The Social Basis of Vaccine Questioning and Refusal: A Qualitative Study Employing Bourdieu's Concepts of 'Capitals' and 'Habitus'

"Parents' connections to and investments in their peer groups may be a central reason that they value peer opinions over those of the experts with whom they disagree."

This article is an in-depth analysis of the social nature of vaccine decision-making, exploring how the beliefs of vaccine hesitant or rejecting parents are socially constructed, acquired, and reinforced. After introducing the sociological theory of Pierre Bourdieu, the paper examines vaccine questioning and rejection as social practices that hold value - identified as "symbolic capital" - in social networks of parents who choose not to vaccinate, or who partially vaccinate, their children. Drawing on research conducted in two Australian cities, the authors identify a parent's choice regarding vaccination as a practice they engage in as members of societies and communities for the purpose of inclusion or belonging. Their investigation suggests that those who design interventions - whether providers, public health officials, or governments - need to understand these parents as socially situated. They offer some suggestions as to how this lens might inform intervention design.

In brief, Bourdieu argues that types of consumption, dispositions, and social practices are stratified along "class" lines, with some being ascribed greater moral and social worth (or, to use Bourdieu's lexicon, "capital") than others. Access to these patterns of consumption or practices are determined in part, by "habitus", which Bourdieu describes as an "embodied disposition shared by members of that class" that is largely unconscious. Cumulative exposure to social conditions leads us to internalise these conditions, and hence we establish patterned responses to the external environment. Practices such as using forms of complementary and alternative medicine (CAM), including vaccination practices, are largely unreflective and socially located. They are thus not only symbolic of, but are also deeply engrained bodily performances of, identity, class, and social relations. These symbols and performances are transmitted, learned, and reproduced in families, across generations, and within groups and communities.

Applying Bourdieu's thinking within this paper means that "vaccine rejection/hesitancy could be seen as a form of cultural and/or symbolic capital" - specifically, as "a differentiated but relational capital. It demonstrates who we are, and who we are not." The authors "explore the evidence that values-based and ethical consumption is viewed as a desirable and/or and/or superior practice - a practice utilized to distinguish between groups on the basis of both vaccination practice and various other practices connected to 'natural lifestyles'." Following Bourdieu, they "argue that the 'place' of vaccine rejection needs to be understood as a reified or valorized practice within some social groups, but not necessarily others.... (In fact, in other groups - such as the medical profession or mainstream society - it is more likely to be questioned and dismissed as having low symbolic capital)." More specifically, they "show how vaccine rejection promotes stability and inclusion for parents in some contexts, generating a sense of belonging and having the 'right' capital in specific social settings or communities. It therefore takes the form of high symbolic capital within these social groups. Vaccine rejection can also promote difficulties in other contexts, leading to self-censorship and fears of judgement, blame and disclosure. In these social contexts, non-vaccination has low symbolic capital. Whether or not vaccine rejection has symbolic capital within a particular social group will be determined by its relationship to other forms of cultural capital within that community, which are recognized by members as linked and meaningful. Specific 'alternative lifestyle' behaviors and consumptive patterns are central here."

They continue: "it is not simply that vaccine skepticism is a social norm that is hegemonic in some social settings, and parents follow the norm because they follow the(ir) crowd. (After all, we are exposed to a variety of social norms as we go about our lives, and someone with a vaccine-rejecting mother or best friend might reject their perspectives in favor of a doctor's recommendation.)" Rather, they are interested in "the processes that encourage some parents to follow the lead of vaccine-critical peers. These processes are observable in particular lifestyle-based social groups, and they exert pressure that we can observe both when individuals ultimately choose to reject vaccines, and when they accept them despite the social cost."

The researchers analysed data from two Australian cities, Fremantle, Western Australia (WA) and Adelaide, South Australia (SA), where they sought to understand parental vaccine hesitancy through semi-structured interviews conducted between October and December 2015 with parents in areas identified as having low immunisation coverage rates. They focused on experiences in which participants encountered negative views towards vaccination in their milieu, rather than (for example) going looking for vaccination information online. The latter could also be regarded as a social experience in that one is engaging with material written and prepared by others, but this research emphasised experiences that occur through face-to-face communal interactions.

In brief, qualitative analysis of the interview data shows that parents experience disjuncture and tugs towards "appropriate" forms of vaccination behaviour in their social networks, as these link to broader behaviours around food, school choices, and birth practices. The researchers demonstrate how differences emerge between the two cities based on study designs, such that it is possible to see some parents at the centre of groups valorising their decisions, whilst others feel marginalised within their communities for their decisions to vaccinate. The story of Anna, shared in the paper, "reveals that one may not 'know' oneself as a member of a social group until connected by specific and recognizable practices afforded high cultural capital. For Anna, this was a commitment to a natural lifestyle as a form of symbolic capital, which she then discovered (i.e. she was previously unaware) that she shared with vaccine refusers. This rather unconscious and non-planned alignment with vaccine rejection connects to the principle of habitus in Bourdieu's work, and Anna's story outlines the relatively unreflexive process of destabilized habitus to habitus tug."

The researchers draw on the work of philosopher Mark Navin to consider how all parents join epistemic communities that reward compliance and conformity with the status quo. "[A]s vaccine denialist epistemic communities form - such as the ones analyzed in this study - they develop and demonstrate particular epistemic vices. Most significantly, they function as supportive spaces, especially for people experiencing what we characterize as 'habitus acceptance' (unlike the adversarial culture of scientific epistemic communities). In this context, alternative forms of reasoning are not aired, nor existing forms challenged (unless those within are experiencing 'disjunctive habitus'). These supportive communication practices do not challenge the 'gut' style instinctive responses to information that we all engage in, and which we usually then overlay with more sophisticated forms of reasoning that nevertheless prop up what we already 'felt'. All this means that the reasoning processes of parents in vaccine rejecting epistemic communities are likely to be oriented towards maintaining beliefs that vaccines are dangerous or unnecessary....Parents who want to fit in - or find that they already do - thus become part of the flawed epistemic practices of the group."

Finally, the paper considers what these findings mean for interventions that seek to influence the flow of pro-vaccine information through vaccine-critical social groups. Challenging how information flows through such groups "may involve intervening in the very dynamics of groups of individuals who are finding their way as parents, seeking to behave appropriately, and make friends....Resources providing parents with challenging but non-combative responses to vaccine-negative comments within their social networks could be one strategy for intervention designers to pursue....[W]e still need to learn more about the role of leaders, charismatic 'experts' and those who are afforded expert status by peers because they are proficient in other valued skills (baby-wearing or cooking organic food, for example). However, it is possible that encouraging vaccine supporting parents to share their skills in these domains could enhance their social and cultural capital to the extent that they are able to better challenge vaccine critical discourses in their friendship groups....Providing people with effective, evidence-based ways to respectfully disagree and introduce different perspectives would be an important start."