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Year: 2008

Attitudes towards vaccination: users of complementary andalternative medicine versus non-users

Zuzak, T J; Zuzak-Siegrist, I; Rist, L; Staubli, G; Simoes-Wüst, A P

Zuzak, T J; Zuzak-Siegrist, I; Rist, L; Staubli, G; Simoes-Wüst, A P (2008). Attitudes towards vaccination: users ofcomplementary and alternative medicine versus non-users. Swiss Medical Weekly, 138(47-48):713-718.Postprint available at:http://www.zora.uzh.ch

Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch

Originally published at:Swiss Medical Weekly 2008, 138(47-48):713-718.

Zuzak, T J; Zuzak-Siegrist, I; Rist, L; Staubli, G; Simoes-Wüst, A P (2008). Attitudes towards vaccination: users ofcomplementary and alternative medicine versus non-users. Swiss Medical Weekly, 138(47-48):713-718.Postprint available at:http://www.zora.uzh.ch

Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch

Originally published at:Swiss Medical Weekly 2008, 138(47-48):713-718.

Attitudes towards vaccination: users of complementary andalternative medicine versus non-users

Abstract

PRINCIPLES: Children whose parents use complementary and alternative medicine (CAM) often showa lower rate of vaccination than those of parents favouring conventional medicine. We have investigatedwhether this applies to the paediatric patients presenting to an emergency department inGerman-speaking Switzerland, where popularity of CAM is rather high. METHODS: A cross-sectionalsurvey was performed of paediatric patients presenting to an urban, tertiary paediatric emergencydepartment. 1007 (63%) of the distributed 1600 questionnaires were available for analysis. RESULTS:12.7% of all respondents reported refusing some basic vaccination: 3.9% because of recommendation ofthe physician, 8.7% despite their physician's recommendation. Socio-demographic characterisation ofthe group of patients refusing vaccination showed older age of children, higher proportion of girls, moresingle-mothers families and decreased household income. Refusal of basic vaccination was significantlymore frequent among CAM-users than among non-users (18.2% versus 3.5%, p

Original article S W I S S M E D W K LY 2 0 0 8 ; 13 8 ( 4 7 – 4 8 ) : 7 13 – 7 18 · w w w. s m w. ch

Peer reviewed article

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Attitudes towards vaccination: users of complementary and alternativemedicine versus non-usersTycho Jan Zuzaka, Isabelle Zuzak-Siegrista, Lukas Ristb,Georg Staublia, Ana Paula Simões-Wüstb

a University Children’s Hospital of Zurich, Zurich, Switzerlandb Paracelsus Hospital Richterswil, Richterswil, Switzerland

Principles: Children whose parents use com-plementary and alternative medicine (CAM)often show a lower rate of vaccination than thoseof parents favouring conventional medicine. Wehave investigated whether this applies to the paediatric patients presenting to an emergencydepartment in German-speaking Switzerland,where popularity of CAM is rather high.

Methods: A cross-sectional survey was per-formed of paediatric patients presenting to anurban, tertiary paediatric emergency department.1007 (63%) of the distributed 1600 question-naires were available for analysis.

Results: 12.7% of all respondents reported refusing some basic vaccination: 3.9% because ofrecommendation of the physician, 8.7% despitetheir physician’s recommendation. Socio-demo-graphic characterisation of the group of patientsrefusing vaccination showed older age of children,higher proportion of girls, more single-mothersfamilies and decreased household income. Refusalof basic vaccination was significantly more fre-quent among CAM-users than among non-users

(18.2% versus 3.5%, p

In the present work, the vaccination rates ofpaediatric patients presenting to an urban, terti-ary paediatric emergency department (Zurich,Switzerland) have been investigated using de-tailed questionnaires. Since the respondents alsodelivered information on their attitudes towardsCAM, the correlation between refusal of basic

vaccination and CAM use could be directly as-sessed. Moreover, the attitudes of the respondentstowards some recommended complementary vac-cination and vaccination for persons at risk havebeen addressed. Taken together, our data shedsome light on the parental decisions behind basicvaccination refusal.

714CAM and vaccination

Patients and methodsThe study characteristics have been described in de-

tail elsewhere [1]. In brief, the study was an analyticalcross-sectional survey of the patients presenting to thepaediatric emergency department of the University Chil-dren’s Hospital of Zurich, in Switzerland. The study,which had been approved by the Hospital Ethical ReviewBoard, was undertaken between October 2006 and March2007. German, English, French and Italian versions of thepatient information sheet, consent form and question-naire were available. The questionnaire was completelyanonymous. Exclusion criteria were: 1) previously filled-in questionnaire, 2) inability to read or write German,English, French, and Italian, 3) resuscitation/emergencypatients, 4) children unaccompanied by a parent or an-other carer, and 5) patients with emotional issues such aschild abuse or psychiatric problems. A multiple choicequestionnaire consisting of 34 multiple-choice questionswas used; an online version of the questionnaire is avail-able for authorised users [1].

The questionnaire contained one section about howthe children were vaccinated, with the possibility to markwith a cross one or more of the following statements: a)the paediatrician vaccinated the child as it is common inSwitzerland, b) the physician advised us to refuse somevaccines, c) we have decided against some vaccines al-though the physician has recommended them, d) thechild has already received one flu-vaccination, e) the child

is vaccinated against tick-borne encephalitis, f) the child isvaccinated against pneumococcal disease, and g) the childis vaccinated against meningococcal disease. It is impor-tant to note that the respondents only had to say whetherthe physician had vaccinated the child as common inSwitzerland with no discrimination among the variousbasic vaccines being performed. In this way, the influenceof the age of the children (and associated vaccines) on theanswer of the parents could be minimised. Question-naires returned with less than 50% of the questions an-swered or with no answers to the specific questions ofvaccination were excluded from the analysis. The remain-ing survey results were entered into a computerised data-base using Remark Office OMR 6.0.4 (Gravic Inc.,Malvern PA, USA). Data entry was performed using aMicrosoft Excel database and all data were analysed usingSPSS for Windows version 14 (SPSS Inc., Chicago IL,USA). Pearson’s chi-square tests and Mann-Whitney-U-tests were used to determine statistically significant dif-ferences between groups, with a p-value (always two-sided) of less than 0.05 considered to be statistically significant. The choice for a statistical test to search forsignificant associations between different parameters wasbased on the nature of these parameters. The presentstudy can therefore, and also because of its originality, beconsidered as exploratory.

Results

Seventy-two per cent of the distributed ques-tionnaires (1158 out of a total of 1600) were re-turned. 151 returned questionnaires were not en-tered into the database as less than 50% of thequestions had been answered (n = 15) or specificquestions of vaccination not answered (n = 136).1007 (63%) questionnaires were available for dataanalysis.

127 (12.6%) of all respondents declared thatthe paediatric patient presenting to the emer-gency department had not been vaccinated “ascommon in Switzerland”, i.e. most likely did notget the basic vaccination recommended by theFederal Office of Public Health (FOPH) ofSwitzerland (diphtheria, tetanus, pertussis, polio,haemophilus influenza, measles, rubella andmumps) [10]. This corresponds to a vaccinationrate among the respondents of 87.3%.

The socio-demographic characteristics of thechildren and of the families completing the ques-tionnaires are depicted in table 1, in which the pa-

tients have been divided in two groups: vaccinatedand non-vaccinated. Note that “non-vaccinated”means that the patients did not entirely follow thebasic vaccination scheme. Whereas the non-vacci-nated children were on average one year olderthan the vaccinated ones (6.6 versus 5.6 years, p = 0.015), the age of the mothers of the non-vac-cinated children (37.8 versus 35.5 years, p

715

children could be found between the vaccinatedand non-vaccinated groups. Whereas no statisti-cally significant difference concerning the schooleducation of the parents could be found betweenthe two groups, the household income was higherin the groups of the vaccinated children (4580versus 5051 Euros, p = 0.05). The type of healthinsurance was identical in the two groups, but theprevalence of an additional insurance for CAMwas markedly higher in the group of the non-vac-cinated children (84 vs. 50%, p

i.e. in 68.7% of the refusals, the parents had de-cided against a vaccination although the physicianhad recommended it. This means that the physi-cians themselves were responsible – in as much asthey had recommended renouncing to certainvaccinations – for merely 31.3% of the refusals,i.e. in only 3.9% of all cases. Users and non-usersof CAM showed comparable rates of immunisa-tion in the case of the mentioned complementaryvaccinations. The rates were as well comparablein the case of the vaccination against flu, which isonly recommended for persons at higher risk.Small tendencies for higher rates of vaccinationsagainst flu and pneumococcal disease could be de-tected among the non-users of CAM, whereas therate of vaccination against meningococcal diseaseseemed to be elevated in the CAM-users group.Against our expectations, the rate for vaccinationagainst tick-borne encephalitis – another vaccina-tion recommended only for persons at higher risk– in the CAM-users group was markedly and in astatistically significant way higher than among thenon-users (21.2 versus 15.4%, p = 0.025).

The respondents were also asked about theattitude of their physicians towards CAM and theanswers were related to the rate and the reasonsfor vaccination refuse (table 3). The rate of vacci-nation-refusal was the highest among patientswho consulted physicians practicing herbal medi-cine (63.6%), followed by those using anthropo-sophical medicine (52.4%) and homeopathy(43.0%). Parents’ choice predominated in thegroups of respondents whose physician is againstCAM (100%), whose physician tolerates CAM,but does not object to its use (88.6%) and of therespondents that do not talk with their physicianabout CAM (75.8%). Parents’ choice still pre-dominated in the groups with a physician practic-ing homeopathy or phytotherapy. In opposition,physicians’ recommendation to some of the basicvaccinations predominated in the group of re-spondents that consulted physicians practicinganthroposophic medicine or Chinese traditionalmedicine.

716CAM and vaccination

Respondents All CAM-users Non-users Significance(p-value)

Number 1007 632 62.8% 375 37.2%

Refused basic vaccinations which are 128 12.7% 115 18.2% 13 3.5%

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Our results show that a considerable propor-tion (13%) of the children presenting to theemergency department of a hospital in the Ger-man-speaking part of Switzerland were missingsome of the basic vaccines, which corresponds toa vaccination coverage of 87%. Although thisnumber derives from information given only bythe parents (see below), it compares well to theSwiss national vaccination coverage level reportedfor 2005 [11], if one looks at the recommendedvaccines which are more often subject of discus-sion, namely those against measles, mumps andrubella (84.9–86.2% for one dose [11]). In opposi-tion, the national coverage level for the doubledoses of the same vaccines are lower (75–72.6%)and those for the vaccines against the remainingdiseases are higher (95.4–87.3%) [11].

The reasons for the refusal of vaccinationmore often reflected a personal decision of theparents than a physician’s recommendation. Al-though the respondents were not directly askedabout the reasons for the refusal of vaccinations,the comparison of the socio-demographic charac-teristics of the group of children missing somevaccinations with those of the group of childrenwith all basic vaccinations unveils some of theparents’ options underlying that refusal (seebelow). Comparable data have been previouslypublished, which showed that the decision for aHepatitis B vaccination is influenced not only bythe physician, but also by the patient’s personalrisk perception and mistrust in the medical estab-lishment [12]. Moreover, the patients tend to be-come more aware of the side effects of a givenvaccine as the incidence of the corresponding dis-ease diminishes due to the vaccination’s success[13]. For most people, the vaccination risks areperceived as being high, probably due to a fewnegative events happening in the last century anda deficient risk communication [14].

The socio-demographic characterisation ofthe group of children missing vaccination showeda higher proportion of girls, implying that parentsmight refrain from submitting girls – more thanboys – to this voluntary medical intervention. Thehigher proportion of mother-only families amongthe group of children missing vaccines might re-flect a particularly critical attitude of women to-wards vaccination. Since the household income ofsingle-mother families is likely to be lower than inintact families, this might be associated with thedecreased household income in the group missingsome basic vaccines. A contradiction seems toexist between the relatively lower income in thegroup of the non-vaccinated children and thehigh prevalence of an additional insurance forCAM in the same group, which implies extracosts. This discrepancy might be related to thelow costs of CAM in general, which translate in amoderate price for the additional insurance

(below 20 Euros per month). Whether this rela-tively low price of an additional insurance forCAM might be associated with the relatively highrate of CAM use in Switzerland will be the subjectof further investigations.

Refusal of basic vaccination was significantlyhigher among CAM-users than among non-users.It is worth mentioning that the major reasons forthe increased popularity of CAM are a stronglycritical attitude to and distrust of conventionalmedicine as well as safety concerns [8, 15]. Thesereasons seem to overlap with the arguments foravoiding basic vaccinations. That the use of CAMoften associates with low vaccination rates in chil-dren has been previously shown in a Canadianstudy on children presenting for naturopathic as-sessment [4]. However, the opinions of the CAM-physicians do vary [6, 7]. The majority of theCanadian naturopaths, for instance, would advisea partial vaccination [5]. Similarly, the Germanhomeopathic physicians often make a clear dis-tinction between the various vaccines, with the‘classical’ vaccines against tetanus, diphtheria andpoliomyelitis being preferred relatively to thoseagainst childhood diseases, as well as those di-rected to risk groups [16].

Approximately two thirds of all parents whosechildren did not receive the complete basic vacci-nation took this decision despite an oppositephysician’s recommendation. These data point inthe same direction as our observations showingthat most CAM-use can be attributed to self-medication [1]. A considerable part of the popula-tion seems to be reluctant to delegate decisionsconcerning medical issues to the physicians, withboth the use of CAM and the decision to vaccineor not being considered to be private issues. Oc-casionally, the parent’s decisions might be surpris-ing, as exemplified by a previous report on thecoverage levels of vaccines against flu and invasivepneumococcal infections showing these to behigher among recent CAM-users in the USA thanamong non-users [17]. Our observation thatCAM-patients opt for the vaccine against tick-borne encephalitis more frequently than non-users goes along the same line. It is conceivablethat the CAM-users have a particularly high levelof interest for health-questions, therefore lookingnot only for alternatives to conventional medicinebut also for new products, such as new vaccines.An alternative explanation for the higher vaccina-tion rate against tick-borne encephalitis might bethat CAM-users may practise a lifestyle withmore contact with nature and higher exposure toticks, which would place them in a high risk groupfor tick-borne encephalitis.

The major limitations of the study are: thelack of clinical data, the exclusion of respondentswho could not read or write German, English,French, and Italian, the lack of differentiation

717S W I S S M E D W K LY 2 0 0 8 ; 13 8 ( 4 7 – 4 8 ) : 7 13 – 7 18 · w w w. s m w. ch

Discussion

713-718 Zuzak 12423.qxp 25.11.2008 9:51 Uhr Seite 717

among the different basic vaccines and a ratherwide definition of CAM. The lack of clinical dataimplies that the description of the vaccination sta-tus of the patients was given exclusively by the re-spondents themselves while answering to thequestionnaires, therefore an overestimation of thevaccination coverage can not be excluded. Alsothe data about their physicians were delivered bythe respondents rather then by questioning thephysicians directly. This has however the advan-tages of preserving the respondents and physi-cians anonymity and keeping the work load of thestudy and corresponding budget rather low. Fur-thermore the fact that the analysis was performedwith only 63% of the distributed questionnairescan be seen as a limitation, since it can not be ex-cluded that some sort of selection bias might havearisen at this stage. Since the filling-in of thequestionnaires required a considerable amount oftime, it is for instance conceivable that the re-spondents were either particularly interested inCAM, or had particularly strong feelings againstCAM. Should the former case be true, the pro-portion of CAM-users might be overestimated,which however is unlikely in face of the associa-tion between CAM-use and vaccine refuse on theone hand, and of the similarity between the esti-mated vaccination coverage values and the na-tional values on the other.

In summary, we could show that the lack ofcoping with the basic vaccination schema in ourstudy-population, which is likely to represent thesituation in the families of the German-speakingpart of Switzerland, is associated with the use of

CAM. The refusal to follow the basic vaccinationschema is mostly based on parents’ choice andoften occurs in opposition to the physician’ rec-ommendations. CAM-users, however, do usesome other vaccinations at least as often as non-users, in the case of the vaccine against tick-borneencephalitis even more often. This observationseems to support the Swiss system of vaccine rec-ommendations in as much as it provides the par-ents with freedom to choose and might shed somelight on how to communicate the informationabout vaccinations to parents. Finally, our workindicates that the parents are making their deci-sions in a differentiated way and probably wouldlike to be more involved in the decisions on med-ical issues affecting their children. It is importantthat the physicians in general are aware of this, sothat they can provide these parents with accurateand detailed information about safety, side effectsand benefits of vaccinations.

We would like to thank the staff, parents and chil-dren of the paediatric emergency department of Chil-dren’s Hospital of Zurich for their time and co-operation.

Correspondence:Dr. med. Tycho J. ZuzakUniversity Children’s HospitalSteinwiesstrasse 75CH-8032 ZurichSwitzerlandE-Mail: tycho.zuzak@kispi.uzh.ch

718CAM and vaccination

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