Healthism vis-à-vis Vaccine Hesitancy: Insights from Parents Who Either Delay or Refuse Children's Vaccination in Portugal

"Using vaccine hesitancy as the starting point,...findings show that healthism and its focus on personal accountability under the umbrella of neoliberalism may jeopardize global public health."

"Healthism" is a phenomenon characterised by high health awareness and expectations, information-seeking, self-reflection, high expectations, distrust of doctors and scientists, healthy and often "alternative" lifestyle choices, and a tendency to explain illness in terms of folk models. Healthism is deeply interwoven with individualism and accountability, which is at the heart of neoliberal thinking. This article aims to deepen the knowledge on the relation between healthism and vaccine hesitancy, using Portugal as a case study. It was conducted as part of the VAX-TRUST project, which intends to understand vaccine hesitancy and improve interactions between healthcare professionals and vaccine-hesitant parents.

In Portugal, only the tetanus and diphtheria vaccines are compulsory. Vaccination is free of charge, though parents who decide to immunise their children in private practices must pay for the administration of the vaccine. Although Portuguese parents have been found to be the most confident in vaccines in comparison to parents from other European countries, two measles outbreaks occurred in the country in 2017 - indicating that vaccine resistance clusters open space for disease susceptibility. In a similar way to other Southern European countries, in recent decades, Portugal has experienced a radical neoliberalisation of health care because of two major international financial crises.

In-depth interviews were conducted with 31 vaccine-hesitant parents between November 2021 and May 2022. Six themes were identified and are described in the paper, featuring illustrative quotations translated in to English: (i) natural birth; (ii) extended breastfeeding; (iii) adoption of a vegetarian/macrobiotic diet; (iv) preference for alternative educational models; (v) "natural medicine"; and (vi) distrust in science.

For example, throughout childhood, parents continuously decide about vaccinating their children on a case-by-case basis considering both the severity and the prevalence of each disease. Leonor, age 46, said that the polio vaccine "is compulsory and the disease is totally eradicated. In other words, there has been no case of polio in Portugal or in other countries for some years now. Therefore, it is assumed that it is eradicated....it doesn't make much sense to have a vaccine now." This quotation is illustrative of misconceptions on the part of vaccine-hesitant parents, which are augmented by the lack of effective communication between parents and healthcare professionals. Indeed, healthcare professionals generally reply evasively, and, according to the study's participants, they used derogatory language to blame parents for having doubts and to pressure them to agree to vaccination.

The findings of this study show that healthism beliefs are likely to go hand in hand with vaccine hesitancy among Portuguese parents. When reasoning about their choices regarding their children's health, the arguments of the hesitant parents interviewed for the current study relied on the dichotomy of natural and artificial, favouring the first. In addition to natural birth, hesitant parents stressed the relevance of extended breastfeeding as the most natural and, thus, most effective means to promote babies' and children's immunity. Moreover, they preferred cooking from scratch rather than using processed foods containing additives and preservatives. Hesitant parents' natural living extended to their views about their children's education; they tended to choose schools providing alternative educational models.

The interplay of the caregiving practices described above was believed to ensure children's health in a natural way and making vaccines needless or, at least, less necessary. This view embodied the concept of healthism as shedding light on the individual responsibility and control for health management. Indeed, parents understood themselves as "active and capable agents" who have the skills and the knowledge to make the best decisions for their children. Hesitancy towards vaccination may be understood as a result of the focus of health promotion and individual agency. Vaccine-hesitant parents consider themselves to be the main "experts" on their children's health, relying more on their own judgment to weigh the pros and cons of vaccination rather than on healthcare providers' recommendations. Parents understood themselves as guardians of children's pure bodies, which need to be protected from contamination by outside sources.

Notably, in light of the fact that commitment to children's health as expressed in the healthist philosophy implies ongoing parental supervision requiring additional time and money: "Vaccine hesitancy may to a certain extent reflect social inequality, as those who are more well educated and have certain financial resources are more able to choose..."

Thus, the vaccine-hesitant parents in the sample "focused on the needs of their own children, [but] they may have put the health of others at risk by not following mainstream public health policies regarding vaccination..." The researchers urge that, to address the distrust in science and medicine evident in the discourse of vaccine-hesitant parents, healthcare professionals should spend more time discussing parental vaccination concerns. They propose that the presumptive or paternalistic model of communication, which has proved ineffective in cases of vaccine hesitancy, as information is usually perceived as biased, should be replaced by a patient-centred approach that takes individual/family characteristics and preferences as a starting point."

In conclusion: "the findings of this study recall that healthcare professionals should pay particular attention to healthism when addressing vaccine hesitancy. Research evidence advocates the need to be sensitive to the broad spectrum of vaccine hesitancy...Indeed, the labeling of 'anti-vaxxers' has been found to increase the polarization of discourses on vaccination, having a backfire effect...Therefore, instead of being critical of vaccine-hesitant parents, a more comprehensive approach on the reasons underlying vaccine hesitancy should be developed."