"Everybody Just Wants to Do What's Best for their Child": Understanding How Pro-vaccine Parents Can Support a Culture of Vaccine Hesitancy

"The decision-making experience in the context of overwhelming and contradictory vaccine information in the media and throughout social networks may be a mechanism that generates and perpetuates a culture of vaccine hesitancy and tolerance for altered schedules, despite high rates of immunization coverage."

This qualitative study used semi-structured interviews to understand how parents make decisions about child vaccination, and the attitudes, perceptions and beliefs underlying these decisions. The researchers used convenience sampling to recruit parents in an upper-middle class neighbourhood in Philadelphia, Pennsylvania, United States. An active neighbourhood parent listserv facilitated recruitment. Two of the authors (YB, AB) conducted 23 interviews between July and September 2010, a year with a particularly large number of pertussis and mumps cases. The interview guide (see Table 1) consisted of open-ended questions about: child health and temperament; a recent health-related decision; the decision process around child vaccination, including information gathering, discussion with others, and interactions with health care providers; the actual experience of vaccination; and attitudes and perceptions about other parents' vaccine beliefs and behaviours. Researchers used a modified Grounded Theory approach to analyse interview data.

No parents in the sample declined all vaccines; 2 (23%) declined some vaccines; 9 (39%) delayed some vaccines due extenuating circumstances at the time of a vaccine appointment (e.g., the child was sick), and 10 (44%) had deliberately spaced out some vaccines. The thematic analysis revealed potential mechanisms that illustrated how a climate of tolerance and accommodation for vaccine refusal can arise, even in a pro-vaccine population:

• "First, parents contemplating vaccination felt frustrated by the overwhelming and conflicting information presented by various sources." In addition to their paediatrician, parents sought information sources such as the scientific literature, the Centers for Disease Control and Prevention (CDC) website, books, a vaccine class, and television shows. "Although confident about their data gathering and synthesis skills, the diversity and discrepancy across sources made it challenging (and time-consuming) to make an unequivocal decision."
• "Second, their decision process was informed by a palpable tension between a 'scientific' and 'non-scientific' approach to decision-making." For example, Some associated getting vaccines with “putting…diseases into this tiny person's body” (Interview 15). For example, receiving too many at once felt like "overloading" or "overwhelming” the immune system of a baby (Interviews 1, 2, 14, 15, 22, 23). The resulting decision to stagger or space vaccines, as one interviewee noted, was not based on scientific evidence, but simply seemed like a "better idea" (Interview 21).
• "Finally, these experiences during the formation and implementation of vaccine intentions generated sympathy and tolerance for vaccine hesitancy and refusal in other parents....Interviewees were particularly sensitive to the fact that hesitant parents might have, or know someone with, a child with autism or a developmental disorder, and that this first-hand experience could influence vaccine decisions. Furthermore, most interviewees did not distinguish between a spaced or delayed schedule and the recommended schedule, arguing that the social responsibility to vaccinate was fulfilled in either case".

The analysis revealed that, though the parents in this sample, are actively engaged in the decision-making processes around their child's health and strong supporters of vaccination, these parents nevertheless exhibited vaccine hesitancy as manifest in deviations from the recommended vaccine schedule. The researchers explain that, although the degree of the impact of vaccine delay depends on how long vaccines are spaced, a delay in one vaccine may produce a domino effect in adhering to the timing of other vaccines. "...[P]revalent vaccine concerns in the media and within social networks can subtly influence the implementation of vaccine intentions leading to deviations." According to the researchers, this points to the importance of the paediatric primary health care provider's response to requests for schedule deviations, particularly for in-the-moment requests.