Vaccinations, children, 91.1% had at least one dose

widely regarded by experts as one of the greatest achievements in public health
in the past century, have contributed greatly to reduced incidence and
childhood mortality from certain infectious diseases.1,2 Despite
these achievements, vaccinations are not without their detractors. Overall
national vaccination coverage remains high despite opposition to vaccination
programs.3 A 2013 report by the US Centers for Disease Control found
that in children, 91.1% had at least one dose of the measles, mumps, and
rubella vaccine and 83.1% had at least four doses of the diphtheria, tetanus,
and acellular pertussis vaccine.3 However, over the past 20 years,
rates of non-medical exemptions that allow parents to refuse vaccinations on
philosophical or religious grounds have been steadily increasing.4,5
A recent survey suggests that approximately 40% of parents delay or refuse vaccinations
for their children.6      


refusal is associated with an increased risk of acquiring vaccine-preventable illness.7.
One study investigating national measles outbreaks between 1985 and 1992, found
that among unvaccinated individuals, those with vaccine exemptions were 35
times more likely to contact measles compared to vaccinated children.8
A second study using data from Colorado from 1987 to 1998 found that children
with vaccine exemptions were 22 times more likely to contract measles compared
to vaccinated children.9 A recent study investigating
vaccine-preventable disease occurrence in unvaccinated children found that of
970 measles cases reported between 2000 and 2015 that included sufficient
information about vaccine status, 574 cases occurred in unvaccinated
individuals and of those cases, 70.6% were intentionally unvaccinated due to
non-medical exemptions.7 Individuals with the disease who received
non-medical exemptions represented a total of 41.8% of reported cases.

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higher exemption rates are associated with higher rates of pertussis in both
unvaccinated and vaccinated populations.7 Among reported pertussis
cases, 24-45% of individuals were unvaccinated with 59-93% of individuals
having been intentionally unvaccinated.7 Among statewide pertussis
outbreak reports that contained sufficient information about the vaccination
status of individuals with the disease, 70% of unvaccinated pertussis cases in
a 2012 outbreak in Oregon and 84% of cases in a 2013 outbreak in Florida were
among children with vaccine exemptions.10,11 One case-control study
found that among pertussis cases between 1996 and 2007, individuals with
vaccine exemptions were 20 times more likely to contract pertussis.12


despite the associations between vaccine refusal and an increased likelihood of
disease acquisition, many parents choose to delay or refuse vaccination for
their children.13 Among parents who choose to delay or refuse
vaccination, there is an association with the use of complementary and
alternative medicine (CAM), defined by the National Institutes of Health as a
group of diverse medical and health care systems, practices, and products that
are not presently considered to be part of conventional medicine and includes
chiropractic medicine, Chinese medicine and acupuncture, massage, and
naturopathic medicine.14 Parents who use CAM have been shown to
express a greater concern about vaccine side effects and a higher likelihood of
refusing vaccination for their children.15 Parents who prefer CAM
therapies have been found to be more skeptical about the benefits of
vaccination and are more likely to believe misconceptions about vaccines.15,16
Additionally, evidence suggests that use of CAM and vaccine skepticism are both
parts of a common attitudinal stance and set of psychosocial values.17
Among CAM providers, including chiropractors and naturopathic physicians, there
have been mixed findings on attitudes toward vaccination. The attitudes of
naturopathic physicians in particular have not been well-studied but published
reports suggest that the minority support full vaccination.13 In one
study of Massachusetts naturopathic physicians, researchers found that 20%
recommended vaccination, 7% actively opposed vaccination, and the rest, a vast
majority, made no recommendation.18


usage among children is estimated to be lower than usage among adults. Among
Washington insurance claims in 2002, only 6% of children under age 17 had used
any form of CAM during the calendar year.19 A 2010 study of CAM
providers, including chiropractors, acupuncturists, massage therapists, and
naturopathic physicians, in the state of Washington investigated practices
among 11,144 pediatric patients based on insurance records from two
non-Medicaid insurance companies.13 In this study, fewer than 4% of
children had any visits with a CAM provider. Researchers investigated rates of
vaccination and incidence of ten vaccine-preventable illnesses based on federal
pediatric vaccination guidelines. The results of the study suggest that
children seeing naturopathic physicians were more likely to be unvaccinated and
that the use of naturopathic medicine by pediatric patients was associated with
an increased likelihood of a diagnosis of a vaccine-preventable illness (OR
1.67 95 percent CI 1.31-2.15). Despite these data, relationship causality
cannot be established as it is possible that parents who are already
vaccine-hesitant choose to seek out CAM providers for pediatric care.


use of CAM has been associated with parental refusal of childhood vaccines and
with an increased risk of vaccine preventable diseases, attitudes and practices
regarding vaccination among providers and students of CAM are still poorly
understood. A 2004 study conducted at the Canadian College of Naturopathic
Medicine in Toronto, Canada, assessed the attitudes of naturopathic medicine
students regarding vaccination.20 This study found that only 12.8%
of students would recommend full vaccination according to the recommended
schedule and 74.4% of students would recommend partial vaccination. Researchers
found that willingness to advise full vaccination and overall trust in public
health and conventional medicine decreased in later years of the program. A
previous version of the current survey, administered at National College of
Natural Medicine in Portland, Oregon, in 2013 found that 100% of naturopathic
medicine students would recommend an alternative vaccination schedule and that
the majority of students would regularly or occasionally recommend vaccines in
their future practice.


current study aims to assess the attitudes, education, and sources of
information surrounding vaccination among students at three U.S.-based
naturopathic medicine programs.




naturopathic medicine schools, National College of Natural Medicine (NCNM),
Bastyr University, and University of Bridgeport, were chosen to participate in
the study. The naturopathic medicine programs at these schools require students
to matriculate with a previous bachelor’s degree and coursework in basic life
sciences. Graduates of these programs complete academic coursework related to
basic sciences, pathology, clinical diagnosis, and laboratory diagnosis, as
well as botanical medicine, physical medicine, clinical nutrition, and
pharmacology. In addition to their academic training, students complete
numerous clinical rotations under the supervision of naturopathic physicians in
a variety of primary care and adjunctive care settings. Naturopathic physicians
are currently licensed in 21 U.S. states and territories.


received approval from the institutional review boards of the three
naturopathic medical schools and Yale University to distribute a survey to all
naturopathic medicine students. The survey was developed in 2013 by a team of
researchers using a variety of quantitative, scale, and open-ended response
questions combining questions from previous surveys and expert opinions. The
survey was aimed at assessing 1) where students were educated about
vaccinations in their medical programs, 2) what other resources students use to
educate themselves on vaccinations, 3) the perceived credibility of educational
and supplemental information sources, 4) attitudes about vaccination, and 5)
intended future practices. The 2015 survey was updated to include questions
related to the 2014-15 Disneyland measles outbreak and proposed laws mandating


59 question survey was distributed to students using Qualtrics web-based
software. Students received a link to complete the survey from the dean or
associate dean of naturopathic medicine at each college. Students were given
three weeks to complete the survey. It was estimated that the study would take
20 to 30 minutes to complete. In order to incentive participation in the study,
upon completing the survey, participants were able to enter their name and
email address to be entered in a drawing for an Apple Watch which would be awarded
to one participant at the end of the study period.


the 59 questions in the survey, 20 questions were focused on assessing the
students’ naturopathic medical education surrounding vaccines. In addition to
basic demographic information about program and year in school, questions in
this section included queries into which classes provided information about
vaccinations. Students were also asked which sources of information they used
to supplement their classroom education on vaccines. Additionally, information
on perceived credibility of both naturopathic and conventional medical
education was assessed. The second section was comprised of 16 questions
related to opinions about vaccinations and their safety and effectiveness. This
section questioned students on their opinions about the safety and
effectiveness of vaccines as well as perceived and observed adverse effects of
vaccination. The third section was comprised of nine questions regarding public
perceptions about vaccines and current events involving vaccination, including
the Disneyland measles outbreak. The final section of the survey included 15
questions focused on students’ intended future practices regarding vaccination.
This section included questions on whether or not participants intended to
recommend vaccinations, how scope of practice would influence their
recommendation, and whether they would use additional or alternative therapies
in conjunction with or instead of vaccination.




total of 242 students provided responses (20.1%). Of these respondents, 108
were from Bastyr University, 103 were from NCNM, and 28 were from University of
Bridgeport. Respondents represented all years of the naturopathic programs with
52 first year students, 54 second year students, 52 third year students, and 81
students from years four, five, and six providing responses.


response to the question, “In which of your courses have you learned about
vaccines?,” participants were asked to select all courses that applied from a
list of six choices: immunology, microbiology, pediatrics, pharmacology, public
health, or other class or elective. A total of 211 participants (87.2%)
provided responses to this question. Of these responses, 81% indicated they
learned about vaccines in immunology; 78% in microbiology; 43% in another class
or elective; 40% in pediatrics; 30% in public health; and 30% in pharmacology
(see Table 1).


addition to classroom education, students provided responses on additional
sources of information regarding vaccination. In response to the question, “Do
you consult other sources of information to learn about vaccines in addition to
your standard classroom education?” students were asked to select all options
that applied from an extensive list of conventional, alternative, and
vaccine-skeptical information sources. A total of 224 participants provided
responses to this question (92.6%). Of these responses, 72% of students indicated
that they consulted the Centers for Disease Control Advisory Committee on
Vaccination Practices (CDC-ACIP); 55% consulted current peer-reviewed
scientific literature; 54% consulted mentors or other clinicians; 34% consulted
the American Association of Naturopathic Physicians; 34% consulted alternative
vaccine schedule sources such as Dr. Sears; and 32% consulted vaccine skeptical
sources such as,, or (see Table 2).


were also asked to evaluate the credibility of these information sources. A
total of 152 students (62.8%) provided responses to the question, “How
trustworthy do you think these various sources of information are?” Students
were asked to score each source on a scale of untrustworthy, represented as a
value of zero, to very trustworthy, represented by a value of two. More
trustworthy sources received values closer to two while sources perceived as
less trustworthy received scores closer to zero (see table 3). Respondents
rated the American Association of Naturopathic Physicians as the most credible
source with a score of 1.26. Current peer-reviewed scientific literature and
personal clinical experience were ranked as the second most credible sources
each with scores of 1.24. Conventional sources including the CDC-ACIP and the
American Academy of Pediatrics were rated as slightly less credible with scores
of 1.16 and 1.14, respectively. Alternative vaccine schedules such as Dr. Sears
were rated as less credible with a score of 0.96. Vaccine skeptical sources
such as,, and were rated as the least
credible sources of information with a score of 0.33.


total of 192 students (79%) provided responses to the question, “Do you support
the general concept of conventional vaccinations for the prevention of
infectious diseases in children and adults?” Of these respondents, 77% answered
“yes,” while 23% answered “no” (see Table 4). In response to the question,
“What is your general opinion of pediatric vaccine schedules?” students were
asked to select all options that applied (see Table 4). Two-thirds (67%) of
students answered that children should be evaluated on an individual basis; 62%
of students responded that children should be given some or all vaccinations
but these should be administered at different ages and/or intervals than the
schedule suggests; 35% of respondents answered that children should be given
some, but not all, scheduled vaccinations; 22% of respondents answered that
children should be vaccinated according to the CDC-ACIP vaccination schedule;
and 7% of respondents indicated that children should be entirely vaccine free.


response to the question, “What do you believe are problems related to
vaccination programs?” a total of 157 students provided responses (64.9%).
Students were asked to select all answers that applied (see Table 5). Of these
responses, 84% of students indicated that preservatives or adjuvants were a
problem associated with vaccines; 83% of students responded that multiple vaccines
administered simultaneously was a problem; 76% of students responded that
vaccines are given too early; 64% of respondents indicated that vaccine adverse
events were under-reported; 62% responded that there are too many vaccines
given overall; and 34% of respondents indicated that autism spectrum disorders
being linked to vaccines was a problem.


response to questions about future practices, 80% of students responded that
they would offer vaccinations in their clinics if insurance or state and federal
programs (such as the Vaccines for Children federal program) cover the costs
for naturopathic physicians to administer vaccinations. Additionally, 43% of
respondents indicated that they would regularly prescribe or recommend
vaccination to their patients; 30% would occasionally recommend; 14% would
rarely recommend; and 12% would never recommend. A total of 73% of respondents
would recommend an alternative schedule for vaccinations based on patient
health status (91%), to reduce the number of vaccines given simultaneously
(87%), and based on their patient’s age (87%). To guide their decision making
in prescribing an alternative schedule, 78% of respondents indicated they would
use current peer-reviewed scientific literature; 69% would consult the American
Association of Naturopathic Physicians; and 67% would consult other clinicians
or mentors (see Table 6).




results of the current study can be compared to the 2013 pilot survey
administered at NCNM to observe possible trends in education and information
regarding vaccines. The 2013 study had a similar total response rate to the
2015 study but overall, fewer participants answered each question so the
validity of any comparison between the two studies is limited. Still, it is
important to note that there were several changes in the answers between
responses in 2013 and 2015. In the 2013 survey, 100% of respondents indicated
that they would recommend an alternative vaccination schedule for their
patients; in 2015, only 62% of students indicated that they would recommend an
altered schedule and 22% of students responded that they would recommend the
full CDC-ACIP schedule for their patients.


the 2013 study, 100% of respondents indicated that they use alternative
vaccination schedules to supplement their classroom education on vaccines; this
number was 34% in 2015. In 2013, 54% of students indicated that they would
consult vaccine-skeptical sources such as,,, and others for information on vaccines; in 2015, less than
one-third of students (32%) indicated they would use these sources.


perceived credibility of various sources of information also changed between
2013 and 2015. In both surveys, students were asked to rate sources on a scale
of not credible (0) to credible (2). Scores closer to two indicate higher
credibility. In 2013, students rated alternative vaccination sources as the
most trustworthy source of information on vaccines with a score of 1.21; in
2015, alternative vaccination schedules scored 0.96. The CDC-ACIP was scored at
0.96 in 2013 but increased to 1.16, and ranked as the fourth most credible
source, in 2015. Similarly, the American Academy of Pediatrics was scored at
0.79 in 2013 and increased to 1.14 in 2015. Vaccine-skeptical sources were
scored as the least credible sources in both surveys and decreased from a score
of 0.57 in 2013 to 0.33 in 2015.


to questions about the perceived problems associated with vaccinations also
changed between the two surveys. In 2013, nearly all participants (96%)
indicated that preservatives and adjuvants were problematic; while still the
most common response, in 2015, only 84% of participants indicated that this was
a problem. Vaccinations given too early was the second most common response in
2013 with 92% of respondents indicating this was a problem; in 2015, only 76%
of respondents chose this option. In 2013, almost half of respondents (46%)
indicated that an association between autism and vaccines was a problem with
vaccination; in 2015, only 34% of respondents chose this option.


the sample size of each survey was too small to be representative, comparisons
of the results from the 2013 and 2015 surveys provide interesting points for
further study. Based on the results of the two surveys, it appears that more
students are consulting conventional sources of information on vaccines and
that they find these sources to be overall more credible than vaccine-skeptical
sources. The results also suggest that alternative vaccination schedules are
used by fewer students in 2015 than in 2013 although the majority of students
in both surveys indicated that they would advise an altered vaccination
schedule for pediatric patients.


results of the current study are also consistent with results of a 2004 study
conducted at the Canadian College of Naturopathic Medicine.20 While
this survey and our study used different study tools with different questions,
the results in the 2004 study suggest that 74.4% of respondents would recommend
partial vaccination which is comparable to the 62% who would recommend the same
in our study. Additionally, the data in our study are consistent with a study
of practicing naturopathic physicians in Massachusetts in which 20% of
respondents would actively recommend vaccinations and 7% would openly oppose
them; the results in the current study suggest that 22% of students support the
full CDC-ACIP vaccine schedule and 7% believe that children should be entirely


results offer an interesting comparison to vaccination attitudes studied in
conventional allopathic medicine students. A recent study of students at the
University of Central Florida found that most students reported strongly
positive attitudes toward vaccination.21 Despite their attitudes,
only 29% of students reported receiving adequate education regarding vaccines in
their medical education. Of particular interest to the comparison with
naturopathic students, 55% of respondents indicated that alternative
vaccination schedules were an acceptable way to minimize parental stress. This
is comparable to the 62% of naturopathic students in our study who indicated
that they would vaccinate according to an alternative schedule.


current study has several limitations. First, the sample size, 242 students
(20.8%), is not large enough to be considered representative. Because the
survey was administered at NCNM in 2013 and again in 2015, it is possible that
the same students responded to both surveys or that completely different
students responded to each survey making comparisons between the results of the
two surveys impossible to evaluate with any level of certainty. Secondly, the
entire sample population did not respond to each question in the survey leading
to the potential for non-responder bias. Finally, it is outside the scope of
this study to determine a whether the attitudes regarding vaccination reported
by naturopathic medicine students are fostered by their naturopathic education
or whether they are previously held attitudes that remain unchanged despite
their medical education. Evidence suggests that support of CAM and vaccine
skepticism are components of a common set of attitudes and values so it is
possible that students of naturopathic medicine subscribe to a set of beliefs
that makes them more likely to pursue a career in CAM as well as maintain
skepticism of vaccines and conventional medicine.17


results of the current study suggest that the majority of respondents support
the general idea of vaccination but would advise pediatric patients to receive
vaccinations on an altered schedule. The public health implications of these
data are significant. Recent research suggests a correlation between the
attitude and personal practices healthcare providers and their knowledge
regarding vaccinations.22 While naturopathic physicians represent
only a small number of providers in the US medical system, they have the
potential influence many parents through CAM-affiliated websites and
literature.23,24 Engaging students and practitioners of naturopathic
medicine in productive dialogue regarding vaccination would provide benefit to
public health programs aimed at increasing vaccination rates in children who
see CAM providers.




regarding vaccination among naturopathic medicine students comes from a variety
of sources. Students consult a number of conventional, alternative, and
vaccine-skeptical sources to supplement their classroom education on vaccines.
These sources have varying levels of perceived credibility. The attitudes
naturopathic students hold regarding vaccination and their intended future
practices may have considerable impacts in public health. Public health
officials should promote dialogue with naturopathic students and providers in
an effort to improve vaccine compliance.