Vaccine xxx (xxxx) xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Short communication

Parental attitudes and decisions regarding MMR vaccination during an

outbreak of measles among an undervaccinated Somali community in
Minnesota
Ben Christianson a,⇑, Fatuma Sharif-Mohamed a, Jennifer Heath a, Margaret Roddy a, Lynn Bahta a,
Hinda Omar a, Todd Rockwood b, Cynthia Kenyon a
a
Minnesota Department of Health, 625 Robert Street North, St. Paul, MN 55164, USA
b
University of Minnesota, 420 Delaware Street SE, MMC 729 Mayo, Minneapolis, MN 55455, USA

a r t i c l e i n f o a b s t r a c t

Article history: Incidence of measles is increasing in the US, largely due to transmission among growing unvaccinated
Received 24 May 2020 communities. To elucidate predictors of parental decision to obtain measles, mumps, and rubella
Received in revised form 4 September 2020 (MMR) vaccine for unvaccinated children during a measles outbreak, we surveyed families among a
Accepted 7 September 2020
vaccine-hesitant Somali community in Minnesota. The survey assessed attitudes and beliefs about
Available online xxxx
MMR vaccine, motivators for vaccinating, and intention to vaccinate future children on time. Among
300 families surveyed, 95% vaccinated their child with MMR due to fear of measles. The predominating
Keywords:
parental concern about MMR vaccine (71%) was a fallacious presumed connection between vaccination
Immunization
Vaccine
and autism. Only 41% of parents intended to vaccinate future children on time with MMR; parents
Measles who received recommendations for MMR vaccination from multiple sources were more likely than other
Measles-Mumps-Rubella Vaccine parents to intend to do so. These findings support the importance of diverse outreach efforts to increase
vaccine coverage among undervaccinated communities.
Ó 2020 Elsevier Ltd. All rights reserved.

1. Introduction prevalent community-level misconception that MMR vaccination

In 2019, 1282 cases of measles were reported in the United
States, representing the largest number of cases nationwide since
1992 [1]. A primary cause of the increasing incidence of measles
is growth of unvaccinated populations in which transmission
occurs rapidly. Indeed, 8 outbreaks among undervaccinated com-
munities accounted for 85% of measles cases reported nationally
during 2019 [2].
Two recent measles outbreaks have occurred in Minnesota
among an undervaccinated, close-knit Somali community in the
Minneapolis/St. Paul metropolitan area [3,4]. In 2011, 8 (38%) of
21 outbreak-associated cases of measles were diagnosed in chil-
dren of Somali descent. Retrospective analysis of statewide immu-
nization data indicated that measles, mumps, and rubella (MMR)
vaccine coverage among 2-year-old Somali children in Minnesota
decreased from 91% in 2004 to 67% in 2010 (Minnesota Depart-
ment of Health [MDH], unpublished data, 2011). Consequently,
MDH interviewed local Somali community members, revealing a
⇑ Corresponding author at: Vaccine Preventable Disease Section, Minnesota
Department of Health, 625 Robert Street North, St. Paul, MN 55164, USA.
E-mail address: Ben.Christianson@state.mn.us (B. Christianson).
can cause autism spectrum disorder (ASD) [5], notwithstanding
an absence of scientific evidence to support this belief [6]. Despite
efforts by MDH to dispel such misinformation, MMR vaccine cover-
age among 2-year-old Somali children in Minnesota further
declined to 42% in 2017 (MDH, unpublished data, 2017). Early out-
reach efforts included small group meetings between parents and a
Somali health educator, informational flyers, listening sessions
with health care providers, and outreach to school and child care
officials that predominantly serve the Somali community.
In 2017, a larger measles outbreak occurred in Minnesota, with
61 (81%) of 75 cases identified in persons of Somali descent [4].
During this outbreak, MDH used pre-existing partnerships within
the local Somali community to raise awareness about the outbreak,
the severity of measles, and the importance of MMR vaccination.
These partnerships included schools and child cares that predom-
inantly serve Somali families, a community advisory group, a net-
work of parents that attended small group meetings with a Somali
health educator, and educational sessions with local mosques. Sub-
sequently, the weekly mean number of MMR doses administered
to Somali persons statewide increased 400% (MDH, unpublished
data, 2017). To elucidate potentially causative factors associated
with this increased vaccine uptake, MDH surveyed Somali parents

https://doi.org/10.1016/j.vaccine.2020.09.022
0264-410X/Ó 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: B. Christianson, F. Sharif-Mohamed, J. Heath et al., Parental attitudes and decisions regarding MMR vaccination during an out-
break of measles among an undervaccinated Somali community in Minnesota, Vaccine, https://doi.org/10.1016/j.vaccine.2020.09.022
B. Christianson et al.
who elected to vaccinate children who previously were overdue for
their initial dose of MMR vaccine.
2. Methods
2.1. Study population and survey design
A cross-sectional telephone survey was conducted between
November 2017 and May 2018 among Somali families in Min-
nesota who obtained MMR vaccination for overdue unvaccinated
children during a measles outbreak in 2017. The primary aim of
the survey was to understand parental attitudes, beliefs, and
decision-making regarding MMR vaccine. Secondary aims included
characterizing the experiences of families during their clinic visits
for MMR vaccination and identifying predictors of parental intent
regarding MMR vaccination of future children.
Eligible participants were parents in the 7-county Minneapolis/
St. Paul metropolitan area with a child of Somali descent who was
born in Minnesota between 2010 and 2015, overdue for the first
dose of MMR vaccine, and received initial MMR vaccination
between April and August 2017. Children were identified using a
statewide immunization information system and birth certificate
data including race of the child and maternal country of birth. To
achieve 80% power at a significance level of P < .05, a sample size
of 300 families was needed. Eligible families were sampled ran-
domly; up to 6 attempts were made to call selected families at dif-
ferent times of day on weekdays and weekends.
The 12-question survey assessed parental attitudes, beliefs, and
decision-making regarding MMR vaccine; factors that motivated
parents to seek MMR vaccination; sources of messaging recom-
mending MMR vaccination; clinic experiences when children
received MMR vaccine; perceived adverse events after MMR vacci-
nation; and parental intention to vaccinate a future child with
MMR on time (Table 1). The questionnaire was translated into
the Somali language. Telephone surveys were conducted by
Somali-speaking public health staff trained in conversational inter-
viewing techniques [7]. Responses were directly translated by the
interviewer and recorded in English. Survey questions and
response categories were pilot tested in 24 preliminary interviews
conducted by 2 interviewers in parallel.
The MDH Institutional Review Board reviewed the protocol and
determined that the survey was within the scope of public health
practice and did not qualify as research; therefore, informed con-
sent of participants was not required. No incentives were provided
Table 1
Survey questions.
Question
What made you vaccinate your child with MMR vaccine?
How do you feel about your decision to vaccinate your child with MMR vaccine? Why?
If you had concerns about getting the MMR vaccine, what made you change your mind?
Who makes the vaccine decisions in your family?
Did you have concerns about MMR vaccine before and, if so, what were they?
Did you hear from somewhere or someone that you needed to get your child vaccinated with
MMR vaccine? If yes, where or who?
How is your child doing since MMR vaccination?
The MMR vaccine is recommended at 1 year of age. If you had another child, would you
vaccinate them with MMR at the recommended time of 1 year old?
How was your clinic visit when your child got the MMR vaccine? Can you tell me more about
why it was good or bad?
Is there anything else you would like to share with me?
How would you like results of this survey shared with you?
Are there any outreach activities that you think MDH should do?
MMR = measles, mumps, and rubella.
2
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to participants. Prior to each survey, interviewers provided a Ten-
nessen warning and confirmed the willingness of the respondent
to participate.
2.2. Statistical analysis
Responses to survey questions were summarized by frequency
distributions. Summary variables were created to categorize
sources of information recommending MMR vaccination, including
a social messengers variable for information from family, friends,
imams, or mosques and a formal messengers variable for informa-
tion from doctors, public health professionals, schools, or childcare
staff. A binary variable was created to indicate presence of fever
after vaccination, which was the adverse event most frequently
perceived by parents.
Bivariate statistical comparisons were performed using a chi-
square test for categorical variables and Student’s t test for contin-
uous variables. Multivariable logistic regression was performed to
identify independent predictors of parental intention to obtain
MMR vaccination on time for a future child. Independent variables
incorporated in the logistic regression model included prior paren-
tal concern about a presumed connection between MMR vaccine
and ASD, a perceived fever after MMR vaccination, good versus
bad experience at the clinic, numbers of social and formal messen-
gers who recommended MMR vaccination, and age at vaccination
of the oldest eligible child in the household. Model fit was deter-
mined using the Akaike Information Criterion and the Hosmer-
Lemeshow test. Statistical analyses were performed using SAS ver-
sion 9.4 (SAS Institute Inc., Cary, NC). For all statistical tests, a P
value < 0.05 was considered statistically significant.
3. Results
We identified 1911 eligible Somali children who received initial
MMR vaccination during the outbreak period (Fig. 1). From this
population, 422 families were randomly sampled, resulting in
completion of 300 (71%) surveys. Of the 122 sampled families that
did not complete a survey, 72 (59%) had an invalid phone number,
47 (39%) did not answer their phone, and 3 (2%) refused to partic-
ipate. Participating families represented 381 (20%) of the 1911 eli-
gible children.
The mean number of children vaccinated with MMR per family
was 1.27 (range: 1 to 4). Among the 381 children vaccinated, mean
Response categories
Fear of measles; Child exposed to measles; Child excluded; Family or
friend; Other
Good; Regret decision
Fear of measles; Child exposed to measles; Child excluded; Family or
friend; Other
Mother; Father; Other
Autism; Other; No concerns
Mosque; Outreach group; Imam; Flyer; TV; Doctor; Radio; Family;
Friends; Child care/school; Other
Normal/no concerns; Fever; Rash; Skin condition; Swollen cheeks;
Crying; Seizure; Pain in joints; Deafness; Other
Yes; No
Good; Bad
B. Christianson et al. Vaccine xxx (xxxx) xxx

Fig. 1. Flow chart of eligible participants. This flow chart summarizes the population from which the survey sample was randomly selected. A statewide immunization
information system and birth certificate data were used to identify children of Somali descent who met the eligibility criteria for the survey. IIS = immunization information
system; MMR = measles, mumps, and rubella vaccine.

age at vaccination was 2.9 years and 205 (54%) were male. Of the
300 participating families, 197 (66%) lived in Hennepin County.
Among parents surveyed, the most prevalent prior concern
about MMR vaccine was a presumed connection between vaccina-
tion and ASD (n = 212, 71%). The second most common prior con-
cern was apprehension regarding speech development of children
after MMR vaccination (n = 29, 10%).
Parents cited various reasons for vaccinating their children,
including fear of measles (n = 285, 95%), school or childcare vacci-
nation requirements (n = 28, 9%), belief that the child had reached
a safe age to vaccinate (n = 15, 5%), and recommendation from their
doctor (n = 10, 3%). Parents recalled receiving information from
various sources recommending MMR vaccination, such as health
care providers (n = 229, 76%), school or childcare providers
(n = 113, 38%), public health officials (n = 86, 29%), family
(n = 159, 53%), friends (n = 113, 38%), and imams or mosques
(n = 32, 11%).
Most parents (n = 275, 92%) described their clinic visit as good.
Upon prompting by the interviewer about perceived adverse
events following vaccination, 65 parents (22%) expressed a concern
about their children after vaccination. Fever was the most common
adverse event perceived by parents among vaccinated children
(n = 60, 20%).
Less than half (n = 124, 41%) of parents indicated that they
would vaccinate a future child with MMR on time at 1 year of
age; 159 (53%) stated that they would delay MMR vaccination until
a child was older than 1 year of age, and 17 (6%) said they would
never get MMR vaccination for a future child. In bivariate analyses,

3
B. Christianson et al. Vaccine xxx (xxxx) xxx

the mean age at MMR vaccination of the oldest eligible child in the
family was higher among families who did not intend to vaccinate
a future child on time than among families who intended to do so.
Parents with prior concern about a presumed association between
MMR vaccine and ASD and those who perceived that their child
experienced an adverse event after MMR vaccination were less
likely to intend to vaccinate a future child with MMR on time than
parents without these concerns or perceptions. Conversely, parents
who received information from at least 3 formal messengers (doc-
tor, school/child care, public health staff) recommending MMR vac-
cination were more likely to intend to get MMR vaccine on time for
a future child than were parents who received such recommenda-
tions from fewer formal messengers (Table 2).
In multivariable logistic regression, the most statistically signif-
icant independent predictor of parental intention to seek MMR
vaccination on time for a future child was prior parental concern
about a presumed connection between MMR vaccine and ASD,
which decreased parental intention to vaccinate (odds ratio [OR],
0.33; 95% CI, 0.19–0.56; P < .001). Age of the oldest eligible child
in the household who received MMR vaccine also was negatively
associated with parental intention to seek on-time MMR vaccina-
tion for a future child (OR, 0.82; 95% CI, 0.70–0.96; P = .01). In con-
trast, parents who received recommendations for MMR
vaccination from at least 3 social messengers, including family,
friends, imam or mosque, (OR, 3.06; 95% CI, 1.02–9.16; P = .046)
or from 3 or more formal messengers (OR, 3.07; 95% CI, 1.01–
9.31; P = .048) were more likely to intend to get MMR vaccination
on time for a future child than were parents who received fewer
such messages (Table 3).
4. Discussion
Vaccine hesitancy is a complex construct that varies by time,
place, population, and vaccine [8]. Concerns about vaccine safety,
perceived lack of benefit from vaccination, and accessibility of vac-
cines are common reasons for delaying or refusing vaccination [8].
Defining population-specific rationales for reluctance to receive
vaccination is essential to overcome vaccine hesitancy [9,10]. Find-
ings from our survey and other studies suggest that concern about
a presumed yet unfounded connection between MMR vaccine and
ASD is prevalent among Somali parents in Minnesota [5,11]. Fur-
thermore, our survey indicated that parents with this apprehen-

Table 2
Bivariate analyses of potential predictors of parental intent to vaccinate a future child with MMR vaccine on time.

Total families Would vaccinate Would NOT OR (95% CI) P value

(n, %) a future child vaccinate a future
on time(n, %) child on time(n, %)
Number of families N = 300 124 (41) 176 (59)
Continuous variables
Age (years) of oldest child at time of vaccine, mean (SD) 2.58 (1.54) 3.08 (1.60) .007*
Binary variables
Family had prior concerns that MMR vaccine caused ASD, n (%) 212 (71) 71 (57) 141 (80) 0.33 (0.20–0.56) <.001*
Family perceived that their child experienced adverse 65 (22) 18 (15) 47 (27) 0.47 (0.26–0.85) .01*
event after MMR vaccination, n (%)
Perceived fever, n (%) 52 (17) 16 (13) 36 (20) 0.58 (0.30–1.09) .09
Family had a good clinic visit, n (%) 275 (92) 117 (94) 158 (90) 1.90 (0.77–4.71) .16
Categorical variables
Number of social messengers recommending vaccination
(family, friends, imam, mosque)y
None, n (%) 97 (32) 36 (29) 61 (35) 1.00 (reference)
1–2, n (%) 185 (62) 77 (62) 108 (61) 1.21 (0.73–2.00) .46
3, n (%) 18 (6) 11 (9) 7 (4) 2.66 (0.95–7.48) .06
Number of formal messengers recommending vaccination
(doctor, school/child care, public health)y
None, n (%) 34 (11) 11 (9) 23 (13) 1.00 (reference)
1–2, n (%) 237 (79) 96 (77) 141 (80) 1.42 (0.66–3.06) .37
3, n (%) 29 (10) 17 (14) 12 (7) 2.96 (1.06–8.30) .04*

ASD = autism spectrum disorder; MMR = measles, mumps, and rubella; OR = odds ratio; SD = standard deviation.
*
Significant at the level of P < .05 (chi-square test for categorical variables, Student’s t test for continuous variables).
y
Values are counts of different messengers from whom parents heard recommendations.

Table 3
Multivariable logistic regression results for model predicting parental intent to vaccinate a future child with MMR on time.

Independent variable OR (95% CI) P value AIC score

Perceived presence of fever, (yes/no) 0.51 (0.26–1.02) .06 387
Family had prior concerns that MMR caused ASD, (yes/no) 0.33 (0.19–0.56) <.001*
Family had a good clinic visit, (good/bad) 1.48 (0.57–3.87) .43
Number of social messengers recommending vaccination (family, friends, imam, mosque)y
None 1.00 (reference)
1–2 1.24 (0.71–2.10) .46
3 3.06 (1.02–9.16) .046*
Number of formal messengers recommending vaccination (doctor, school/child care, public health staff)y
None 1.00 (reference)
1–2 1.67 (0.73–3.81) .23
3 3.07 (1.01–9.31) .048*
Age of oldest child at time of vaccine (years) 0.82 (0.70–0.96) .01*

AIC = Akaike Information Criterion; ASD = autism spectrum disorder; MMR = measles, mumps, and rubella; OR = odds ratio.
*
Significant at the level of P < .05.
y
Values are counts of different messengers from whom parents heard recommendations.

4
B. Christianson et al.
sion were less likely to intend to seek MMR vaccination on time for
a future child than were parents without this concern.
Prior studies have suggested that persons who do not fear
vaccine-preventable diseases may not seek vaccination [12,13],
even during an outbreak. Most respondents in our survey, how-
ever, indicated that fear of measles motivated their decision to vac-
cinate their child with MMR. Thus, many vaccine-hesitant Somali
parents in Minnesota may be characterized as vaccine ‘‘pragma-
tists” or ‘‘attentive delayers” who perceive measles as serious,
delay vaccination until older ages, and are more likely to seek
MMR vaccination during an outbreak than are those who lack fear
of measles [14]. Among such communities, timely information
about risk of measles may positively influence parental decisions
to vaccinate children at younger ages.
Our survey also indicated that parents who received recom-
mendations regarding MMR vaccination from multiple social or
formal messengers were more likely to intend to vaccinate a future
child with MMR on time than were parents who received such rec-
ommendations from fewer messengers. Other studies also have
concluded that human networks (e.g., spouses, family members,
friends, and health care providers) influence decision-making
about vaccination [15].
Limitations of our survey include potential recall and response
biases. The time between MMR vaccination and the survey inter-
view could have biased parental recall. Additionally, because pub-
lic health staff conducted the interviews, parents may have been
biased to overestimate their intentions to vaccinate future chil-
dren. We were unable to assess differences between responders
and nonresponders due to limited parental demographic data
available in the statewide immunization information system.
Lastly, our survey was specific to Somali families in Minnesota
who sought MMR vaccination for previously overdue unvaccinated
children during a measles outbreak, which limits the generalizabil-
ity of the results.
Our findings highlight the importance of efforts by health care
providers, public health professionals, school staff, religious lead-
ers, and community members to educate parents about dangers
of measles, safety of MMR vaccine, and the urgency of timely vac-
cination. Although an increase in vaccination was seen temporarily
during 2017, there has since been a steady decline resulting in only
43% MMR uptake among 2-year-olds of Somali descent in 2020
(MDH, unpublished data, 2020). Future research is needed to
explore how messaging by social networks and formal influencers
can affect decision-making regarding vaccination during outbreaks
and non-outbreak periods. Greater understanding and utilization
of these relationships could maximize the efficacy of outreach
strategies to increase and sustain vaccine coverage among under-
vaccinated communities.
5. Conclusions
Due to fear of measles, many vaccine-hesitant Somali parents in
Minnesota got MMR vaccine for their previously unvaccinated chil-
dren during a recent outbreak. A minority of these parents
intended to vaccinate a future child with MMR on time, although
parents who received recommendations about MMR vaccination
from multiple social or formal messengers were more likely than
other parents to intend to do so. These findings support the efficacy
of community outreach efforts using messages from diverse
sources regarding measles disease and MMR vaccination. MDH
continues to build upon the existing partnerships in the Somali
community to ensure multiple trusted messengers encourage vac-
cination. Further review and assessment of the outreach efforts
5
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during the 2017 outbreak will be helpful in understanding what
may have contributed to the temporary increase.
Author contributions
All authors contributed to the conceptualization and the design
of the survey questionnaire. CK and JH obtained the governance
approvals. LB, MR and HO conceived of the project. BC, FM, CK,
JH drafted the protocol and pilot tested the survey questions. TR
provided expert guidance on survey design and conversational
interviewing techniques. FM and BC oversaw the interviewer train-
ing, survey administration, data entry and data curation. BC, CK,
FM conducted formal analysis and interpreted the results. BC,
FM, JH and CK participated in writing original draft. All authors
critically reviewed and edited the final manuscript. All authors
reviewed and approve the final manuscript.
Funding sources
This survey project did not receive any specific grant from fund-
ing agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgements
Authors would like to acknowledge Asli Ashkir, Hamdi Ali, and
Ismahan Mohamed for their contributions in survey design, data
collection and language interpretation. Additionally, Wendy Mills
(Wendy Mills Medical Writing, LLC, Saint Paul, MN, USA) provided
professional medical editing and developmental consultation for
this article.
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