BACKGROUND. The high visibility of controversies regarding vaccination makes it increasingly important to understand how parents decide whether to vaccinate their infants.
OBJECTIVE. The purpose of this research was to investigate decision-making about vaccinations for infants.
DESIGN. We conducted qualitative, open-ended interviews.
PARTICIPANTS. Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 months.
RESULTS. We addressed 3 topics: attitudes to vaccination, knowledge about vaccination, and decision-making. Mothers who intended to have their infants vaccinated (“vaccinators,” n = 25) either agreed with or did not question vaccination or they accepted vaccination but had significant concerns. Mothers who did not intend to vaccinate (“nonvaccinators,” n = 8) either completely rejected vaccination or they purposely delayed vaccinating/chose only some vaccines. Knowledge about which vaccines are recommended for children was poor among both vaccinators and nonvaccinators. The theme of trust in the medical profession was the central concept that underpinned all of the themes about decision-making. Promoters of vaccination included trusting the pediatrician, feeling satisfied by the pediatrician’s discussion about vaccines, not wanting to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors included feeling alienated by or unable to trust the pediatrician, having a trusting relationship with an influential homeopath/naturopath or other person who did not believe in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable diseases are not serious, and feeling that since other children are vaccinated their child is not at risk.
CONCLUSION. Trust or lack of trust and a relationship with a pediatrician or another influential person were pivotal for decision-making of new mothers about vaccinating their children. Attempts to work with mothers who are concerned about vaccinating their infants should focus not only on providing facts about vaccines but also on developing trusting and positive relationships.
Given the high visibility in the media of controversies about vaccination of infants, it is important to understand how parents decide whether to vaccinate their children to be able to communicate appropriately with parents about vaccinations.1–10 Previous studies have identified important promoters and inhibiters of parents' acceptance of vaccines.11–18 Promoters have included the desire to prevent disease,11 a belief in the social contract (the desire to help the community by participating in herd immunity, also called “altruism”),12 and the desire to do what is the cultural norm/what most other people do (also called “bandwagoning”).12 Inhibitors have included a fear of harming their child,18 adhering to a reversed social contract (feeling that their unvaccinated child is not at risk for disease, because most other children are vaccinated, also called “free-riding”),12,15 a preference for making acts of omission over acts of commission (preferring not to have acted when there is any risk to the action),15,16,19 a perceived ability to control their child's susceptibility to and outcome of the disease,15 a low perceived susceptibility to disease,18 a belief that it is better to develop immunity from disease than from vaccination,18 doubts about the reliability of information about vaccines,15,18 and a fear that too many immunizations may be dangerous.11,18
Existing studies11–18 have been largely quantitative or based on hypothetical decision-making about vaccination and, thus, may not have adequately elicited the comprehensive range of mothers' attitudes in the way that a qualitative study can. Qualitative research provides a framework for describing social phenomena, such as comprehension and behaviors, that are based on complex beliefs that may be difficult to measure in a standardized quantitative manner.20–23 A qualitative approach is based in inductive reasoning whereby hypotheses are drawn from observations (in contrast to deductive or hypothesis-testing methods).24 This approach allows for the generation of hypotheses that can subsequently be tested in a quantitative manner.24 We sought to use qualitative methodology to describe the full range of mothers' attitudes about vaccinating their children and the promoters and inhibitors of mothers' acceptance of vaccinations during the time when mothers are actively deciding whether to vaccinate their infants.
Study Design and Sample
The study was a qualitative study based on a 2-phase open-ended interview of 33 postpartum mothers from May 2002 to July 2003. English-speaking mothers with infants healthy enough to be in a level 1 nursery and who delivered at the Yale-New Haven Hospital (New Haven, CT) or who delivered at home in the care of 1 of 2 participating midwifery practices in Connecticut were eligible for the study. If hospitalized, mothers were approached for inclusion during their hospitalization at a time when they were not receiving narcotic pain medications or needing more than routine medical care. Mothers who were recruited through midwifery practices were identified before their delivery; after they delivered, the interviewer went to their homes to perform the interviews. We chose to interview mothers of newborns, because parents face a decision about vaccination against hepatitis B shortly after the birth of their child, and we wanted them to be actively involved in the decision-making process at the time of the interview. We also wanted to be able to explore the degree to which mothers may make decisions about vaccination while they are pregnant.
As is frequently done in qualitative research,20,22,25,26 we used purposeful sampling with a random component. To ensure saturation of themes related to nonvaccination and trust, once we had interviewed 2 pilot mothers and 15 mothers selected randomly, we switched to a purposeful sampling of black mothers and of mothers who did not want to vaccinate their infants. Black mothers were sampled randomly from mothers who delivered in the hospital and who indicated on their admission sheet that they were black. Mothers who did not want to vaccinate their infants were referred by midwives or by pediatricians; all who were referred were included. Only 2 mothers whom we approached refused to participate; they refused because of inconvenient timing. This type of purposeful sampling is appropriate for qualitative work, because the goal is to select information-rich cases who will “illuminate the questions under study” (not to select a probability-based sample).26
Mothers were enrolled until no new concepts were identified by the additional interviews, that is, until the point of “theoretical saturation,”22: (1) no new or relevant data seem to emerge regarding a category, (2) the category is well developed in terms of its properties and dimensions demonstrating variation, and (3) the relationships among categories are well established and validated.22 The study was approved by the Institutional Review Board at Yale University School of Medicine. Informed consent was obtained from all of the mothers before the interviews.
For the first phase of the study, 1 author (A.L.B., a white, female pediatrician), conducted in-depth, open-ended interviews23,27,28 in person with postpartum mothers during their immediate postpartum period. The interviewer was not involved in the medical care of the participants. Open-ended questions assessed mothers' attitudes about vaccination, their concerns about vaccination, and the sources they used to obtain information about vaccination. Questions included general questions about how parents felt about vaccinating their infant, for example, “How do you feel about vaccinating your infant?” “What do you see as the benefits of vaccinating your new infant?” and “What do you see as the risks of vaccinating your new infant?” We also included several questions designed to elicit how mothers obtained information about vaccines and how they wanted to obtain information: “Where do you get information about vaccines?” and “What information do you want about vaccines?” Closed-ended questions elicited information about demographics, number of children, plans for vaccination, general health practices, and knowledge about vaccination.
For the second phase of the study, the same interviewer performed open-ended interviews by telephone when the child was between 3 and 6 months old. The follow-up interview reassessed knowledge and attitudes about vaccination, as well as sources of information used. By the time of follow-up, children should have received ≥1 set of vaccinations if they were going to get them. Questions focused on parents' experiences related to vaccinating their infants and their interactions with the medical system related to vaccination. The main questions included, “Tell me about your experience when you took your infant to the doctor to get shots/went for a checkup (for those refusing vaccinations)?” “How did you feel about it?” “Did you have any concerns? What were they?” and “Tell me how you felt about the process of deciding whether to vaccinate.”
For both the first and the follow-up interviews, we used standardized interview guides with probes and follow-up questions to elicit detail and clarification. We audio taped all of the interviews, including those by telephone, and the tapes were transcribed in their entirety by an independent transcriptionist.
Evaluation of Knowledge
Questions regarding knowledge about vaccines were asked after both the first and the follow-up interviews. With the first interview, 10 multiple-choice questions inquired about common adverse effects of vaccines, about common controversies about vaccines, and about which vaccines parents had heard about and thought their child might either get or have gotten. The focus of the questions was intended to explore mothers' recognition of the names of vaccines and the diseases prevented. With the follow-up interview, a subset of 6 of the 10 questions was repeated. Before asking these questions, without prompting, we asked mothers to list the names of the vaccines their child had received. In addition, as one measure of how many mothers in this group held misconceptions about vaccines, we counted how many mothers spontaneously offered erroneous information during the open-ended interviews.
We analyzed transcribed data by using common coding techniques for qualitative data and the methods of grounded theory.20,22,23,26,27 In this process, we read the transcripts of the interviews and identified themes within the mothers' answers. Using these themes that we identified, we generated a structured classification of codes. We coded the data in a series of iterative steps, and we revised and refined the code structure multiple times as we developed new insights and elicited new relationships between the themes present in the mothers' comments. To develop the code structure, 2 members of the research team (A.L.B. and D.J.S.) independently read each of the transcripts line-by-line, abstracted key themes and ideas, and coded each of the transcripts. They then met and assigned final codes through a negotiated process. During its development, the code structure was reviewed and refined multiple times by the full research team. Once coded, we entered data into a software package (NUD*IST, QSR N6, Doncaster, Victoria, Australia) designed to manage unstructured, qualitative data. This software aids in the cataloguing of and reporting of supporting quotations. Interviews lasted between ∼30 minutes and 2 hours.
After the analysis was completed in that the coding structure and classification schema was fully developed and all of the transcripts had been analyzed, 2 members of the research team (A.L.B. and D.J.S.) independently reread all of the transcripts, recoded them using the main subset of the coding structure (56 codes), and classified mothers into categories. The researchers then met and assigned final codes and classification together, resolving differences through negotiation. By this stage, independently, the researchers had virtually complete agreement on coding and classification. This recoding process provided a check of validity as a form of “multiple coding,” a technique by which independent researchers code an interview so that coding strategies can be cross-checked.29 To ensure that our analyses were systematic and verifiable,20,23 we used interview guides, audio taping of the interviews, and transcription by an independent transcriptionist, as well as detailed documentation of analytic decisions and changes in the coding structure.
As a way to characterize knowledge about vaccination by mothers in the study, we tallied correct responses and used the Wilcoxon rank-sum test with a 2-tailed P value to compare the median number of correct responses between each group of mothers and the group of mothers who were vaccine acceptors.
We interviewed 33 mothers 19 to 43 years old (median: 32 years; interquartile range: 26–35 years) from both suburban and inner-city areas of Connecticut; 10 (33%) were primigravida. The majority, 22 (67%), were white, 8 (30%) were black, and 3 (9%) were Hispanic. Nine (30%) received assistance from the Women, Infants, and Children program. We were able to reach 19 (58%) for follow-up interviews.
Attitudes About Vaccination
Based on a combination of mothers' actions and the attitudes that they expressed during the interviews, we categorized mothers into 2 main groups: “vaccinators” (n = 25) or “nonvaccinators” (n = 8; Fig 1). These categories of vaccinators and nonvaccinators were further subdivided into 4 categories. Vaccinators were subdivided into: (1) “accepters,” mothers who agreed with or did not question vaccination (n = 20); or (2) “vaccine-hesitant mothers,” mothers who accepted vaccination but had significant concerns about vaccinating their infants (n = 5). Nonvaccinators were subclassified as (3) “late vaccinators,” mothers who either purposely delayed vaccinating or chose only some vaccines (n = 3); or (4) “rejecters,” mothers who completely rejected vaccination (n = 5). These categories are depicted in Fig 1 as occurring along a continuum, because mothers expressed ranges of attitudes that did not fit simply into discrete categories but rather occurred along a spectrum.
Mothers who were categorized as vaccine-hesitant and those who were categorized as late vaccinators comprised the middle of the continuum (Fig 1). These 2 groups of mothers were very similar to each other with respect to their desire for knowledge and their approach to obtaining information. We chose the themes important to these mothers in the middle of the continuum to be the focus of the data that we are reporting here because they sought information from their pediatric providers and because they expressed a clear interest in obtaining information about vaccines. We hypothesize that they are the most amenable to improved contact with traditional pediatric and public health providers. In contrast, mothers who were nonvaccinators on the far right end of the spectrum seemed less amenable to, or interested in, such contact; they cited, for example, that they did not vaccinate because it says not to in the Bible or “to keep their bloodline pure.”
Knowledge About Vaccination
Sixteen mothers spontaneously offered erroneous information during the open-ended interviews (8 vaccinators and 8 nonvaccinators). Examples of erroneous information included but were not limited to: a belief that their 3- to 6-month-old infant had received vaccines against chicken pox, smallpox, or measles, mumps, and rubella; a belief that they themselves had received a vaccination against chicken pox as a child and subsequently developed disease with chickenpox regardless of that vaccination; a belief that their infant could become infected with the human immunodeficiency virus from vaccines; a belief that vitamin K is a vaccine; and a belief that infants develop influenza from the influenza vaccine.
Mothers had poor knowledge about which vaccines children receive. At the time of the first interview, only 2 mothers could identify even 1 of the vaccines that are recommended at 2 months of age from a list of possible vaccines that was included as part of the multiple-choice questions that followed the interview (Tables 1 and 2). During the follow-up interview, in response to the open-ended question (ie, mothers received no prompting), “what vaccines has your child received?” only 2 of the mothers who had reported that they had vaccinated their infants could correctly name ≥1 of the 5 vaccines their child would have received. Mothers frequently named chicken pox and measles, mumps, and rubella vaccines, vaccines that their child would not have received because all of the interviews were done by 6 months of age, and those vaccines are administered later.
In response to the closed-ended multiple-choice questions that followed the first interview, mothers in this study who were late vaccinators answered most of the 10 multiple-choice questions correctly (median: 9; range: 6–9; P = .014 versus vaccine acceptors), mothers in this study who were vaccine-hesitant answered a median of 6 correctly (range: 4–7; P = .048 versus vaccine acceptors), mothers in this study who were rejecters answered a median 5.5 correctly (range: 1–9; P = .93 versus vaccine acceptors), and mothers in this study who were vaccine accepters answered the fewest questions correctly (median: 4; range: 2–9; reference group).
Domains Associated With Decision-Making About Vaccination
We identified 3 main domains related to decision-making about vaccination: (1) mothers' key sources of information, (2) promoters of accepting vaccination, and (3) inhibitors of accepting vaccination. We focused on how mothers' attitudes about vaccination aligned with these domains with particular emphasis on the issues that were relevant to the mothers in the middle of the continuum (Fig 1) because of their desire for more information and their expressed willingness to consider additional discussion regarding vaccinations. We found that the themes elicited from our conversations with mothers all revolved around the central concept of trust and whom mothers had decided to trust regarding vaccination.
Key Sources of Information
Fig 2 shows the key characteristics of mothers with regard to sources of information about vaccination. For mothers who were vaccinators and the subset of nonvaccinating mothers who were late vaccinators, the preferred, trusted source of information was the pediatrician. For nonvaccinators, the preferred, trusted sources of information were the homeopath or naturopath, the Internet, books, and Mothering magazine. Mothering: The Magazine of Natural Family Living is a bimonthly magazine that “celebrates the experience of parenthood as worthy of one's best efforts and fosters awareness of the immense importance and value of parenthood and family life in the development of the full human potential of parents and children.”30 It regularly includes articles both in favor of and opposed to vaccination and is known to have a readership that includes a high proportion of nonvaccinators.15
As depicted in Fig 2, the preferred sources of information among nonvaccinating mothers who were late vaccinators overlapped with that of the vaccinators. These late vaccinators often expressed conflicting feelings about how to get their questions answered and whom to trust. For example, 1 mother who was a late vaccinator described the many sources of information she had tried and expressed her lack of satisfaction with the resulting information:
“I've gotten some information from the baby care books…. From peers, too, friends…. Getting information about why the vaccination schedule is the way it is, no one can seem to really answer for me, even my doctor. I've asked my doctors that question…. I really haven't gotten a really good answer…. I feel like I can't get really solid information.”In direct contrast to how these mothers felt, those mothers who were vaccinators had decided to trust the doctor. For example, one mother said, “You know I really … feel that I've made a decision to trust our pediatrician … So that, you know, I'm kind of ceding the responsibility of getting more information over to them, trusting her.” These mothers did not want too much information, because they trusted the doctor.
Because of the implications for planning the best timing for approaching mothers with information about vaccinations, we questioned mothers about when they sought information and when they made their decisions regarding vaccination. Except for some mothers who were vaccine acceptors, mothers sought information while they were pregnant and had decided about whether to vaccinate during their pregnancy. The following is a quote from a woman discussing her desire to have information prenatally.
“I think it should be prior [to delivery] because you never know what's going to happen…. So I think if you have information beforehand…. It's like, ‘OK, got the information on this. I know it. If they come to me and ask me if there's something I want to do, I can make a decision.’”
Promoters of Accepting Vaccination
Overwhelmingly, we found that for vaccinators, the main promoter of accepting vaccination was trusting the doctor (Table 3). As one mother phrased it, “I don't know enough about how [vaccines] are put together and tested to have a confidence level about that. But that's where the doctors come and you have to trust them.”
Another important promoter was feeling satisfied by the pediatrician's discussion about vaccination, which led to trusting that pediatrician. In particular, vaccinators who were vaccine-hesitant recounted positive, often lengthy discussions with the pediatrician.
“[The pediatrician] respected the fact that … we wanted to sit and talk for an hour and a half about vaccinations…. And he stayed very late one night … it wasn't something that they could charge us for…. And it's a very busy practice. It wasn't as if he needed to solicit our business.”
Part of being able to trust their pediatrician was finding that their pediatrician was able to answer their questions satisfactorily and completely. Mothers needed to feel as though their pediatrician was knowledgeable and had all of the relevant information.
Other promoters included a perception that vaccinating was a “cultural norm” and not wanting to depart from that norm (also called “bandwagoning”12), believing in the social contract, mothers' past experiences with diseases and vaccines for themselves or for older children, and wanting to prevent disease in their child (Table 3).
Inhibitors of Accepting Vaccination
Vaccinators and nonvaccinators expressed a fear of mistakes being made, and several mothers described instances when their child had received the wrong vaccine and how this event made them question their trust in the pediatrician. For both vaccinators and nonvaccinators, inhibitors included the belief that their child would get the diseases anyway, especially chicken pox and influenza. Mothers also believed that vaccine-preventable diseases are “not so bad”; a sizeable number of mothers (12) cited chicken pox in this regard.
For nonvaccinators, the list of inhibitors to vaccination was lengthy. Inhibitors that were important to late vaccinators are shown in Table 1. There were a number of other inhibitors mentioned by only a few mothers or by those on the far end of the continuum that we have not included here.
Most nonvaccinators expressed a sense of feeling alienated by the pediatrician and/or the medical establishment, for example, “You just feel really painted into a corner and there's really no support in the medical community. I went through … a dozen doctors who were just being like, ‘I will not treat you if you're not going to vaccinate your child.’” Alienation was tightly tied to their loss of trust in the pediatrician and the medical establishment. They were not able to enter a trusting relationship, yet they clearly were seeking such relationships with traditional pediatrics. Six of the 8 nonvaccinators expressed a clear desire to have a trusting relationship with a traditional pediatrician and had sought such relationships but had been turned away. The following are quotes from 2 different mothers.
“Because we wanted to find a pediatrician … I called 4 different pediatric groups that were listed in my medical insurance book and all 4 of them said they would not see my child…. I had nurses on the phone who would normally book appointments. My question was, ‘Do you have a pediatrician who would be willing to discuss with us, to vaccinate or not to vaccinate?’ She was like, ‘How could you do that to your child?’”
“I'm very comfortable that they [the medical establishment] have a wonderful place in what they've done and in what's possible and certainly would want to be an American citizen with access to medical hospitals here … when it comes down to it … I would love to have access to the health care that we have here.”
Several nonvaccinating mothers distrusted traditional medical care because of negative previous experiences with the medical establishment in general, such as misdiagnoses or poor communication about a diagnosis. Instead, nonvaccinating mothers ended up having a trusting relationship with an influential naturopath or homeopath or another person who supported not vaccinating.
“I really trust my homeopath. She's amazing … she is like one of my number one sources on this topic. She … keeps herself really updated in this since it's her passion…. Her clarity and the volume of information that she has on antivaccination is so compelling that you want to be like, ‘OK, I'll never vaccinate. I'll never, ever vaccinate.’”
In direct contrast to this manner in which mothers who were nonvaccinators felt that their homeopath explained immunizations with passion and expertise, these mothers found that the doctors left them feeling as though they could not trust the doctor's information, the doctors did not have adequate knowledge about vaccines, and the doctors did not have time to talk about vaccines. “But [the doctors] don't have the answers for me to these specific questions [about vaccines]…. I like them a lot, but I don't think they have the time or the motivation to find me the answers.”
Many of these mothers distrusted the motives of pediatricians and the medical establishment and explained that vaccination was exclusively for making money for pediatricians and the vaccine industry, as one mother described:
“What I would like to see is that pediatricians are educated more on the potential detrimental side to the vaccine program and not financially rewarded for giving [vaccines]…. I mean, in Connecticut, there's a financial reward given to pediatricians who have a full vaccine record.”
Inhibitors for nonvaccinators also included fears about permanent adverse effects, such as autism, sudden infant death syndrome, AIDS, and other immune diseases. Moreover, nonvaccinators expressed a belief that vaccine-preventable diseases are nonexistent, are not serious, and are easily treatable.
“I'm not overly concerned with the incidence of these diseases…. My infant is not at risk for tetanus right now…. My doctor said that, if we lived on a farm, he would recommend that she get tetanus right away. But we don't live on a farm…. And as far as the diphtheria, there's no diphtheria…. To give her diphtheria, it's like the same argument with the polio.”
What we have called the “reverse social contract” also acted as an inhibitor: mothers felt that because most other children are vaccinated, their child was not at risk for vaccine-preventable diseases (also called “free-riding”12).
Qualities of Trustworthy Relationships
Both mothers who were vaccinators and those who were nonvaccinators described qualities of a trustworthy health care provider. These qualities included spending a long period of time with them, discussing the subject of vaccines in a passionate manner, having a large amount of scientific information, using a “whole-person” approach, behaving in a manner that was not patronizing, and treating mothers/infants as individuals with individual needs.
We developed a schema classifying mothers' attitudes to vaccination and described their attitudes as existing along a continuum: mothers were vaccine accepters, vaccine-hesitant, late vaccinators, or vaccine rejecters, similar to a conceptualization developed independently by Gust et al31 and published after we completed our analysis. This characterization of the continuum of attitudes to vaccination can be used to help pediatricians formulate how to approach individual patients and to help public health programs tailor messages for the mothers in the middle of the continuum (mothers who are vaccine-hesitant and late vaccinators). These mothers in the middle of the continuum have significant concerns about vaccination, are interested in obtaining information, and play an active role in deciding whether to immunize their infants.
Trust or lack of trust and relationships were main determinants of mothers' decisions about vaccination; this reliance on trust was especially impressive, because mothers perceived that “diseases are not around” or are “not so bad,” and they had little experience with vaccine-preventable diseases. Medical knowledge was not the main driver of vaccination: mothers in this study who were most knowledgeable about vaccination were those in the middle of the continuum (possibly because they had the most concerns and, accordingly, had sought out information).
Discussions about vaccination can be one of the first opportunities to form a trusting relationship between parents and pediatricians. Communication about risks and benefits of vaccines has been the typical approach to this interaction32,33 and is legally mandated.34,35 However, this communication does not always meet parents' needs, and the dialogue between parents and pediatricians on this subject is not always trusting and open, as evidenced by studies showing that approximately one quarter of pediatricians do not allow patients in their practice whose parents refused vaccinations.36,37
Our findings indicate that relying only on dissemination of medical knowledge to parents in itself is not a satisfactory approach to communication regarding vaccines. Instead, discussions with the mothers who were in the middle of the continuum of attitudes to vaccination suggest that pediatric health care providers may need to focus both on developing trusting, open relationships and also on providing factual, scientific information about vaccines and vaccine controversies. As found in other studies,11,17 mothers, including many nonvaccinators, looked to their pediatric providers for information about vaccines. Yet, when we spoke with mothers who actively sought information from the traditional medical establishment, there were clear differences in the quality of the experiences with the pediatric-care provider between those mothers who chose to vaccinate (mothers who were vaccine-hesitant) and those who did not (mothers who were late vaccinators). Mothers who vaccinated had found a pediatric provider who could answer their questions in detail and spend time with them. In contrast, those who did not vaccinate had a pediatric provider who did not know the answers to their questions about vaccine controversies, who could not spend time with them, or who treated them condescendingly. Many of these mothers had found a passionate, trustworthy homeopath or naturopath who could offer them detailed, scientifically based information against vaccinating.
Mothers identified as more trustworthy those relationships in which their providers expressed a passion about vaccination, seemed knowledgeable, were able to offer satisfactory answers to questions that were asked, did not act condescending or rushed, and treated them like an individual. These factors fall into the domain of trust in physicians that is referred to as “trust in competence.”38–41 Perception of competence is a primary component of patients' trust in physicians; yet, because most patients cannot directly assess their physician's competence, interpersonal skills and communication style largely determine how patients perceive their physician in this domain.39,41 Unfortunately there are little data on how to successfully intervene to improve patients' trust of physicians.40
Having a vaccine program that relies to such a large extent on trust leaves it vulnerable. Trust can be fragile in the face of scandals, conflicts of interest in the profession, and proliferation of negative information, even false negative information.33 In lieu of trust alone, communication with parents and the public about risks and benefits of vaccines has been proposed as a means to strengthen immunization activities.17,32,33,42,43 However, our data suggest that a more complex picture of communication needs to be developed. Although parents want to receive information on vaccination from their pediatrician,11 pediatricians have very little time to spend discussing vaccination.44,45 Moreover, it is hard to communicate about risk with patients,42,46 and, specifically, it is hard to educate parents about vaccines.44,47,48 This study provides a broader context through which to approach communication about vaccination. These mothers suggest that developing trusting relationships regarding vaccination may include not establishing policies of excluding nonvaccinators from pediatric practices; having a detailed understanding of vaccine controversies and scandals so that when faced with concerned mothers who are in the middle of the continuum, providers can address their needs for information; being able to explain risks and benefits in clear and simple terms, because most mothers have limited recognition of the names and diseases that vaccines prevent; and beginning the process of education about vaccination during pregnancy, because concerned mothers decide about vaccination during their pregnancy. Many of these suggestions have also been proposed by other authors, including the recent statement from the American Academy of Pediatrics Committee on Bioethics.10,37,49–52 The question remains unanswered as to how busy pediatric providers can have time to follow these suggestions. It is possible that new Current Procedural Terminology codes for counseling about vaccination are a small step toward facilitating these efforts.53 In addition, given the reliance of mothers on providers of alternative medicine, pediatricians and the public health community may consider forging alliances with these groups, as well as with groups offering prenatal classes.
Our findings should be considered in light of limitations to the study's generalizability and validity. We relied on information from a fairly modest sample of English-speaking mothers in 1 geographical area; thus, we cannot ensure that these results would apply nationwide. Also, we cannot comment on the relative frequencies of attitudes held by mothers, because, as is appropriate for qualitative research, we did not base the study on a random sample of participants.23 We cannot exclude that there may be alternate valid explanations of the data we collected;26,54,55 however, we used methodologic techniques that were intended to enrich validity: purposeful sampling, grounded theory, coding by 2 researchers, and a form of multiple coding.26,29,54–58 Moreover, our findings are both credible, as well as consistent with those of published studies using varied methodologic approaches.26,29,31,54–58
We have not addressed the extent to which inherently distrustful attitudes held by nonvaccinators before they entered into a relationship with a pediatrician affected the development of a trusting relationship. This issue is particularly relevant because parents who are less confident about vaccine safety may also be less apt to follow the advice of their pediatrician in general.17 Indeed, we propose that some mothers who were vaccine rejecters on the extreme right of the continuum do hold inherent beliefs that lead them to reject vaccination regardless of any interaction with a health care provider. For example, these mothers told us that they did not vaccinate “to keep their bloodline pure.” They had low scores on the questions regarding knowledge about vaccinations suggesting that they had not sought information about vaccines. Because we found that these mothers did not seem amenable to discussing vaccination, we did not concentrate this report on them. Instead we focused on mothers, both vaccinators and nonvaccinators, in the middle of the continuum, mothers who told us that they had sought information from pediatric providers, desired information from pediatric providers, or desired to be included in the mainstream medical system. Although some of these mothers may be inherently distrustful of the medical system, we hypothesize that they are interested in, and would benefit from, being included in open discussions about vaccination.
In this study, we synthesized the factors found in previous studies11–17,31,49,50 with newly found/emphasized factors and placed them into a broad conceptual framework. These data suggest that attempts to work with mothers who are concerned about vaccinating their infants should focus on developing positive relationships in addition to providing facts about vaccines.
This work was supported in part by a grant from the National Institutes of Health (K24-AI01703), by the Yale General Clinical Research Centers Program of the National Center for Research Resources, National Institutes of Health (M01-RR06022), and by the Robert Wood Johnson Clinical Scholars Program.
We thank the mothers who spent their precious postpartum hours discussing vaccination with us, the midwives who generously referred their patients to us, and Drs Marjorie Rosenthal and Elizabeth Bradley for their thoughtful comments.
- Accepted October 17, 2005.
- Address correspondence to Andrea L. Benin, MD, 789 Howard Ave, New Haven, CT 06519. E-mail:
Dr Benin is independent of any commercial funder, had full access to all of the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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- Only 80% of children have MMR jab. The Independent. September 24, 2004:24
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- MMR uptake still falling. BBC News. September 8, 2003. Available at: http://news.bbc.co.uk/2/low/uk_news/scotland/3090316.stm. Accessed January 26, 2005
- Increase in MMR reports. BBC News. October 30, 2003. Available at: http://news.bbc.co.uk/2/low/uk_news/scotland/3227345.stm. Accessed January 26, 2005
- Elliott F. Health officials warn parents of imminent measles epidemic. The Independent. October 31, 2004:7
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