Background
Despite efforts of international and national health authorities, immunization coverage and timeliness of vaccination against dangerous childhood diseases have been adversely affected by parental choice to decline childhood vaccination in high-income countries [
1-
3]. This led to large-scale outbreaks of vaccine preventable diseases in Europe and the US such as measles in the Netherlands, Italy, France, Germany, Switzerland and the UK over the last ten years [
4]. In Switzerland, after several years with a relatively low annual incidence rate, there have been several waves of large measles epidemics since 2006 [
4,
5]. As a consequence of these outbreaks and increased population awareness, coverage rate for two MMR doses among 2-year old children has slightly increased since 2005 to 86% [
6], which is still considerably below the WHO target of 95% coverage. Moreover, coverage rates vary strongly between language zones and cantons ranging from 50 to 93% [
7].
Recent studies argue that in today’s industrial countries vaccine refusal rates can only partially be explained by parents’ information deficit, lack of access to facts and misinformation [
8,
9]. Instead recent social-scientific literature has emphasized the importance of identifying broader social, political and conceptual structures that may shape parents’ immunization decisions in order to better understand reasons behind parental resistance to immunize their child [
10]. Several authors see the reason behind parental hesitation to vaccinate their children as a combination of an increasing erosion of trust in stakeholders involved with vaccination and a parallel trend of an increasing personalization/individualization of risk [
9,
11]. However, in the last decade several studies have also reported on vaccination refusal among social groups having “alternative” lifestyles and philosophical outlooks [
12-
14]. Streefland [
15] shows that there is a trend particularly among well-educated parents in Europe and the USA to believe in keeping good health by maintaining bodily balances and gaining immunity in a natural way. In his analysis of recent anti-vaccination movements Blume [
1] also points to the emerging questioning of immunization among parents who advocate holistic ideas about health, natural child birth and breast feeding. Several studies support his observation: In a study exploring how parents in Brighton were thinking about the MMR vaccine in the context of the autism-controversy raised in the UK in the 1990s, several mothers backed up their arguments against MMR vaccination with the idea of the value of acquired natural immunity through nutrition and appropriate nurturing and the particularity of individual immunity [
10,
13]. Arguing that “alternative” views of health and medicine seem to be finding increasing sympathy among the population at large Blume [
1] calls for a better understanding of them. Until now, there has been little formal research on these trends despite their influence on health care use [
16,
17].
In this paper we are especially interested in better understanding the influence of parents’ emerging views linked to “natural and healthy” lifestyles on their decision regarding childhood vaccination. This is particularly pertinent in Switzerland, where immunization costs are covered by insurance companies, but where vaccination coverage depends on parents’ initiative to bring their children to private pediatricians for vaccination. Based on the parents’ narratives we examined in particular how Swiss parents used themes around what they perceived as ‘natural development’ of the body and the immune system to explain their critical attitudes towards immunization against measles and other childhood diseases.
Discussion
Parents’ perceptions of the importance of a “natural” development of the body and the immune system emerged as a significant theme in explaining parents’ critical attitudes towards the immunization of their child(ren) against measles, mumps and rubella as well as other childhood diseases in Switzerland. Rather than simply “resisting” vaccination, this group of middle-class parents, a high proportion of which worked in the health and education sectors, showed a surprisingly strong faith in and appraisal of the “natural” development and functioning of the human immune system in their arguments. Earlier studies on parents’ vaccine decision-making in the UK have highlighted the close interconnection of parents’ decisions on natural birth, breastfeeding and vaccination [
10,
13,
19]. Although not referring to natural ways of delivering, the interviewed parents in Switzerland similarly depicted worldviews emphasizing a particular notion of “the natural”. They repeatedly emphasized the important role of breastfeeding and healthy natural food to build up their children’s immune system. The health system itself has played an important role for the last two decades in promoting breastfeeding as the best way to protect an infant from infections through public health messages [
20]. This may have contributed to a local culture of vaccination [
21], which goes along with the underestimation of the need to vaccinate the child for specific diseases. In addition, recent campaigns to promote the consumption of particular foods such as fruits may support perceptions that a “natural” choice is a healthier choice. In our interviews, parents perceived diseases as a natural way to build-up a robust individual immunity, health and development, similar to what Leach and Fairhead described for the UK [
10]. Our results support Blume [
1] as well who has stressed the importance of considering parents’ ideas about holistic health and the importance of a natural life style and environment for a child’s well-being in order to understand parents’ vaccination decision-making.
One question, which emerges from these findings, is to what extent the preference for the natural over the artificial reflects a more deeply rooted distrust in the dominant bio-medical health care system. In their recent review on reasons for vaccine hesitancy in Europe Yaqub et al. identified distrust as a key barrier to vaccination, more precisely ‘distrust of doctors’, ‘distrust of government sources’, and ‘distrust of pharmaceutical companies’ [
9]. The authors stressed that vaccines per se were not mistrusted, but the institutions delivering the vaccines. In some cases the motivation of health system actors was perceived as being influenced by larger economic interests. Our study differed in this respect in that distrust in institutions did not seem to be an overruling barrier to vaccination, albeit it was observed as well. But many of the interviewed parents worked themselves in the Swiss health care system, so that it is unlikely that they are overly critical of the system. Nonetheless they decided not to follow the official recommendations for vaccination.
Unlike in other studies our findings thus reveal a certain ambiguity as regards the importance of distrust of the health care system for vaccine hesitancy. Helpful for the interpretation of our findings is the conceptual distinction between trust and legitimacy. Yaqub et al. defined trust as ‘ability to rely on somebody else’s claims about a situation’ in the absence of full information, whereas legitimacy refers to the grounds (or discourses) upon which truth claims are made [
9]. Among our respondents vaccine hesitancy seems to originate strongly in doubts about the legitimacy of an artificial intrusion into the “natural” development of the immune system rather than merely reflecting a general distrust in the actors of the health care system. When parents question the legitimacy of prioritizing the artificial stimulation of a child’s immune system over naturally acquired immunity, their uncertainty about bodily reactions to vaccinations might be part of “an increasing unease with modernity” which is paralleled by general concerns about the safety of mobile phones or environmental pollution, for example [
17]. Helman postulated a general shift in the interpretation of the health-nature relationship: “In the 1970s . . . […] nature had become a threat. People were exhorted to keep it at bay, to protect themselves from the elements. In the new model, nature has come full circle and is once again valued as a positive, health-giving force (at least among the middle classes) (cited in [
16]). Parents’ juxtaposition of naturally acquired immunity and health and their perception of vaccination as an artificial intrusion into the bodily order of the child refers well to what he described as part of a Western modern dualism endowing positive qualities to anything ‘natural’ and holistic as opposed to anything scientific or technical.
Besides doubts about the legitimacy of interfering with a “natural” process, fears about vaccination side effects played a role as well. Similar to what has been described by other authors, parents in Switzerland feared that vaccines combining several antigens could potentially overwhelm or “contaminate” the child’s immune system, even more so in the case of the still immature immune system of an infant [
2,
3,
19]. Emily Martin described this phenomena already 20 years ago as a paradigm shift from a general concern of “disinfection” to “detoxification” [
22]. Parental concerns of “overloading” their infants’ immune system with vaccines in the first months of life further open up discussions about the “right” timing of vaccines. Current practice of “one size fits all” immunization plans and combined vaccines raises concerns about not meeting every individual child’s needs. The rationale for recommendations as regards the timing of a specific vaccination is based on immunological and epidemiological considerations, which are usually not known to parents. Their desire for a personalized, patient-centered approach to vaccination in terms of age of the child and timing of vaccination may be accommodated with more precise information in this regard. A clear rationale for the recommended timing may motivate parents to follow the immunization schemes; in cases where flexibility is possible this could be communicated.
It is further notable that despite national information campaigns, the majority of interviewed parents associated childhood diseases such as measles, rubella and mumps with mild illnesses that many of them had gone through themselves when they were children, which was reported by other studies as well [
2,
23]. This illustrates again the very personalized perspective of parents when judging the risks and benefits of immunization versus disease [
24]. Moreover, it points to the fact that risk perception always depends on the available possibilities to counter specific threats, such as the availability of a high quality curative health system [
25]. In the Swiss context, contracting an infectious disease seemed to constitute a smaller threat to these parents than the uncertainty of the child’s bodily reaction to the vaccine.
We limited the focus of this paper on parents talking about nature, body and health as this reflects important lifestyle concepts in Switzerland and other high-income countries, which have up to this point received little attention in public health campaigns promoting vaccination. Decision-making on immunization involves many more dimensions, including parents’ understanding of their responsibility, their trust in health professionals and authorities, parents’ own health history, and social relationships with other mothers and parents [
13]. Moreover, the small sample of parents critical to fully immunize their children cannot be generalized to the Swiss population. Nonetheless, our results provide important insights into parental reasoning on immunization, which may help to better adapt public health and vaccination messages.
Conclusions
In the context of the Swiss health system vaccination coverage depends on parents’ initiative to take their child to a private pediatrician. Our findings suggest that well-informed parents make health-related decisions for their children on the basis of their own assessment, informed by their own worldview rather than basing it on experts’ recommendations alone. Unless emerging trends and lifestyles, such as the trend towards a more “natural” way of life, are addressed in vaccination campaigns, they might miss the target population. A related aspect is parents’ wish for a more personalized timing of vaccinations. To satisfy the increasing parental demand for an individualized, patient-centered approach to vaccination, a more flexible immunization plan, where possible, might help to increase immunization coverage. Moreover, national vaccination campaigns need to be integrated in a meaningful way into other public health messages that promote ‘natural’ ways to develop the human immune system, such as exclusive breastfeeding, to avoid seemingly contradictory messages. However, most importantly, there is a need for more research on the issue.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KH, SM and EZ have contributed to the conception and design of the study, and KH has collected the data. KH and KG have analyzed and interpreted the data, and all authors were involved in drafting the article or revising it critically for important intellectual content. All authors have provided approval of the final version as submitted.