The Politics of Picking: Selective Vaccinators and Population-level Policy

"...selective vaccinators lack a voice and a place in policy..."

Community mobilisation formed the basis for the research project discussed in this article, which explores how parents who broadly concur that vaccination is an individual and social good (they are pro-vaccination) nonetheless choose to vaccinate their children selectively - that is, they refuse only some vaccines, or delay some or all of them. They may hesitate to universally follow authorities' vaccination recommendations because they are worried about the number of vaccines in the schedule, the giving of numerous vaccines at once, the age at which vaccination commences, and/or the necessity of all of vaccines. The article thus considers whether and how those seeking vaccine compliance could implement systemic and policy changes to address hesitant parents' vaccination needs and wishes.

In Australia, where this project was conducted, up to one-third of parents report concerns about the number of vaccines and distrust newer ones, but refusal rates remain at around 3.3%. Hence, most parents who worry still vaccinate. In that context, the project was embedded in the development of a pro-immunisation social marketing campaign called "I Immunise" (see Related Summaries, below), which was carried out in January 2014 by the Immunisation Alliance of Western Australia (IAWA). The campaign used role models representing parenting choices popular in Fremantle, Western Australia, such as home birthing, using cloth nappies (diapers), and breastfeeding, to start a community conversation around the benefits of vaccines and social responsibility.

The research underpinning "I Immunise" involved, in part, exploring how selective vaccinators understood themselves in relation to "the system" that sought their timely vaccination, and how "the system" might respond to the parents' concerns. Using a community-based participatory research methodology, the author of this paper, who also designed "I Immunise" for IAWA, conducted face-to-face interviews with six parents during 2013 and early 2014.

A key finding of this study was that participants, within societal discourse and engagement with the medical profession, felt alienated from the two visible camps - pro- and anti-vaccination - and yet were often lumped into the category of vaccine refusers. They reported distrust of the information they encountered, lacking the certainty of either vaccine advocates or refusers. This affected decision-making, which they recounted as following an extensive process of self-education and critical thinking. In general, many of these parents experienced a tension between belief in vaccination as a social good, and a sense that it was not appropriate in its standard form for one's own child.

The parents worked to create a legitimate social category of selective vaccinators, advocating for systemic change. They demanded: a neutral source of facts, characterised by balanced information; the ability to separate vaccines; and greater publicity for alternative schedules. As the parents sought to navigate such issues, they sought an advocacy organisation for people in their position. "In its absence, participants appealed to the IAWA. Yet IAWA, like other organisations working in the public health space, would find it very problematic to pursue these agendas..." For example, IAWA concluded they could not feature parents following alternative schedules in the campaign. "Catering for selective vaccinators could cue people to reject vaccines, or make vaccines less effective or available."

In conclusion: "Delivering cues to hesitant parents would risk generating greater hesitancy amongst all parents. Yet the parents in this study are not currently catered for. This poses a significant dilemma for designers of vaccination programmes and health professionals. Further research and pilot interventions might determine whether (and which, if any) coded cues could be made available to hesitant parents without increasing hesitancy generally. However, even if such cues proved effective, they could still not fully resolve the tension between individual and population-level health interventions that this study illuminates."