Caregivers' Perceptions on Routine Childhood Vaccination: A Qualitative Study on Vaccine Hesitancy in a South Brazil State Capital

"Contact with other hesitant families proved to be the main trigger for questioning routine vaccination, social circles proved to be the primary source of information used to answer those questions and maintain positions."

Brazil's National Immunization Program has faced significant challenges regarding vaccination coverage due, in part, to vaccine hesitancy, a complex, multi-causal, and context-specific phenomenon. This qualitative study aims to understand the factors associated with decision-making and the drivers of vaccine hesitancy in Florianopolis, the Santa Catarina state capital, regarding caregivers' perceptions of routine childhood vaccination. In this city, childhood vaccination coverage is lower among families with higher income and education level.

Between March and June 2021, the researchers conducted in-depth interviews with 29 caregivers (16 mothers and 13 fathers) of children up to 6 years old. Three themes emerged from thematic analysis:

1. Access to information and the decision-making process - It is noteworthy that caregivers describe Florianopolis as a place where vaccine questioning is culturally naturalised and accepted, which makes them feel respected in their decisions and less judged for not following what would supposedly be expected or hegemonic. The primary source of doubts regarding vaccine information mentioned by the hesitant caregivers was the social circles in which they are nested (e.g., prenatal groups and parents and school groups). Healthcare workers, especially paediatricians and those linked to natural childbirth groups, are characterised as essential sources of information for decision-making. For most families, the internet is not a reliable environment to seek vaccine information. Even when they do, they try to confirm the information they find. (The researchers believe that this finding about questioning information found on the internet is due to the context in which the research was conducted: the COVID-19 pandemic, which was accompanied by an infodemic that led to a truth crisis.)
2. Individual-institutional power relationships - The interviewed families present various criticisms about the irreducibility and inflexibility of institutions in the face of their doubts about vaccination. The families feel that healthcare workers stand in a position of insurmountable moral superiority - and they question this status. The criticism of vaccines is also a critique of power relations established in the healthcare provider-patient relationship.
3. Reasons and motivations - Among the interviewed families, elements that stand out in decision-making for (not) vaccinating are: the relationship between perceived risk and benefit, the fear of possible adverse effects and long-term vaccine sequelae, criticism of the medical-pharmaceutical industry and perceived profit prioritisation over health, the idea that vaccines "contaminate" the body, and the high number of vaccines and doses that children are supposed to take early in life.

In reflecting on the findings, the researchers note that, in Brazil, the strong immunisation culture initially built by the National Immunization Program's success made childhood vaccination unquestionable. The vaccination practice was moralised; that is, the meaning of care was attributed to those who vaccinate, and the meaning of negligence to those who hesitate. This process makes  dialogue between health professionals and hesitant families challenging, since the more one moralises a truth, the more difficult it is to interact with someone who disagrees. Thus, vaccination has become a topic with no space for debate.

In this vein, the results showed that the relationship between individuals and health services/professionals is often based on a hierarchical power relationship. Contemporary parental norms include caregivers' active participation in their children's health. The idea of following the health professionals' guidelines passively is avoided; the families interviewed consume information and make active, informed decisions. Ideas of individual freedom and autonomy are increasingly advocated in Brazil, especially by the middle and upper classes and highly educated families.

Thus, the study highlights the fragility of the family-health professional relationship, which is essential for effective communication in health and should be at the centre of immunisation policies, per the researchers.

In conclusion: "It is critical to highlight that deciding not to vaccinate is not only about the vaccines themselves. Often, this decision informs a way of seeing the world. Lifestyle and worldview relate directly to health choices, and, for many families, the option not to vaccinate is only part of a package of choices for a 'natural' life....Understanding that each social group's notions of health are steeped in their experiences and representations of the world is essential for successful immunization programs."