The influence of social class and institutional relationships on the experiences of vaccine-hesitant mothers: a qualitative study

For the dissertation study, we sought to sample mothers in the greater Philadelphia metropolitan area who had refused medical interventions for their children and those who had not. Respondents were recruited from the general public and identified through two in-person support groups for those interested in alternative medicine (in which some, but not all members were opposed to vaccines), as well as one non-denominational conservative Christian church in which congregants refused vaccines. Participants were also identified through three Philadelphia neighborhood parent listservs, as well as one Facebook group devoted to vaccine refusal, and two Facebook groups devoted to refusing conventional medicine in favor of alternative medicine. All recruitment was conducted by the lead author, then a doctoral candidate in sociology at the University of Pennsylvania. Approximately one third of the sample was snowballed from previous respondents. All potential respondents were told that the researcher aimed to understand how parents make health decisions for themselves and their families, with a focus on if and what conventional medicine parents have ever refused.

Semistructured interviews were conducted using a guide containing open-ended questions designed to elicit participant perceptions with minimal prompting from the researcher. [25] The interview guide was created based on a review of existing literature as well as emergent themes identified during the first three months of ethnographic observations.[26] Questions were designed to elicit a narrative of mothers’ medical decision-making in the context of their social and family backgrounds, and focusing on mothers’ interactions with health information resources, such as physicians, alternative medical practitioners, other parents, and the internet (see Additional File 1 for the interview guide). We gathered data on self-reported race, age, occupation, and number of children. In order to maintain rapport with the interview respondent we did not ask for self-reported income, data whose exclusion we also justified since they are subject to a wide range of error properties. [27] Respondents were given the choice between an in-person or telephone interview. The lead researcher, a female sociologist with experience interviewing parents about their children's health, conducted all the interviews. Participants provided oral consent following a verbal presentation of the informed consent form, and retained a copy of the form for their records. All participants took part in a single interview, which was audio recorded with participants’ permission and transcribed verbatim. The lead researcher wrote field notes immediately following each data collection session, [28] and memos of emerging themes from each interview. [29] Memos were used to determine sample size adequacy. We ceased data collection once thematic saturation of each major interview question domain was achieved. [30] This study was approved by the Institutional Review Board at the University of Pennsylvania (Protocol #826,314).

Transcripts were uploaded to Atlas.ti qualitative data analysis software for management and coding. [31] We used a combination of analytic open and focused coding strategies to analyze the interview transcripts. We began data analysis by creating a codebook that contained codes derived from the major domains in the interview guide, including health beliefs, clinical interactions, and decision-making processes around medical choices (including, but not limited to, vaccination). The codebook was revised to allow for the inclusion of new codes that emerged as salient from the transcripts. [32] All analysis was performed by the lead researcher, who wrote analytic memos while coding to explore emerging themes and identify supporting and falsifying data. [33] Participant demographic information and degree of refusal of medical interventions were matched with transcripts for further analysis.

Following this first round of coding we isolated all segments of data related to vaccination and performed a more focused analysis to better understand how mothers from different social class backgrounds described their concerns and choices related to vaccination. While one question in the interview protocol asked explicitly about vaccines, we found that respondents’ discussion of vaccination was not limited to this question, and rather arose naturally in the course of conversations about making medical decisions for children.

In keeping with previous research, [34] vaccine hesitancy was defined as a spectrum of delays in acceptance or refusal of vaccines, [35] as well as those who expressed strong misgivings about the safety or efficacy of vaccines but ultimately chose to follow the recommended vaccination schedule. [24] We started by examining vaccine decisions by social class category. Four types of vaccine decisions were described by our respondents: refusal of school-mandated vaccines, refusal of seasonal influenza vaccine, delayed vaccines, and concern regarding vaccines (but no delay or refusal). We classified participants’ social class by education level and occupation. [17, 36] Middle-class mothers were defined as having completed a four-year college degree or more who were also either pursuing a conventionally white-collar profession [37] or parenting full-time. Working-class mothers were defined as those without a four-year degree who were also working in administrative or traditionally blue-collar roles [37] or parenting full time. [36] If a mother was parenting full time social class categorization was based on educational level alone.

Interviews were conducted with 37 mothers, and lasted between one and three hours, with an average length of 81 min. Twenty-five interviews were conducted in person, with the other 12 (four middle-class respondents and eight working-class respondents) occurring over the phone due to time or distance constraints. Of the 37 participants, 22 were middle-class and 15 were working-class. The majority were white, in their thirties and forties, and had two or three children. Working-class mothers were more likely than middle-class mothers to have four or more children, reflecting higher total fertility rates among American women without a college degree.[38] Participant characteristics are summarized in Table 1.

The vaccine decisions of participants mapped to social class background are summarized in Table 2. Most participants [22] fell into multiple categories – for example, mothers who refused a school-mandated vaccine and the influenza vaccine for their child(ren).

Analysis of the variation in experiences recounted by the middle- and working-class mothers in our study demonstrated that vaccine decisions were influenced by mothers’ relationship to social institutions (e.g. schools, medical care, law enforcement). We found that when mothers described their feelings about the context in which these decisions were made, they invoked distinct levels of authority in relation to social institutions. This influenced their perceptions of the actions available to them when considering vaccination for their children.

Mothers we spoke with discussed these relationships, and the power dynamics therein, through three types of interactions: 1) interactions with pediatric clinicians; 2) interactions with school administrators; and 3) interactions with emergency room staff. These interactions highlighted the ways in which the middle- and working-class mothers in our study felt differently empowered and constrained in their vaccine choices, ultimately impacting their experiences of vaccine decision-making.

Mothers we interviewed from both the middle and working classes reported clinician pushback on their vaccine hesitancy. Importantly, however, mothers’ responses to that pushback differed, specifically regarding concerns about the consequences of refusing vaccines. Middle-class mothers typically viewed these discussions with clinicians as irritating, saying that medical professionals were “shaming” them, or repeatedly pushing them to vaccinate:

Every time we are at the pediatrician they’re like, “You all need to get flu shots, get them right now.” You know, it’s, “What? You haven’t gotten your flu shot yet? What’s wrong with you?” …I mean, the flu shot comes with a lot of shaming…We had a doctor literally shame [my husband] in the office and then she felt the need to call me afterwards because – I don’t quite know why! [exasperated tone, rolling her eyes].

With the pediatrician, she asked about vaccinations the first time, and I said, “No.” She has not asked again. [But] the nurses, they kind of are like, “Well, why aren’t you vaccinating? Are you going to vaccinate? What are you going to do for school?” I get it every single time. I just say, “Right now I’m not vaccinating,” and they’ll be like, “Well, what about later?” I’m like, “We’ll think about that later.”

While frustrating, these mothers did not perceive clinicians’ feedback as fundamentally coercive. Indeed, they felt comfortable refusing vaccines, even in the context of social judgement and repeated appeals to vaccinate.

By contrast, working-class mothers perceived clinician pushback as coercive, and even threatening. Rather than the annoyance of their middle-class counterparts, these mothers felt that clinicians used authoritative tones to pressure them into vaccine compliance.

I felt very scare-tactic’d into [vaccines]. Without so many words, “You’re going to kill your children. You’re a bad mom and you need to do this. I’m a doctor, I know better.”

Three working-class mothers voiced concerns specifically that clinicians would act as reporters for Child Protective Services (CPS), while six others noted concerns about potential state intervention regarding parents’ medical choices. Discussing her interest in complementary and alternative medicine (CAM) for immunity instead of vaccines, one mother described her fears:

It’s very hard to find a doctor that doesn’t look at you like you’re crazy if you bring up anything [about] natural [medicine]. When you have young children you’re even scared to ask because you don’t know if they’re going to be very watchful and call Child Protective Services on you or something like that.

In expressing these concerns, working-class mothers in our study described a feeling of vulnerability in relation to medical and state authorities. This perceived vulnerability impacted their experience of vaccine decision-making.

Securing paperwork for school vaccination exemptions was another interaction that revealed divergent and class-based relationships with institutional authorities among mothers we interviewed. Religious exemptions were the only non-medical option available in respondents’ states, and several mothers from both class backgrounds used religious beliefs – whether or not sincerely held, by their own admission – to avoid vaccination for their children. One middle-class mother described the process of seeking a religious vaccine exemption for school:

The schools do require vaccinations, but they allow religion as an exemption. There is a place locally that you can actually get a religious exemption. It’s literally an online church. It’s $75, I think, for a lifetime membership. You just send [the school] your membership with a seal and everything. I handed it in to my one daughter’s daycare, and they didn’t ask any questions. There’s no meeting place or anything [for the church]…They have them in every state…So we’re into it. I’m not declaring it as my religion, but it works [for the schools].

However, while middle-class mothers in our study felt entitled to use whatever means necessary to secure their desired goal, working-class mothers were more hesitant. Even when employing the same rationale for vaccine refusals as middle-class mothers, working-class mothers were uniquely worried about state interventions in their families.

You can’t take a philosophical exemption in my state, but you can do a religious exception. That’s what I claimed because the MMR immunization, I’ve done a lot of research on it, but that’s the one that I specifically know that they have used stem cells from aborted baby tissue to manufacture that at some point in time. They may not anymore, but my point is, I’m not even going to mess with that. I also feel like, if I started immunizing my kids now, if I ever had to stand before a judge he would say, “Well, why are you immunizing them now when you couldn’t before?” So I’m trying to keep that continuity.

This mother shared her belief that she must maintain consistency in her expressed vaccine hesitancy to avoid future censure from legal authorities, a concern not expressed by middle-class mothers. For those among our respondents who did not seek vaccine exemptions, working-class mothers were also the only to report not doing so because they viewed school vaccines as truly compulsory:

For the kids I do [all the vaccines]. It’s a requirement. They won’t even let you in the school if your stuff is not done. [My kids] get all of [the vaccines]. I don’t particularly want them to, but I’m only doing it because I think it’s required.

The view that vaccines could be compulsory highlights the constraint in vaccine decision-making experiences among these working-class mothers.

Finally, middle- and working-class mothers in our study described distinct thought processes around vaccine hesitancy in relation to potential engagement of their child with emergency medical services, in hospital-based emergency room settings, for any medical needs (not only care for vaccine-preventable illness). Middle-class mothers described approaching interactions with clinicians in emergency rooms on their own terms, seeking advice but ultimately viewing medical decisions as an individual choice.

Our pediatrician now knows our family, and she knows how we want to do an alternative science [of medicine] and so she'll talk to us in that way…”You guys aren't [going to vaccinate], and so I'm gonna talk to you in this way.” But she wasn't putting us down in the way that a lot of doctors do. Yeah, it was like, “If you go to an emergency room, you need to tell them this because your child doesn't have the traditional vaccines that another child would and you need to tell them this is what you want to do because of that.”

Middle-class mothers in our study expressed autonomy in their relationship to emergency medical staff, including the right to dictate care based on their vaccine choices. Importantly, these mothers did not report concerns about the emergency room as a contact point for CPS intervention based on vaccination status.

By contrast, in our interviews working-class mothers viewed the emergency room as fraught with opportunities for authorities to intervene. For example, one working-class mother described her concern when taking her partially vaccinated son to the emergency room:

I started getting a little concerned, because I’m low income; I don’t want be looked at as negligent. That’s the worry that I have, is that [the emergency room clinicians] say I’m neglecting my children, and then the next thing you know, I’m going to get in some type of trouble…I do have a right of not taking [vaccines], but if you don’t know that, then they can come to you [and say], “Oh, it’s neglect.”

For some of the working-class mothers we spoke with, refusing vaccines had ramifications for their perceived ability to obtain other forms of medical care, including emergency care, because they viewed medical staff as a contact point for potential state intervention. These concerns were not shared by our middle-class respondents.