8) 0 (0) 2 (9)
Bachelor's degree 4 (44) 9 (75) 1 (50) 14 (61)
Master’s degree or higher 2 (22) 1 (8) 0 3 (13)
Annual Household Income
Less than $50,000 0 1 (8) 0 1 (4)
$50,000-$100,000 6 (67) 7 (58) 0 13 (57)
More than $100,000 3 (33) 4 (33) 2 (100) 9 (39)
Respondents Age
18-30 0 (0) 1 (8) 0 (0) 1 (4)
31-40 5 (56) 7 (58) 1 (50) 13 (57)
41+ 4 (44) 4 (33) 1 (50) 9 (39)
Respondents’ race/ethnicity
White 8 (89) 8 (67) 2 (100) 18 (78)
Asian 1 (11) 1 (8) 0 2 (9)

RATES 32
Hispanic/Latino 0 (0) 1 (8) 0 1 (4)
Two or more ethnicities 0 (0) 1 (8) 0 1 (4)
Prefer not to answer 0 (0) 1 (8) 0 1 (4)
Table 2
Vaccination Rates
Vaccination Status
By Respondent
n (%)
By Child
n (%)
Up-to-date 9 (39) 16 (32)
Some, but not all 12 (52) 27 (54)
None 2 (9) 7 (14)
Total 23 (100) 50 (100)

RATES 33
Table 4
Descriptives: Perceived Susceptibility
Vaccination Status N Mean
Std.
Deviation
Std.
Error
95% Confidence Interval
for Mean
Minimum Maximum
Lower
Bound
Upper
Bound
Up-to-date 9 2.1481 .78371 .26124 1.5457 2.7506 .33 3.00
Some, but not all 12 1.9722 .70293 .20292 1.5256 2.4188 1.00 3.33
None 2 .8333 .70711 .50000 -5.5198 7.1864 .33 1.33
Total 23 1.9420 .78914 .16455 1.6008 2.2833 .33 3.33
Table 3
Construct: Perceived Susceptibility
Variable Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)
If there is a vaccine available for a disease and my child is not vaccinated for that disease, they will catch
the disease
Strongly agree/Agree/Somewhat agree 1 (4.3) 2 (8.7) 0 (0) 3 (13.0)
Strongly Disagree/Disagree/Somewhat
disagree
8 (34.8) 10 (43.5) 2 (8.7) 20 (87.0)
Most of the diseases that the vaccines are supposed to prevent are rare.
Strongly agree/Agree/Somewhat agree 3 (13.0) 8 (34.8) 2 (8.7) 13 (56.5)
disagree
6 (26.0) 4 (17.4) 0 (0) 10 (43.5)
If there is a vaccine available for a disease and my child is not vaccinated for that disease, my child's chance
of catching that disease is low.
Strongly agree/Agree/Somewhat Agree 7 (30.4) 9 (39.1) 1 (4.3) 17 (73.9)
disagree
2 (8.7) 3 (13.0) 1 (4.3) 6 (26.1)

RATES 34
Table 5
ANOVA: Perceived Susceptibility
Sum of
Squares df Mean Square F Sig.
Between Groups 2.852 2 1.426 2.629 .097
Within Groups 10.849 20 .542
Total 13.700 22
Table 6
Construct: Perceived Severity
Variable Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)
VPDs could be deadly
disagree
0 (0) 0 (0) 2 (8.7) 2 (8.7)
VPDs could make child very sick
disagree
0 (0) 1 (4.3) 1 (4.3) 2 (8.7)
VPDs could make my child physically disabled
disagree
1(4.3) 1(4.3) 1(4.3) 3 (13.0)
VPDs could make my child mentally disabled
disagree
2 (8.7) 3 (13.0) 1 (4.3) 6 (26.1)
Catching a VPD would be expensive
Strongly agree/Agree/Somewhat Agree 9 (39.1) 10 (43.5) 0 (0) 19 (82.6)
disagree
0 (0) 2 (8.7) 2 (8.7) 4 (17.4)

RATES 35
If my child caught a VPD it would be stressful
disagree
0 (0) 1 (4.3) 0 (0) 1 (4.3)
Table 7
Descriptives: Perceived Severity
N Mean
Std.
Deviation
Std.
Error
for Mean
Minimum Maximum
Lower
Bound
Upper
Bound
Up-to-date 9 3.6111 .64550 .21517 3.1149 4.1073 2.83 5.00
Some, but not all 12 3.5833 .70173 .20257 3.1375 4.0292 2.00 4.67
None 2 2.1667 .47140 .33333 -2.0687 6.4021 1.83 2.50
Total 23 3.4710 .75987 .15844 3.1424 3.7996 1.83 5.00
Table 8
ANOVA: Perceived Severity
Sum of Squares df Mean Square F Sig.
Between Groups 3.731 2 1.865 4.158 .031
Total 12.703 22
Table 9
Multiple Comparisons: Tukey HSD. Perceived Severity
(I) Vaccination Status (J) Vaccination Status
Mean
Difference
(I-J)
Std.
Error Sig.
Lower
Bound
Upper
Bound
Up-to-date Some, but not all .02778 .29535 .995 -.7194 .7750
None 1.44444*
.52359 .031 .1198 2.7691
Some, but not all Up-to-date -.02778 .29535 .995 -.7750 .7194
None 1.41667*
.51156 .030 .1224 2.7109
None Up-to-date -1.44444*
.52359 .031 -2.7691 -.1198
Some, but not all -1.41667*
.51156 .030 -2.7109 -.1224

RATES 36
Table 10
Construct: Perceived Barriers
Variable Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)
Childhood vaccinations are safe
disagree
2 (8.7) 4 (17.4) 2 (8.7) 8 (34.8)
Vaccinations might cause learning disabilities
disagree
7 (30.4) 4 (17.4) 2 (8.7) 13 (56.5)
Vaccines that contain thimerosal (a mercury-based preservative) are safe
Strongly agree/Agree/Somewhat Agree 4 (18.2)* 2 (9.1) 0 (0) 6 (27.3)
disagree
4 (18.2)* 10 (45.5) 2 (9.1) 16 (72.7)
Vaccines that do not contain thimerosal are safe
Strongly agree/Agree/Somewhat Agree 7 (31.8)* 11 (50.0) 0 (0) 18 (81.8)
disagree
1 (4.5)* 1 (4.5) 2 (9.1) 4 (18.2)
Vaccines can cause uncomfortable side-effects
disagree
1 (4.3) 1 (4.3) 1 (4.3) 3 (13.0)
Too many vaccines given at one time can overwhelm a child's immune system
disagree
3 (13.0) 0 (0) 0 (0) 3 (13.0)
Children under the age of 2 receive too many vaccines.
disagree
4 (17.4) 0 (0) 0 (0) 4 (17.4)

RATES 37
*Data missing from one “up-to-date” respondent
Table 11
Descriptives: Perceived Barriers
N Mean
Std.
Deviation
Std.
Error
for Mean
Minim
um
Maximu
m
Lower
Bound
Upper
Bound
Up-to-date 9 2.7524 1.19087 .39696 1.8370 3.6678 .57 4.29
Some, but not all 12 1.8095 .69275 .19998 1.3694 2.2497 .57 2.57
None 2 1.1429 .40406 .28571 -2.4875 4.7732 .86 1.43
Total 23 2.1205 1.03249 .21529 1.6740 2.5670 .57 4.29
Table 12
ANOVA: Perceived barriers
Sum of
Between Groups 6.666 2 3.333 3.971 .035
Total 23.453 22
Table 13
Multiple Comparisons: Tukey HSD. Perceived Barriers
(I) Vaccination status (J) Vaccination status
Mean
Difference
(I-J)
Std.
Error Sig.
Lower
Bound
Upper
Bound
Up-to-date Some, but not all .94286 .40399 .074 -.0792 1.9650
None 1.60952 .71621 .087 -.2025 3.4215
Some, but not all Up-to-date -.94286 .40399 .074 -1.9650 .0792
None .66667 .69974 .614 -1.1037 2.4370
None Up-to-date -1.60952 .71621 .087 -3.4215 .2025
Some, but not all -.66667 .69974 .614 -2.4370 1.1037
Table 14
Construct: Perceived Benefits
Variable Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)

RATES 38
Vaccinations are important for keeping children healthy
disagree
1 (4.3) 1 (4.3) 2 (8.6) 4 (17.4)
Vaccines do a good job preventing disease
disagree
0 (0) 0 (0) 2 (8.6) 2 (8.6)
Our bodies can naturally fight the diseases vaccines are supposed to prevent
disagree
4 (17.4) 4 (17.4) 0 (0) 8 (34.7)
Table 15
Descriptives: Perceived Benefits
N Mean
Std.
Deviation
Std.
Error
for Mean
Minim
um
Maximu
m
Lower
Bound
Upper
Bound
Up-to-date
9
3.666
7
1.08012 .36004 2.8364 4.4969 2.00 5.00
Some, but not all
12
3.305
6
.70293 .20292 2.8589 3.7522 2.33 4.33
None 2 .0000 .00000 .00000 .0000 .0000 .00 .00
Total
23
3.159
4
1.30217 .27152 2.5963 3.7225 .00 5.00
Table 16
ANOVA: Perceived Benefits
Sum of
Between Groups 22.536 2 11.268 15.259 .000
Total 37.304 22

RATES 39
Table 17
Multiple Comparisons: Tukey HSD. Perceived Benefits
(I) Vaccine Status (J) Vaccination Status
Mean
Difference
(I-J)
Std.
Error Sig.
Lower
Bound
Upper
Bound
None 3.66667*
.67176 .000 1.9671 5.3662
None 3.30556*
.65631 .000 1.6451 4.9660
None Up-to-date -3.66667*
.67176 .000 -5.3662 -1.9671
Some, but not all -3.30556*
.65631 .000 -4.9660 -1.6451
Table 18
Construct: Government’s Role
Variable Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)
Individual states should grant vaccination exemptions for religious beliefs
Strongly agree/Agree/Somewhat
Agree
7 (30.4) 12 (52.2) 2 (8.7) 21 (91.4)
disagree
2 (8.6) 0 (0) 0 (0) 2 (8.6)
Individual states should grant immunization exemptions for personal beliefs
Strongly Disagree/Disagree/Somewhat disagree 2 (8.6) 0 (0) 0 (0) 2 (8.6)
It is the government’s right to mandate vaccinations
Strongly agree/Agree/Somewhat Agree 1 (4.3) 0 (0) 0 1 (4.3)
Strongly Disagree/Disagree/Somewhat disagree 8 (34.8) 12 (52.2) 2 (8.6) 22 (95.7)
It is the government’s obligation to mandate vaccinations
Strongly Disagree/Disagree/Somewhat disagree 5 (21.7) 11 (47.8) 2 (8.6) 18 (78.3)

RATES 40
Table 19
Descriptives: Government’s Role
N Mean
Std.
Deviation
Std.
Error
for Mean
Minim
um
Maximu
m
Lower
Bound
Upper
Bound
Up-to-date
9
1.638
9
1.12577 .37526 .7735 2.5042 .00 3.75
Some, but not all 12 .7292 .71873 .20748 .2725 1.1858 .00 2.00
None 2 .2500 .35355 .25000 -2.9266 3.4266 .00 .50
Total
23
1.043
5
.99044 .20652 .6152 1.4718 .00 3.75
Table 20
ANOVA: Government’s role
Sum of
Between Groups 5.635 2 2.818 3.534 .049
Total 21.582 22
Table 21
Multiple Comparisons: Tukey HSD, Government’s Role
(I) Vaccination Status (J) Vaccination Status
Mean
Difference
(I-J)
Std.
Error Sig.
Lower
Bound
Upper
Bound
None 1.38889 .69803 .141 -.3771 3.1549
None .47917 .68198 .765 -1.2462 2.2046
None Up-to-date -1.38889 .69803 .141 -3.1549 .3771
Some, but not all -.47917 .68198 .765 -2.2046 1.2462
Table 22
Construct: Vaccination mandates and homeschooling
Variable Up-to-date
n (%)
Some, but not all
n (%)
None
n (%)
Total
N (%)
Vaccination mandates in public and private schools have played a role in my decision to
homeschool my children.
disagree
8 (34.7) 10 (43.5) 0 (0) 18 (78.2)

RATES 41
If vaccinations were mandatory for homeschoolers, I would seek an exemption.
disagree
6 (26.1) 4 (17.4) 0 (0) 10 (43.4)
Table 23
Descriptives: Vaccination mandates and homeschooling
N Mean
Std.
Deviation
Std.
Error
for Mean
Minim
um
Maximu
m
Lower
Bound
Upper
Bound
Up-to-date
9
3.833
3
1.50000 .50000 2.6803 4.9863 1.00 5.00
Some, but not all 1
2
2.791
7
1.17663 .33967 2.0441 3.5393 1.00 4.00
None 2 .7500 1.06066 .75000 -8.7797 10.2797 .00 1.50
Total 2
3
3.021
7
1.52612 .31822 2.3618 3.6817 .00 5.00
Table 24
ANOVA: Vaccination mandates and homeschooling
Sum of
Between Groups 16.885 2 8.442 4.915 .018
Within Groups 34.354 20 1.718
Total 51.239 22
Table 25
Multiple Comparisons: Tukey HSD. Vaccination mandates and homeschooling
(I) Vaccine status. (J) Vaccine status.
Mean
Difference
(I-J)
Std.
Error Sig.
Lower
Bound
Upper
Bound
Up-to-date Some, but not all 1.04167 .57793 .194 -.4205 2.5038
None
3.08333* 1.0245
5
.018 .4912 5.6754
Some, but not all Up-to-date -1.04167 .57793 .194 -2.5038 .4205
None
2.04167
1.0010
0
.129 -.4908 4.5742
None Up-to-date
-3.08333* 1.0245
5
.018 -5.6754 -.4912
Some, but not all
-2.04167
1.0010
0
.129 -4.5742 .4908

RATES 42
Appendix A
Survey first draft
1. Are you currently homeschooling in Washington?
Yes [move on to Q2]
No [end survey]
2. Do you attend a homeschool program that reports on vaccination status?
Yes
No
Not sure
3) Do you believe that childhood vaccinations are:
Very safe, Safe, Somewhat safe, Not safe
4) Are you concerned that vaccinations might cause learning disabilities?
Very concerned, concerned, somewhat concerned, not concerned
5) Are you concerned that ingredients of immunizations are unsafe?
6) Do you think that immunizations are important for keeping children healthy?
Not important, Somewhat important, important, very important
7) Are you concerned that unvaccinated children will get or transmit diseases such as measles?
8) Are you concerned vaccines are given for diseases children are not likely to get?
9) Are you concerned that people your children are interacting with are not vaccinated?
Very concerned, Concerned, Somewhat concerned, Not concerned
10) Should states grant immunization exemptions for religious beliefs?
Yes, No
11) Should states grant immunization exemptions for personal beliefs?
Yes, No
12) Have immunization mandates in public and private schools played a role in deciding to homeschool
your children?

RATES 43
Yes, No
13) If vaccinations were mandatory for homeschoolers, would you seek exemptions?
Yes, No
14) Do you trust the government to set policy for vaccines?
Yes, No
15) Have you discussed your vaccination decisions with a physician?
Yes, No
16) I have enough access to information to make good immunization decisions.
Strongly agree, Somewhat agree, Somewhat disagree, Strongly disagree
17) I trust the vaccine advice my primary care provider gives me.
Strongly agree, Agree, Disagree, Strongly disagree
1. How many children do you currently homeschool?
______ (Fill in blank)
For child A/1 (etc.):
2) Has he/she ever attended a public or private school?
Yes [Skip Q3]
No [Go to Q3]
3) Has he/she ever participated in activities (such as sports, drama) at a public or private school?
Yes
No
4) Grade level:
0 K-5
0 6-8
0 9-12
4) Vaccination status on pertussis (also known as whooping cough):
0 Up-to-Date
0 Some, but not all
0 None/exempt
5) Vaccination status on tetanus/diphtheria:
0 Up-to-Date
0 Some, but not all
0 None/exempt

RATES 44
6) Vaccination status on measles, mumps, rubella (MMR):
0 Up-to-Date
0 Some, but not all
0 None/exempt
7) Vaccination status on polio:
0 Up-to-Date
0 Some, but not all
0 None/exempt
8) Vaccination status on Hepatitis B:
0 Up-to-Date
0 Some, but not all
0 None/exempt
9) Vaccination status on varicella (also known as chicken pox):
0 Up-to-Date
0 Some, but not all
0 None/exempt

RATES 45

RATES 46
Appendix B
Informed Consent
Dear Participant,
Thank you for taking the time to participate in our survey! By responding this short, online
survey, you will be assisting Community Health students at Western Washington University in
conducting research on vaccinations opinions and decisions of homeschooling parents. Your
participation provides valuable insight into a population that is largely unstudied, and potentially
misunderstood.
There are no risks or discomfort expected as a result of participating in this survey, and
participation time is expected to take 7-10 minutes. The survey consists of 31 questions through
which we hope to better understand your opinions on vaccine safety, importance, and decisions.
Participation in this survey is voluntary and as a participant, you have the right to skip any
questions you prefer not to answer, or withdraw from the survey at any time.
Your responses as a research participant will be kept confidential and anonymous. In other
words, there will be no personal identifying information requested and responses will be coded
into a secure online survey system, called Qualtrics. Results of this study may be published and
shared with the Washington State Department of Health. However, what is shared with the
Washington State Department of Health will be the results of the study as a whole, and
individual responses will be protected.
If you have any concerns or questions regarding this survey or research procedures, please
contact the faculty advisor, Dr. Ying Li via phone: (360) 650-3513 or by email at
Ying.Li@wwu.edu. Questions concerning your rights as a research subject, or regarding any
adverse effects as a result of participating in this research may be directed to the WWU Human
Protections Administrator at (360) 650-3220. We encourage you to print a copy of this consent
form for your personal records.
By providing your electronic signature, you consent to participate in the survey and are at least
18 years of age. We do recommend that you complete the survey on a computer, as
formatting issues may arise on a cellular phone.

RATES 47
Appendix C
Final Qualtrics Survey

RATES 48

RATES 49
*Vaccine Schedule courtesy of the Washington State Department of Health (2015).

RATES 50

RATES 51

RATES 52
Click the next green arrow button and you are done!

RATES 53

RATES 54
Appendix D
Scoring Guidelines
Question: if some children have different vaccination status what do we do?
Perceived susceptibility of VPDs. The higher the score, the higher the perceived
susceptibility. Max score = 15, low 0.
1. If there is a vaccine available for a disease and my child is not vaccinated for that
disease, they will of catch the disease
Strongly agree, +5
agree, +4
somewhat agree, +3
somewhat disagree, +2
disagree, +1
strongly disagree 0
1. Most of the diseases that the vaccines are supposed to prevent are rare.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
strongly disagree +5
1. If there is a vaccine available for a disease and my child is not vaccinated for that
disease, my child's chance of catching that disease is low.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Perceived Severity of VPDs. The higher the score, the higher the perceived severity. Max
score = 30.
If my child got a disease vaccines are supposed to prevent…
It could be deadly
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
It could make him/her/zie very sick
Strongly agree, +5
agree, +4

RATES 55
somewhat agree, +3
disagree, +1
strongly disagree 0
He/she/zie could be physically disabled.
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
He/she/zie could become mentally disabled
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
It would be expensive
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
It would be stressful
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Perceived barriers to vaccination. The Higher the score, the LOWER the perceived barriers
Max score 35
Childhood vaccines are safe.
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Vaccines might cause learning disabilities
Strongly agree, 0

RATES 56
agree, +1
somewhat agree, +2
disagree, +4
Vaccines that contain thimerosal (a mercury-based preservative) are safe
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Vaccines that do not contain thimerosal are safe
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Vaccines can cause uncomfortable side-effects
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Too many vaccines given at one time can overwhelm a child's immune system.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Children under the age of 2 receive too many vaccines.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Perceived Benefits The higher the score, the higher the perceived benefits. Max score 15
Vaccinations are important for keeping children healthy.
Strongly agree, +5

RATES 57
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Vaccines do a good job preventing disease.
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Our bodies can naturally fight the diseases vaccines are supposed to prevent.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Beliefs surrounding government’s authoritarianism regarding vaccines. The higher the
score, the more people believe the government should require vaccines. High score: 20
Individual states should grant vaccination exemptions for religious beliefs
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Individual states should grant immunization exemptions for personal beliefs
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
It is the government’s right to mandate vaccinations
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
It is the government’s obligation to mandate vaccinations

RATES 58
Strongly agree, +5
agree, +4
somewhat agree, +3
disagree, +1
strongly disagree 0
Vaccine mandates and homeschooling decision. The higher the score, the more friendly
they are to vaccination requirements for homeschoolers. Highest score = 10.
Vaccination mandates in public and private schools have played a role in my decision to
homeschool my children.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
If vaccinations were mandatory for homeschoolers, I would seek an exemption.
Strongly agree, 0
agree, +1
somewhat agree, +2
disagree, +4
Total = 125 points
The higher the score, the more positive views of vaccines and vaccine requirements.

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