Addressing Vaccination Hesitancy in Europe: A Case Study in State-Society Relations

In June 2017, a group of parents in Northern Italy announced that they would seek asylum in Austria in reaction to the introduction of mandatory childhood vaccinations against 12 diseases in Italy. The introduction of mandatory requirements was a policy response by the Italian government to a rise in outbreaks of preventable illnesses such as measles, with Italy not the only country to change vaccination requirements. This paper explores concern over decreasing vaccination rates and increasing vaccination hesitancy as a case study in state-society relations. The contention is that paying closer attention to individual reasons why parents are vaccine hesitant might allow for designing strategies that are more suited to address concerns.

As is explained here, the current understanding of state-society relations is to view relations as nuanced, complex, and interdependent processes in which the distinctions between state actors such as ministers and bureaucrats, and society actors such as interest groups and grassroots movements, are viewed as unhelpful. Discourse-analytical approaches emphasise the importance of storylines, politics, and social context in explaining a range of phenomena. Given the number and strength of prevailing discourses in groups with anti-vaccination sentiments, the literature on discourse coalitions is used here to offer perspectives on the challenges that arise in designing strategies to address vaccine hesitancy.

"Vaccination scepticism represents an interesting case study of state-society relations as the power of vaccination sceptics stems largely from an inaction to partake in a recommended, or mandatory, public health intervention without the need to be organized in formalized coalitions or interest groups; this is also what distinguishes anti-vaccination groupings from other social movements." Another distinguishing feature - and challenge - is that it is difficult to define the policy audience: The space where sceptics are found might be in schools or kindergartens (parent communities), or it could be in paediatric offices (scepticism can be found among physicians as well), or it could be on the internet. With regard to the latter space, the groups, individuals, and websites promoting anti-vaccination sentiments are not always affiliated with an established organisation or movement. This makes it difficult to identify groups or individuals with whom to talk if state or health authorities seek to engage in a dialogue.

On the whole, "Vaccination sceptics can be conceptualized as informal coalitions of individuals or groups who find their personal beliefs reflected in the storylines promoted in the anti-vaccination discourse. The storylines are characterized by a scepticism about the credibility of scientific evidence and a distrust in the authorities, government or otherwise, who are the disseminators or producers of scientific knowledge." That said, there are a variety of beliefs and messages put forth by anti-vaccination groups, and each reason for choosing not to vaccinate children in theory requires its own tailored policy response. The concern about the safety of vaccines, for instance, which could be addressed through public education campaigns, is of a different nature than the concern about the interference of the state in parental autonomy. With regard to the latter, "The ongoing debate over the appropriate balance between coercion and autonomy in public health and other areas of state activity is one of the reasons why we are seeing divergent policy approaches to the same problem of decreasing vaccination rates across Europe as countries seek to ensure that national and local state-society relationships are not undermined."

Having outlined the complexities, the article offers some proposals about how we might open the space to more tailored policy solutions to vaccination hesitacy. For example, while the comparative effectiveness and positive impact of large-scale vaccination programmes is scientifically proven, this accomplishment does not negate the fact that the quest for certainty in science involves engaging with individuals or groups who are not convinced of the evidence with which they are presented. Similarly, acknowledging mutual concerns about the role of the pharmaceutical industry, short of conspiracy theories, might lead to a more constructive dialogue. Finally, it is advisable to explore the perceived tension between the advocacy of patient choice in health care on the one hand, and the more punitive measures in vaccination policy if parents decide against vaccinating their child, on the other.

In conclusion, it is suggested that, when it comes to vaccination policy, actors at all levels, across governmental and non-governmental institutions, must work together. "In doing so, it is crucial to recognize the storylines that make anti-vaccination discourses powerful, and to embrace the possibility of moving away from policy narratives that are focussed solely on factual information to ones that are interspersed with personal stories to which people might relate and connect."