Journal of Bioethical Inquiry

, Volume 14, Issue 1, pp 65–76 | Cite as

Vaccine Rejecting Parents’ Engagement With Expert Systems That Inform Vaccination Programs

  • Katie AttwellEmail author
  • Julie Leask
  • Samantha B. Meyer
  • Philippa Rokkas
  • Paul Ward
Symposium: Public Trust in Expert Knowledge


In attempting to provide protection to individuals and communities, childhood immunization has benefits that far outweigh disease risks. However, some parents decide not to immunize their children with some or all vaccines for reasons including lack of trust in governments, health professionals, and vaccine manufacturers. This article employs a theoretical analysis of trust and distrust to explore how twenty-seven parents with a history of vaccine rejection in two Australian cities view the expert systems central to vaccination policy and practice. Our data show how perceptions of the profit motive generate distrust in the expert systems pertaining to vaccination. Our participants perceived that pharmaceutical companies had a pernicious influence over the systems driving vaccination: research, health professionals, and government. Accordingly, they saw vaccine recommendations in conflict with the interests of their child and “the system” underscored by malign intent, even if individual representatives of this system were not equally tainted. This perspective was common to parents who declined all vaccines and those who accepted some. We regard the differences between these parents—and indeed the differences between vaccine decliners and those whose Western medical epistemology informs reflexive trust—as arising from the internalization of countering views, which facilitates nuance.


Vaccination Vaccine hesitancy Qualitative Trust Giddens Modernity 


Compliance with ethical standards


The Fremantle data was gathered by Katie Attwell while working for the Immunisation Alliance of Western Australia, a not-for-profit immunization advocacy organization. The Alliance received funding from Sanofi Pasteur in the form of a $20,000 unrestricted grant to develop and evaluate the “I Immunise” campaign, which itself was funded by the Department of Health, Western Australia. Neither external organization contributed to the study design; data collection, analysis, interpretation, or writing, nor did they influence manuscript submission decisions. The data collection in South Australia was funded by the Flinders Medical Centre Foundation as a Seeding Grant, with no input into the decisions and processes outlined above. Julie Leask receives funding from the Australian Government Department of Health and the National Centre for Immunisation Research and Surveillance for research in addressing vaccine hesitancy. She is in receipt of an NHMRC Career Development Fellowship.


  1. Australian Technical Advisory Group on Immunisation (ATAGI). 2015. The Australian immunisation handbook, 10th ed (2015 update). Canberra: Australian Government Department of Health.Google Scholar
  2. Andre, F., R. Booy, H. Bock, et al. 2008. Vaccination greatly reduces disease, disability, death and inequity worldwide. Bulletin of the World Health Organization 86(2): 140–146.CrossRefPubMedGoogle Scholar
  3. Attwell, K., and M. Freeman. 2015. I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs. Vaccine 33(46): 6235–6240.CrossRefPubMedGoogle Scholar
  4. Austin, H., C. Campion-Smith, S. Thomas, and W. Ward. 2008. Parents’ difficulties with decisions about childhood immunisation. Community practitioner : The journal of the Community Practitioners’ & Health Visitors’ Association 81(10): 32–35.Google Scholar
  5. Beard, F.H., B.P. Hull, J. Leask, A. Dey, and P.B. McIntyre. 2016. Trends and patterns in vaccination objection, Australia, 2002–2013. Medical Journal of Australia 204(7): 275.CrossRefPubMedGoogle Scholar
  6. Benin, A.L., D.J. Wisler-Scher, E. Colson, E.D. Shapiro, and E.S. Holmboe. 2006. Qualitative analysis of mothers’ decision-making about vaccines for infants: The importance of trust. Pediatrics 117(5): 1532–1541.CrossRefPubMedGoogle Scholar
  7. Brown, K.F., J.S. Kroll, M.J. Hudson, et al. 2010. Factors underlying parental decisions about combination childhood vaccinations including MMR: A systematic review. Vaccine 28(26): 4235–4248.CrossRefPubMedGoogle Scholar
  8. Brown, P.R. 2009. The phenomenology of trust: A Schutzian analysis of the social construction of knowledge by gynae-oncology patients. Health, Risk & Society 11(5): 391–407.CrossRefGoogle Scholar
  9. Brown, P.R., and S.B. Meyer. 2015. Dependency, trust and choice? Examining agency and “forced options” within secondary-healthcare contexts. Current Sociology doi:  10.1177/0011392115590091.Google Scholar
  10. Brownlie, J., and A. Howson. 2005. “Leaps of faith” and MMR: An empirical study of trust. Sociology 39(2): 221–239.CrossRefGoogle Scholar
  11. Casiday, R., T. Cresswell, D. Wilson, and C. Panter-Brick. 2006. A survey of UK parental attitudes to the MMR vaccine and trust in medical authority. Vaccine 24(2): 177–184.CrossRefPubMedGoogle Scholar
  12. Cline, R.J.W., and K.M. Haynes. 2001. Consumer health information seeking on the Internet: the satate of the art. Health Education Research 16(6): 671–692.CrossRefPubMedGoogle Scholar
  13. Crawford, R. 2004. Risk ritual and the management of control and anxiety in medical culture. Health, An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 8(4): 505–528.CrossRefGoogle Scholar
  14. Donovan, H., and H. Bedford. 2013. Talking with parents about immunisation. Primary Health Care 23(4): 16–20.CrossRefGoogle Scholar
  15. Dube, E., M. Vivion, and N.E. MacDonald. 2015. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact, and implications. Expert Review of Vaccines 14(1): 99–117.CrossRefPubMedGoogle Scholar
  16. Gambetta, D. 1988. Trust: Making and breaking cooperative relations. Oxford, Cambridge: Basil Blackwell.Google Scholar
  17. Gaudino, J.A., and S. Robison. 2012. Risk factors associated with parents claiming personal-belief exemptions to school immunization requirements: Community and other influences on more skeptical parents in Oregon, 2006. Vaccine 30(6): 1132–1142.CrossRefPubMedGoogle Scholar
  18. Giddens, A. 1990. The consequences of modernity. Cambridge: Polity Press.Google Scholar
  19. ———. 1991. Modernity and self-identity: Self and society in the late modern age. Stanford: Stanford University Press.Google Scholar
  20. ———. 1994. “Risk, trust, reflexivity.” In Reflexive modernization: Politics, tradition and aesthetics in the modern social order, edited by U. Beck, A. Giddens and S. Lash, 194–197. Cambridge: Polity Press.Google Scholar
  21. Govier, T. 1998. Dilemmas of trust. Montreal: McGill-Queen’s University Press.Google Scholar
  22. Greenhalgh, J., J. Howick, and N. Maskrey. 2014. Evidence based medicine: A movement in crisis? BMJ 348: g3725.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Habermas, J. 1997. The theory of communicative action, Vol. 1. Cambridge: Polity Press.Google Scholar
  24. Hilton, S., M. Petticrew, and K. Hunt. 2006. “Combined vaccines are like a sudden onslaught to the body’s immune system”: Parental concerns about vaccine “overload” and “immune-vulnerability”. Vaccine 24(20): 4321–4327.CrossRefPubMedGoogle Scholar
  25. Janko, M. 2012. Vaccination: a victim of its own success. American Medical Association Journal of Ethics 13(1): 3–4.Google Scholar
  26. Jolley, D., and K.M. Douglas. 2014. The effects of anti-vaccine conspiracy theories on vaccination intentions. PloS one 9(2): e89177.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Larson, H.J., C. Jarrett, E. Eckersberger, D.M.D. Smith, and P. Paterson. 2014. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine 32(19): 2150–2159.CrossRefPubMedGoogle Scholar
  28. Leach, M., and J. Fairhead. 2007. Vaccine anxieties: Global science, child health and society. London; Stirling, VA: Earthscan.Google Scholar
  29. Leask, J., and S. Chapman. 2002. “The cold hard facts” immunisation and vaccine preventable diseases in Australia's newsprint media 1993–1998. Social Science & Medicine 54(3): 445–457.CrossRefGoogle Scholar
  30. Luhmann, N. 1979. Trust and power: Two works by Niklas Luhmann. Translated by Howard Davis, John Raffan and Kathryn Rooney. Brisbane: John Wiley and Sons.Google Scholar
  31. ———. 1995. Social systems, Writing science. Stanford, Calif.: Stanford University Press.Google Scholar
  32. MacDonald, N.E., and SAGE Working Group on Vaccine Hesitancy. 2015. Vaccine hesitancy: Definition, scope and determinants. Vaccine 33(34): 4161–4164.Google Scholar
  33. Meyer, S., P.R. Ward, J. Coveney, and W. Rogers. 2008. Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann. Health Sociology Review 17(2): 177–186.CrossRefGoogle Scholar
  34. Mills, E., A.R. Jadad, C. Ross, and K. Wilson. 2005. Systematic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccination. Journal of Clinical Epidemiology 58(11): 1081–1088.CrossRefPubMedGoogle Scholar
  35. Mollering, G. 2001. The nature of trust: From Georg Simmel to a theory of expectation, interpretation and suspension. Sociology 35(2): 403–420.CrossRefGoogle Scholar
  36. ———. 2006. Trust: Reason, routine, reflexivity. Oxford: Elsevier.Google Scholar
  37. MuMullan, M. 2006. Patients using the Internet to obtain health information: How this affects the patient-health professional relationship. Patient Education and Counseling 63(1–2): 24–28.CrossRefGoogle Scholar
  38. National Health Performance Authority. 2014. Healthy communities: Immunisation rates for children in 2012–2013. Sydney, NSW: National Health Performance Authority.Google Scholar
  39. Offit, P.A., and C.A. Moser. 2009. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics 123(1): e162–e169.CrossRefGoogle Scholar
  40. Omer, S.B., K.S. Enger, L.H. Moulton, N.A. Halsey, S. Stokley, and D.A. Salmon. 2008. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. American Journal of Epidemiology 168(12): 1389–1396.CrossRefPubMedGoogle Scholar
  41. Parliament of Australia. 2015. Social services legislation amendment (No jab, no pay) bill Australia.Google Scholar
  42. Riessman, C.K. 2008. Narrative methods for the human sciences. Los Angeles, London, New Delhi, Singapore: Sage Publications.Google Scholar
  43. Rimer, B.K., P.A. Briss, P.K. Zeller, C.C.Y. Chan, and S.H. Woolf. 2004. Informed decision making: What is its role in cancer screening? Cancer 101(S5): 1214–1228.CrossRefPubMedGoogle Scholar
  44. Scambler, G. 2001. Class, power and the durability of health inequalities. In Habermas, critical theory and health, edited by G. Scambler, 86–118. London: Routledge.Google Scholar
  45. Scambler, G., and N. Britten. 2001. System, lifeworld and doctor–patient interaction: Issues of trust in a changing world. In Habermas, critical theory and health, edited by G. Scambler, 45–67. London: Routledge.Google Scholar
  46. Smith, P.J., G.H. Sharon, E.K. Marcuse, et al. 2011. Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the health belief model. Public Health Reports (1974-) 126: 135–146.Google Scholar
  47. Sobo, E.J. 2015. Social cultivation of vaccine refusal and delay among Waldorf (Steiner) school parents. Medical Anthropology Quarterly 29(3): 381–399.CrossRefPubMedGoogle Scholar
  48. ———. 2016. Theorizing (vaccine) refusal: Through the looking glass. Cultural Anthropology 31(3): 342–350.Google Scholar
  49. Sobo, E.J., A. Huhn, A. Sannwald, and L. Thurman. 2016. Information curation among vaccine cautious parents: Web 2.0, pinterest thinking, and pediatric vaccination choice. Medical Anthropology: Cross Cultural Studies in Health and Illness: 1–18.Google Scholar
  50. Sztompka, P. 1999. Trust: A sociological theory. Cambridge: Cambridge University Press.Google Scholar
  51. Ward, P.R., C. Coffey, and S. Meyer. 2015. Trust, choice and obligation: A qualitative study of enablers of colorectal cancer screening in South Australia. Sociology of Health & Illness 37(7): 988–1006.CrossRefGoogle Scholar
  52. Ward, P.R., P. Rokkas, C. Cenko, et al. 2015. A qualitative study of patient (dis)trust in public and private hospitals: The importance of choice and pragmatic acceptance for trust considerations in South Australia. BMC Health Services Research 15(1): 297.CrossRefPubMedPubMedCentralGoogle Scholar
  53. Willis, K., J. Daly, M. Kealy, et al. 2007. The essential role of social theory in qualitative public health research. Australian and New Zealand Journal of Public Health 31(5): 438–443.CrossRefPubMedGoogle Scholar
  54. Yaqub, O., S. Castle-Clarke, N. Sevdalis, and J. Chataway. 2014. Attitudes to vaccination: A critical review. Social Science & Medicine 112: 1–11.CrossRefGoogle Scholar
  55. Zuzak, T.J., I. Zuzak-Siegrist, L. Rist, G. Staubli, and A.P. Simões-Wüst. 2008. Attitudes towards vaccination: Users of complementary and alternative medicine versus non-users. Swiss Medical Weekly 138(47–48): 713–718.PubMedGoogle Scholar

Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2016

Authors and Affiliations

  • Katie Attwell
    • 1
    • 2
    Email author
  • Julie Leask
    • 3
  • Samantha B. Meyer
    • 4
  • Philippa Rokkas
    • 5
  • Paul Ward
    • 6
  1. 1.Sir Walter Murdoch School of Public Policy and International AffairsMurdoch UniversityMurdochAustralia
  2. 2.Immunisation Alliance of Western Australia, Cockburn Integrated Health and Community FacilitySuccessAustralia
  3. 3.School of Public Health, Faculty of Medicine, Faculty of NursingUniversity of SydneySydneyAustralia
  4. 4.University of WaterlooWaterlooCanada
  5. 5.Faculty of Medicine, Nursing and Health SciencesFlinders UniversityAdelaideAustralia
  6. 6.Department of Public HealthFlinders UniversityAdelaideAustralia

Personalised recommendations