Descendants of the Swiss Anabaptists, the Old-Order Amish (hereafter referred to as Amish) are the most distinctive of all Amish sects, relying on traditional beliefs and practices and rejecting as worldly the majority of modern conveniences. Because of a birth rate of approximately 7 children per family and a 90% retention rate for its youth, the Amish population in the United States has increased from 8200 in the early 1900s to approximately 180,000 now.1
In Illinois, the largest Amish community is centered around the town of Arthur in the east-central region of the state. Eight additional smaller communities are located throughout central and southern Illinois. Amish genealogic records from the year 2003 list 4538 persons living in these 9 communities; 3431 (76%) of these persons resided in the Arthur community, which consists of 775 households, including 374 households with children aged <15 years.2
Amish views on health and health care might contribute to their lack of adoption of vaccination as a means of disease prevention. Health is considered a gift from God and is not solely the result of preventive behaviors or medical intervention.1 Vaccination is not prohibited by the church; however, it is often not encouraged either. Additionally, Amish consciously avoid dependence on government assistance and might consider acceptance of free vaccinations a form of government welfare.
Multiple studies in the context of outbreaks of vaccine-preventable diseases have made a direct link between the low rate of reported vaccine coverage in Amish communities and their susceptibility to disease outbreaks. Outbreaks of rubella,3 measles,4 pertussis,5Haemophilus influenzae,6 and polio,7 as well as increased cases of childhood tetanus,8 have disproportionately affected Amish communities in the United States. In each of these outbreaks, the vaccination rates were too low to confer herd immunity to the Amish communities, which provided the opportunity for vaccine-preventable diseases to spread largely unchecked among community members and placed vulnerable members of the surrounding community at risk for contracting these diseases. Unvaccinated Amish communities can serve as environments where vaccine-preventable diseases persist, putting unvaccinated persons at risk for illness and slowing progress towards national goals of elimination of vaccine-preventable diseases.
No data exist on vaccination beliefs and practices among the Amish in Illinois. We initiated this study to quantify the proportion of Amish households that reject vaccination and determine how often this rejection is due to religious beliefs.
MATERIALS AND METHODS
In September 2005, questionnaires were mailed to all Amish households in the Arthur community through a community newsletter. To ensure that the questionnaire was culturally sensitive and understandable, Amish community leaders were consulted on appropriate study content and methodology before distribution. The questionnaire asked about the respondent’s vaccination status and that of all children aged <15 years residing in the household, where they had received vaccinations, and if applicable, reasons for not receiving vaccinations. Factors that might influence vaccination use (eg, the age of parents and frequency of nonemergency medical care) were also included in the questionnaire. Households without children only answered demographic and personal vaccination history questions. The questionnaires were returned to the Illinois Department of Public Health in prepaid envelopes, with no identifying information provided by the respondents. Univariate analysis was performed by using EpiInfo, version 3.3.2, statistical software (Centers for Disease Control and Prevention, Atlanta, GA) in which odds ratios (ORs) were calculated and hypotheses tested by using the χ2 test. ORs with 95% confidence intervals (CIs) that excluded 1.0, and P values <.05 were considered statistically significant.
Responses were received by 225 (60%) of the 374 Amish households in the community with children aged <15 years. An additional 120 responses were received by households without children. A total of 189 (84%) households with children reported that all of their children had received vaccinations; 28 (12%) reported that some of their children had received vaccinations; and 8 (4%) reported that none of their children had received vaccinations. Among the 36 respondents who had unvaccinated children, 16 (44%) cited concerns about vaccine safety as the reason their children were unvaccinated; 3 (8%) attributed their children’s unvaccinated status to religious objections (Table 1). Not having received vaccinations as a child (OR, 4.2; 95% CI, 1.1–16.3) and seeking nonemergency medical care ≤2 times during the preceding year (OR, 2.6; 95% CI, 1.1–6.0) were statistically associated with having unvaccinated children. Decisions about children’s medical care were made by fathers in 6 households (3%), were made by mothers in 29 households (13%), and were made jointly in 188 households (84%). Approximately three quarters (74%) of respondents had gone to the doctor’s office to receive vaccinations.
Among all respondents who knew their own vaccination status, 281/313 (90%) reported that they had received vaccinations as children. Stratified analysis revealed that younger respondents were statistically significantly more likely to have been vaccinated as children; 194/202 (96%) respondents aged <45 years had received vaccinations, whereas 87/111 (78%) respondents aged ≥45 years had been vaccinated (OR, 6.7; 95% CI, 2.7–16.9; P < 0.0001). The majority of respondents (93%) were uninsured, and the majority of those without insurance (71%) relied on a mutual aid network to assist with medical expenses.
This study reveals that Amish households do not universally reject vaccines, and Amish objections to vaccines are not typically for religious reasons. Additionally, the decision to accept vaccinations is based on multiple factors and might be influenced by information on vaccine safety provided by trusted medical providers. These data demonstrate that previous reports of Amish vaccination status derived from previous studies should not be generalized to all Amish communities.
The study finding that 90% of respondents had received vaccinations and 84% of families had vaccinated all of their children was surprising, on the basis of our past understanding of Amish vaccination rates. No comprehensive study has examined vaccination coverage among Amish in the United States. Common methods of assessing vaccination status (eg, telephone surveys9 or college entry surveys) lack the ability to include the Amish as part of the study population because the Amish do not have telephones or attend college. Small community-based surveys of Amish in Pennsylvania1,6 and Wisconsin10 demonstrated that the vaccination rates of children in these Amish communities were too low to prevent vaccine-preventable diseases, if introduced, from spreading within the community. This study demonstrates that previous reports of Amish vaccination status should not be generalized to all Amish communities.
The higher rate of vaccination among young adults in our study demonstrates that adoption of vaccination in this community has increased over time. Although the reasons for this increase are not entirely clear, this finding demonstrates that Amish beliefs and practices regarding vaccination are not static and can be influenced by factors in the community.
The objections to vaccinations expressed in this survey indicate that Amish concerns about vaccines are similar to those expressed by other parents of unvaccinated children. Amish parents of unvaccinated children cited objections to vaccines based on concern for their children’s well-being rather than objections based on theological, ideological, or philosophic reasons, supporting previous findings that religious objection is not the primary reason for rejecting vaccinations.1,6 Safety concerns were the most frequently listed reason for not vaccinating, replicating findings from nationwide surveys9 of non-Amish parents of unvaccinated children. These important concerns, when understood, can be addressed by medical providers.
The Amish rely on trusted health-care providers for information about preventive practices.1 The study finding that the overwhelming majority of households visit their physicians for vaccinations underscores the importance of the doctor-patient relationship in influencing their decision to vaccinate their children. Additionally, because the majority of Amish families do not have insurance coverage for vaccinations, the fact that the majority qualify for the Vaccines for Children Program makes obtaining vaccinations at their doctor’s office economically feasible. These visits provide an important opportunity for the health-care provider to ask about the vaccination status of all eligible children.
Although Amish society is often considered patriarchal, this study revealed that, in the majority of households, the mother is considered to have a joint role in making decisions about their children’s medical care. This fact is important to consider when developing educational messages for Amish communities.
Study limitations include a moderate response rate, the lack of ability to correlate survey response with vaccine registry data, and the lack of detailed vaccination information for each child.
The vaccination rate reported in this study has critical implications for efforts to promote vaccinations among Amish communities. The results of this study indicate that Amish communities might be influenced to accept vaccines if medical providers openly address the topic of vaccination with Amish patients and deal with individual concerns about vaccination. We recommend that federal, state, or local health agencies create culturally sensitive educational materials that specifically address vaccine safety and make these materials available to Amish patients through their health-care providers. These findings provide hope that improved vaccination coverage among Amish communities can be achieved through building relationships and targeted public health efforts.
We appreciate the contributions of Chuck Jennings and Alicia Fry in the conception of this project; of Susan Hays, Angie Hogan, Kae Hunt, and Debbie Rowe in the development of the survey instrument; of Michele McGee for data entry; and of Carol Stutzman and Dorothy Kunz for providing community contacts.
Neither of the authors has a commercial or other association with products or processes that might pose a conflict of interest. No grants or other outside funding sources were used in the collection of these data. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
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