Stigmatized for standing up for my child: A qualitative study of non-vaccinating parents in Australia

Parents' attitudes towards the No Jab No Play legislation in Western Australia: a mixed methods study

BACKGROUND

Mandates provide a relatively cost-effective strategy to increase vaccinate rates. Since 2014, five Australian states have implemented No Jab No Play (NJPlay) policies that require children to be fully immunised to attend early childhood education and childcare services. In Western Australia, where this study was conducted, NJNPlay legislation was enacted in 2019. While most Australian families support vaccine mandates, there are a range of complexities and unintended consequences for some families. This research explores the impact on families of the NJNPlay legislation in Western Australia (WA).

METHODS

This mixed-methods study used an online parent/carer survey (n = 261) representing 427 children and in-depth interviews (n = 18) to investigate: (1) the influence of the NJNPlay legislation on decision to vaccinate; and (2) the financial and emotional impacts of NJNPlay legislation. Descriptive and bivariate tests were used to analyse the survey data and open-ended questions and interviews were analysed using reflexive thematic analysis to capture the experience and the reality of participants.

RESULTS

Approximately 60% of parents intended to vaccinate their child. Parents who had decided not to vaccinate their child/ren were significantly more likely to experience financial [p < 0.001] and emotional impacts [p < 0.001], compared to those who chose to vaccinate because of the mandate. Qualitative data were divided with around half of participants supporting childhood immunisation and NJNPlay with others discussing concerns. The themes (a) belief in the importance of vaccination and ease of access, (b) individual and community protection, and (c) vaccine effectiveness, safety and alternatives help understand how parents' beliefs and access may influence vaccination uptake. Unintended impacts of NJNPlay included: (a) lack of choice, pressure and coercion to vaccinate; (b) policy and community level stigma and discrimination; (c) financial and career impacts; and (d) loss of education opportunities.

CONCLUSIONS

Parents appreciation of funded immunisation programs and mandates which enhance individual and community protection was evident. However for others unintended consequences of the mandate resulted in significant social, emotional, financial and educational impacts. Long-term evidence highlights the positive impact of immunisation programs. Opinions of impacted families should be considered to alleviate mental health stressors.

Public values to guide childhood vaccination mandates: A report on four Australian community juries

OBJECTIVE

Governments use vaccination mandates, of different degrees of coerciveness, to encourage or require childhood vaccination. We elicited the views of well-informed community members on the public acceptability of using childhood vaccination mandates in Australia.

METHODS

Four community juries were conducted in Canberra, Launceston, Cairns and Melbourne, Australia between 2021 and 2022. We recruited 51 participants from diverse backgrounds, genders and ages through random digit dialling and social media. Two juries were held in metropolitan areas, and two in regional/rural settings. Outcome measures included jury verdicts and reasons in response to structured questions.

RESULTS

All juries were concerned about collective protection and individual rights but prioritised the former over the latter. A majority in all juries supported mandates but juries disagreed with respect to the appropriate mandate types. All juries endorsed using the least restrictive or coercive means to encourage vaccination (providing incentives or education, e.g.) before imposing penalties such as financial losses and school exclusions. The overriding view was that it is fairer to place a direct burden on parents rather than children and that mandates should be designed to avoid inequitable impacts on less advantaged groups in society. Many jurors found conscientious objection acceptable as a controlled option for resolute refusers, provided that overall vaccination coverage remains high.

CONCLUSION

This paper gives policymakers access to the reasons that Australians have for supporting or opposing different mandates under conditions of high knowledge, understanding and deliberation regarding policy options. Sustaining high rates of vaccination requires high levels of co-operation between governments, public health actors and the public. Our findings highlight the importance of considering public values in the design and implementation of vaccination mandates.

PATIENT AND PUBLIC INVOLVEMENT

We sought input from individuals who did and did not vaccinate during the study design. The views and perspectives of nonvaccinating parents were presented in the evidence to juries. We deliberately excluded nonvaccinating individuals from participating, as the divisive and often hostile nature of the topic, and their minority status, made it difficult to ensure they would feel safe as members of the jury without overrepresenting their perspective in the sample. Two related projects engaged directly with these parents.

Pushed to the Fringe - The Impact of Vaccine Hesitancy on Children and Families

Vaccine hesitancy has been described as any delay or refusal of vaccines despite their availability and is increasing in Australia and other middle to high-income countries. The aim of this study is to gain a deep understanding of the experiences and influences on vaccine hesitant children and their families. A qualitative interview approach was undertaken with vaccine hesitant parents and pregnant women (n = 12). Semi-structured interviews were conducted by telephone. Inductive thematic analysis was undertaken on data obtained using the guidelines of Braun and Clarke. Three main themes were identified in this study, including Pushed to the fringe; A culture of Distrust; and Coerced choices. The study revealed that vaccine hesitant parents felt isolated and pushed to the fringe of society. They also expressed dissatisfaction with the Australian "No Jab - No Pay" and "No Jab - No Play" legislation. This contributed to feelings of marginalization. Participants also cited a breakdown in the therapeutic relationships, which impacted their child's health. Additionally, a lack of sufficient information was received to achieve informed consent. These results suggest that there is a need for enhanced education for some health-care professionals, many of whom have reported being confronted by conversations with vaccine hesitant parents.

Touching the cornerstone: An illustrative example of the effects of stigma and discrimination on vaccine-hesitant parents

Objectives

The concept of vaccine hesitancy encompasses multiple views on the subject. However, there has been an increasing polarization of the discourse on vaccine hesitancy leading to the stigmatization of those parents who expressed doubts or concerns regarding vaccination practices. The present study aimed to explore the drivers and consequences of polarized discourses on vaccination in the Portuguese context. This paper is part of a broader study which aims to gain a deeper understanding about the phenomenon of vaccine hesitancy at the European level.

Study design

A qualitative research design was used.

Methods

The sample was comprised of thirty-one Portuguese vaccine hesitant parents who were interviewed. A thematic analysis of the transcribed interviews was performed which allowed us to identify key themes.

Results

The results showed that the labelling of vaccine-hesitant parents as 'anti-vaxxers' along with social media play a crucial role in promoting the polarization of vaccine-related attitudes. The stigmatization of vaccine hesitant parents has a disruptive impact on their social network leading them to search for online platforms where they can exchange vaccines-related information without being discriminated.

Conclusions

The stigma and discrimination experienced by vaccine-hesitant parents stimulated that hesitancy becomes more entrenched. Therefore, pluralism should be used to tailor vaccination promotion campaigns to different targets, promoting its reach and efficacy.

Childhood vaccine refusal and what to do about it: a systematic review of the ethical literature

BACKGROUND

Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature.

METHODS

Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field of Research codes, and normative content was analysed using a framework analytical approach.

RESULTS

Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled 'refusal arguments'); and (2) Whether strategies for dealing with those who reject vaccines are justifiable ('response arguments'). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent's will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom.

CONCLUSIONS

This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy.

Recruiting a Hard-to-Reach, Hidden and Vulnerable Population: The Methodological and Practical Pitfalls of Researching Vaccine-Hesitant Parents

While recruitment is an essential aspect of any research project, its challenges are rarely acknowledged. We intend to address this gap by discussing the challenges to the participation of vaccine-hesitant parents defined here as a hard-to-reach, hidden and vulnerable population drawing on extensive empirical qualitative evidence from seven European countries. The difficulties in reaching vaccine-hesitant parents were very much related to issues concerning trust, as there appears to be a growing distrust in experts, which is extended to the work developed by researchers and their funding bodies. These difficulties have been accentuated by the public debate around COVID-19 vaccination, as it seems to have increased parents' hesitancy to participate. Findings from recruiting 167 vaccine-hesitant parents in seven European countries suggest that reflexive and sensible recruitment approaches should be developed.

Communication Interventions and Assessment of Drivers for Hendra Virus Vaccination Uptake

Hendra virus disease (HeVD) is an emerging zoonosis in Australia, resulting from the transmission of Hendra virus (HeV) to horses from Pteropus bats. Vaccine uptake for horses is low despite the high case fatality rate of HeVD in both horses and people. We reviewed evidence-based communication interventions to promote and improve HeV vaccine uptake for horses by horse owners and conducted a preliminary evaluation of potential drivers for HeV vaccine uptake using the Behavioural and Social Drivers of Vaccination (BeSD) framework developed by the World Health Organization. Six records were eligible for review following a comprehensive search and review strategy of peer-reviewed literature, but evidence-based communication interventions to promote and improve HeV vaccine uptake for horses were lacking. An evaluation of potential drivers for HeV vaccine uptake using the BeSD framework indicated that horse owners' perceptions, beliefs, social processes, and practical issues are similar to those experienced by parents making decisions about childhood vaccines, although the overall motivation to vaccinate is lower amongst horse owners. Some aspects of HeV vaccine uptake are not accounted for in the BeSD framework (for example, alternative mitigation strategies such as covered feeding stations or the zoonotic risk of HeV). Overall, problems associated with HeV vaccine uptake appear well-documented. We, therefore, propose to move from a problems-focused to a solutions-focused approach to reduce the risk of HeV for humans and horses. Following our findings, we suggest that the BeSD framework could be modified and used to develop and evaluate communication interventions to promote and improve HeV vaccine uptake by horse owners, which could have a global application to promote vaccine uptake for other zoonotic diseases in animals, such as rabies.

FEAR AND STIGMATIZATION IN THE GENERAL POPULATION DURING THE COVID-19 PANDEMIC

OBJECTIVE

Aim: The aim of the study was to investigate the feeling of fear and stigmatization in the general population, during the pandemic. .

PATIENTS AND METHODS

Materials and Methods: The study sample consisted of 1076 people attending a vaccination center in the Region of Argos, a prefecture of Peloponnese Region. The study was conducted from May 2021 to August 2021. In this study we used the Fear Investigation Scale(FCV-19S) and the COVID-19 Stigma scale.

RESULTS

Results: A total of 1076 participants took part in the study. Vaccinated participants for Sars Cov-2 had higher levels of fear (U=117,569.00, p<0.001) and individuals with unspecified employment status had a higher level of fear compared to civil servants, pensioners, unemployed, private employees and freelancers (H = 17.225, p=0.004). Higher levels of fear were also seen by those who reported that they were uncertain that the COVID-19 pandemic was likely to be treated soon compared to those who believed it would be treated soon and those who did not believed this (H = 31.299, p<0.001). Vaccinated citizens showed a higher stigmatization rate of health professionals. Professional uncertainty and unemployment shows that they are a factor for increased fear. Strong social and family ties also indicate the reduced presence of stigmatization.

CONCLUSION

Conclusions: An important imprint of the pandemic was the stigmatization of population's groups, such as health professionals, foreigners, as well as the infected by COVID-19. It is evident in society, that it was the fear of contracting the disease that contributed to stigmatization and isolation.

'Get your own house in order': Qualitative dialogue groups with nonvaccinating parents on how measles outbreaks in their community should be managed

Objective

Communities with high levels of vaccine rejection present unique challenges to vaccine‐preventable disease outbreak management. We sought perspectives of nonvaccinating parents to inform public health responses in such communities.

Methods

Nineteen purposively sampled nonvaccinating Australian parents participated in one of seven online dialogue groups. We asked what they thought parents, school principals and public health professionals should do in a hypothetical school measles outbreak and used a framework approach to data analysis.

Results

Parents' views were grounded in strong beliefs in parental responsibility and the belief that vaccines are not effective, thus unvaccinated children do not therefore pose a threat. They then reasoned that the forced exclusion of unvaccinated children from school in a measles outbreak was disproportionate to the risk they pose, and their child's right to education should not be overridden. Nonvaccinating parents judged that all parents should keep sick children at home regardless of disease or vaccination status; that school principals should communicate directly with parents and avoid using social media; that public health professionals should provide information to parents so they can decide for themselves about excluding their children from school; that public health responses should avoid accidental identification of unvaccinated children and that mainstream media should be avoided as a communication tool.

Conclusion

Nonvaccinating parents do not always agree with current Australian approaches to measles outbreak management. Their perspectives can inform approaches to outbreak responses in communities with high levels of vaccine rejection.

Patient or Public Contribution

We sought input from individuals who did and did not vaccinate on study design in its early phases. Individual conversations were used deliberately as we felt the group advisory situation may have felt less safe for nonvaccinating parents, given the divisive and often hostile nature of the topic.

Social Stigma of Patients Suffering from COVID-19: Challenges for Health Care System

The meaning of the term social stigma has changed over the years. The history of this concept dates back to ancient times. Currently, social stigma is defined as the attitude of discrimination, disapproval, or negative perception of a given group due to the properties and features it represents. Stigmatization concerns the physical and mental spheres of an individual. The burden of stigma affects many people. Moreover, it is present in medicine, affects people with COVID-19 and presents a challenge for the health care system. Social stigma of individuals with COVID-19 is a worldwide problem and can be compounded by including race, profession, social status, religious identity, and vaccination status. Stigmatization may lead to negative consequences, including discrimination and social rejection of stigmatized individuals. In addition, it affects the close relatives of stigmatized individuals. The main goal of this review paper is to present the problem of stigma among patients suffering from COVID-19 and to list major challenges for the health care system in solving this problem. We undertook a review of literature published in PubMed systems, Scopus and Google Scholar. The results indicate that the stigmatization bears many negative consequences including limited access to health care, potential impact on health status of patients and worse outcomes. Early identification of the problem may help to implement appropriate strategies to combat the stigma.

Becoming skeptical towards vaccines: How health views shape the trajectories following health-related events

Recent studies on skepticism towards childhood vaccination urge scholars to analyse vaccination trajectories. Focusing on a social group that recent studies point out as being especially relevant because of its relatively high level of skepticism toward childhood vaccination, we use in-depth interviews resembling open conversations to explore how more-educated parents' views on vaccination came about. Providing an in-depth understanding of these vaccine-skepticism trajectories, we additionally analyse 1) how health-related events play a role in parents' trajectories, and 2) how these trajectories are shaped by parents' pre-existing health views. Interviews with 31 more-educated Dutch parents reveal that different types of events incite respondents to start questioning vaccinations. Next to more commonly studied events that directly involve parents' or their children's health (e.g., (perceived) adverse effects of treatments), events that are also related to the topic of health or vaccination but do not involve parents' or their children's health (e.g., when health issues come up in a conversation) may incite parents to start questioning vaccination. Moreover, how respondents experience (different types of) health-related events, and how they go through distinct stages after this, proves shaped by their pre-existing health views: parents with nature-oriented health views came to doubt the fundamental principles of vaccination, turning instead to 'alternative' resources and practices; parents with science-oriented views queried the potential risks of vaccination and sought out what they viewed as the most scientifically sound information. We discuss the implications of our findings for scholarly debates and provide suggestions for further research.

Labels matter: Use and non-use of 'anti-vax' framing in Australian media discourse 2008-2018

Childhood vaccine refusal is a globally contentious topic, with some jurisdictions addressing it with punitive policies. Media discourse influences how solutions are framed by implying blame - a process known as framing. We examined Australian media discourse on vaccine rejection over a period in which mandatory childhood vaccination policies were discussed and introduced, focusing on the common Australian pejorative term 'anti-vaxxer'. We mapped frequency of use from January 2008 to December 2018. We then searched Factiva for print media articles on childhood vaccination and parents published in that period, searching separately for articles using and not using 'anti-vaxxer' and variants. We constructed a set of 85 articles that did, and 85 articles date-matched that did not use the term to make comparisons and conducted a frame analysis of each set. 'Anti-vaxxer' was absent in Australian media discourse 2008-2010, rising to a peak of 247 articles using the term at the height of legislative change in 2017. Parents were framed as: 1) deviant "others"; 2) ignorant and in need of informing; 3) vulnerable and in need of protection from anti-vaccination activists; 4) thoughtful, critical, informed, and in need of agency and respect; 5) entitled, privileged and selfish; and finally, 6) lacking access to vaccination, rather than being unwilling. Articles using 'anti-vax' terms were more likely to negatively characterise non-vaccinating parents, while articles not including this language were more likely to frame them as thoughtful or lacking access. This study clearly demonstrates strategic use of pejoratives in the Australian mass media around a time of pressure for legislative change and conflation of anti-vaccination activists with non-vaccinating parents. We suggest fundamental changes to how non-vaccination is framed and dealt with in the media to curb polarization and fostering more respectful dialogue, and better social and public health outcomes.