Risk, Responsibility and Negative Responses: A Qualitative Study of Parental Trust in Childhood Vaccinations

"It is critical to understand how parents who wholly or partially reject vaccination interpret and make sense of risk if we are to identify appropriate interventions to maximise uptake."

By sharing the results of in-depth interviews with non-vaccinating and/or vaccine-hesitant parents in two Australian cities, this paper explores the ways in which such parents talk about the perceived risks and benefits incurred by vaccinating (or not vaccinating) their children. Noting that vaccine-refusing parents have often been framed in the popular media as being ignorant, irresponsible, and selfish, this study emphasises that vaccine-questioning or -refusing parents are acting in what they see as the best interests of their children and consequently, engaging with risk assessments as part of the requisite practice of being vigilant about vaccines.

A detailed description of the methods and analysis used in this study has been provided in other publications by the research team (see, e.g., Related Summaries, below), but, in brief, between 2013 and 2016, the team interviewed 9 parents from Fremantle, WA, and 20 from Adelaide, South Australia. Analysis of the interviews identified particular constructions of risk and responsibility, and it mirrors the chronological process through which parents navigate risk:

• The concept of "responsibilisation" involves parents demonstrating a high level of agency and self-trust in ensuring their child's development, well-being, and health. They see vaccination not as a given (i.e., something they have to do because the State advises it) but, rather, as an individual choice and decision. Through this lens, the decision whether (or not) to vaccinate is part of a broader project of pursuing a professionalised, highly considered, and labour-intensive parenting practice that the researchers call "salutogenic parenting".
• Responsibilised parents "do their research", which involved reading information, talking with healthcare professionals and friends/family, and searching for information online. The parents talked about trusting their own abilities to search for relevant information, their trust in what they found, and their ability to analyse the information and make appropriate decisions.
• Parents then attempt to navigate multiple and conflicting risks: the risk of vaccine-preventable diseases (VPDs), risks associated with vaccination, and risks associated with their own perceived lack of understanding. "Most parents talked about the uncertainties embedded in an epidemiological framing of risk factors (e.g. 1:10,000 risk), which communicators often employ to show that vaccines are far less risky than VPDs. The parents remained ultimately unconvinced, both in terms of the risk of contracting an illness and the risk of an adverse reaction from receiving a vaccination. In part, this was because population-level framing does not resonate well when, for parents any risk to their own child as unacceptable." Lack of trust in governments, medical science, and the pharmaceutical industry often led them to construct vaccines as both unnecessarily risky and of little/no health benefit for their child.
• After engaging with risk, parents justify the decision and accept the associated responsibility. "This responsibility was not necessarily easily navigated, however. Information gathering on the risks and benefits of vaccinating/not vaccinating often created uncertainty, confusion and anxiety. Parents recognised the existence of conflicting information, but also the social and individual responsibility, which came with their decision. Nevertheless, once parents had made the decision not to vaccinate, they were comfortable with the responsibility, maintaining and promoting their child's health and well-being but also expressing a sense of social responsibility for the health of others."
• Parents use this sense of responsibility to navigate through the responses of others, which the researchers conceptualise as including risks to social relationships and medical care. (For example, parents described experiences with judgemental general practitioners (GPs), which then affected the likelihood they would seek treatment for their children.) Thus, "although they took personal and social responsibility for their decision not to vaccinate, they bore both blame and stigma from friends/family and healthcare professionals, which they believed to be unfair and unfounded."

In reflecting on the findings, the researchers note that these data reframe the act of not vaccinating from being deficit-based (parents are doing something wrong) to being assets-based (parents are basing their lives around what they regard as positive parenting and health promotion for their children). Practically, then, the healthcare provider should not simply try to "change" what they see as the "wrong" decision but, rather, to "seek to understand the logic and moral position of parents so that communication can occur in a socially, culturally and ethically appropriate way, helping parents make decisions that are both evidence-informed and consonant with their values."

In conclusion: "Healthcare professionals need to remain open to discussion regarding vaccinations with vaccine-hesitant and non-vaccinating parents. An 'open door' policy enables individuals seeking vaccine information and advice to access services and appropriate treatment of children in healthcare, assured they would be received in a respectful manner, so that conversations and the building and maintenance of trust can occur."