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Primary Submission Category: Health behaviors
Understanding Multilevel Variation in Non-Medical Vaccine Exemptions to Kindergarten School Entry Requirements in the United States: A Systematic Review
Authors: Kacey Clayton-Stiglbauer, Emma Elias, Jennifer Heisler-MacKinnon, Lauren Gorstein, Natalicio Serrano, Melissa Gilkey,
Presenting Author: Kristin Goddard*
The US recorded over 2200 measles cases in 2025, threatening the nation’s 25-year measles elimination status. Although all US states require measles and other vaccines before school entry, rising non-medical exemptions (NMEs) threaten to undermine their effectiveness. To inform future interventions that build trust in vaccination and related policies, we synthesized existing research to determine correlates of NMEs.
We conducted a systematic review of original, peer-reviewed, English-language studies reporting quantitative data on kindergarten NMEs (PROSPERO CRD420251036823). We searched Embase, PubMed, Scopus, CINAHL, and PsychINFO for studies published from 2010–present. Two reviewers independently screened 2660 unique titles and abstracts, followed by full text review and data abstraction.
Twenty-one studies met inclusion criteria and reported variation in kindergarten NMEs by school communities, geographic areas, and individuals. Charter (6 of 6 studies) and private schools (8 of 10 studies) had higher rates than traditional public schools. Schools or communities with higher proportions of white residents had higher NMEs (9 of 10 studies). Higher SES was associated with NMEs (11 of 13 studies) across measures including free-and-reduced-price lunch eligibility, median income, and educational attainment. NMEs clustered in rural areas (3 of 4 studies) and suburbs or small towns (3 of 4 studies) versus urban areas. Only 1 study assessed individuals, finding higher rates among parents with vaccine concerns or distrust of local doctors. Limitations include the concentration of studies in California (14 of 21 studies), a lack of recent publications (i.e., post 2021), and the use of aggregated versus individual-level data. Researchers, public health departments, and community partners should develop multilevel interventions to meet the needs of populations with higher NMEs, focusing on trust surrounding childhood vaccines and related policies.