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What maintains parental support for vaccination when challenged byanti-vaccination messages? A qualitative study

Julie Leask a,b,∗, Simon Chapman b, Penelope Hawe c, Margaret Burgess a

a National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases,The Children’s Hospital at Westmead, Discipline of Paediatrics and Child Health,

Faculty of Medicine, University of Sydney, Australiab School of Public Health, University of Sydney, Australia

c Markin Institute, University of Calgary, Canada

Received 17 January 2006; received in revised form 9 May 2006; accepted 9 May 2006Available online 23 May 2006

bstract

This study sought to explore how parents respond to competing media messages about vaccine safety. Six focus groups with mothers ofnfants were shown television vignettes of typical pro- and anti-vaccination claims. Thematic analysis of transcripts was undertaken. Mothersxpressed surprise and concern about alleged vaccine risks but quickly reinstated their support for vaccination by deference to authoritygures; type-casting immunisation opponents; and notions of anticipatory regret, good parenting and social responsibility. We conclude that

ersonal experiences, value systems and level of trust in health professionals are fundamental to parental decision making about vaccination.accination advocacy should increase the focus on matters of process such as maintaining trust and public confidence, particularly in healthrofessionals. Stories about people affected by vaccine-preventable diseases need to re-enter the public discourse.

2006 Elsevier Ltd. All rights reserved.

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eywords: Immunisation; Focus groups; Mass media; Measles-mumps-rub

. Introduction

Worldwide, higher vaccination rates and declining dis-ase incidence are providing a new climate for public debatebout vaccine safety. Increased consumerism, an increasedillingness to question medical intervention and a broaden-

ng interest in alternative and complementary health practices1] are potentially changing the way health information isccepted and used. This, coupled with an apparent rise ofhe anti-vaccination movement, challenges public health pro-essionals to rethink the way we use the media to promote

hildhood vaccination.

Promotion of vaccination traditionally employs ratio-al logic (i.e., the benefits of vaccination outweigh the

∗ Corresponding author at: National Centre for Immunisation Researchnd Surveillance, The Children’s Hospital at Westmead, Locked Bag 4001,estmead NSW 2145, Australia. Tel.: +612 98451422.

E-mail address: JulieL3@chw.edu.au (J. Leask).

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264-410X/$ – see front matter © 2006 Elsevier Ltd. All rights reserved.oi:10.1016/j.vaccine.2006.05.010

MR) vaccine

otential risks) and any accompanying rhetoric typicallyesorts to using militaristic metaphors which are common-lace throughout medicine (“the fight against AIDS” “thear against cancer ”) [2]. Previous research has examined

nti- and pro-vaccination discourse in the newsprint media,ncovering the striking sophistication of the “anti” vacci-ation case [3–5]. Anti vaccination arguments appeal on aroad level by alluding to deep anxieties and social issueshat concern many 21st century citizens, such as cover-ps by medical professionals (who protect each other, orlose rank when confronted); faceless bureaucrats regulatingarenting and finally, a profit-driven pharmaceutical indus-ry. Anti-vaccination lobbyists align themselves with broad,ocially acceptable structures, framing non-vaccination as annformed choice made by parents who are dissatisfied with

fficial assurances, venerate freedom of choice and are sus-icious of government intervention [5].

Few studies have examined how parents interpret anti-accination claims and negotiate competing vaccination mes-

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ages [6]. In this study, we sought to investigate how parentsespond to the messages about vaccination typically broad-ast on television by pro and anti vaccination proponents.ur purpose is to see if new ways of ‘marketing’ vacci-ation might be indicated in our rapidly changing sociallimate

Focus groups are commonly used in studies of audienceeception to media messages and in formative research forampaign planning [7,8]. Focus groups are best thought ofs group conversations. They are particularly useful whenesearchers wish to understand social communication pro-esses – the ways in which people talk about, frame andeframe issues to each other to communicate and builddeas.

. Methods

.1. Recruitment

This study aimed to recruit at least six groups of sixothers – a number considered sufficient to elicit a “sat-

rated” amount of information [9]. One researcher (JL)pproached mothers in waiting rooms of well child clinics inour demographically varied but predominantly middle-classreas across metropolitan Sydney, Australia. Areas includedne high income suburban, three middle income suburban,ne middle income inner urban and one low income subur-an area. Middle class mothers are more likely to questionmmunisation and can have a disproportionate influence onthers in opinion formation [10]. Mothers were asked to par-icipate in a study of how parents are affected by differentrguments about immunisation.

Exclusion criteria included women unable to speaknglish (which would preclude involvement in focus groupiscussions). We also excluded those clearly opposed tommunisation for two reasons: first, divergent views wouldreate unhelpful group conflict and second, the study was ask-ng how parents are swayed in their support of vaccinationy media rhetoric. To identify those ineligible, each motheras given a short screening survey about their attitudes toaccination which established whether they had ever had anyoncerns about immunisation. Those eligible were invited tottend a focus group. Each participant received $20 to coverravel costs. Child care was available on-site.

.2. Data collection

Each group was moderated by the primary researcher (JL).efore groups commenced, participants completed a ques-

ionnaire to obtain demographic information, children’s agend immunisation status. A list of question prompts were used

o initiate open discussion about immunisation. This includedsking participants to mention spontaneous thoughts abouthildhood immunisation and asking what reassures andrompts concerns about immunisation. Then, all groups were

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hown two video prompts. Video 1 constituted typical exam-les of negative media coverage about vaccination. It washosen because it exemplified anti-vaccination mass mediahetoric identified in previous research [5]. The video was7 min excerpt from a documentary with allegedly vaccineamaged children, parents discussing their opposition to vac-ination and doctors questioning the practice and its safety.t alluded to possible cover-up of information about vaccineisk. It contained accounts of parents whose children sufferedisability or death after vaccination [11].

Video 2 contained typically positive coverage. The 5 minxcerpt from a nightly current affairs programme includeddoctor speaking about the dangers of non-vaccination,

ootage of children with measles and pertussis, a cryingother, and a reporter speaking about Australia’s low vacci-

ation rates. It was chosen primarily to support reassurancesbout vaccination.

Early focus groups indicated that mothers placed greatmportance on the source of information. Therefore, two ofhe final groups viewed a 5 min excerpt from a third videoVideo 3) which is circulated by Australia’s anti-vaccinationobby and shows, among others, five medical doctors pre-enting their arguments against vaccination. Each group wassked to discuss their reaction to each video prompt.

A day or two after each group met, each woman waselephoned by the primary researcher for further discussionnd debriefing. These interviews were not tape recorded butxtensive notes were taken.

.3. Coding and analysis

All focus group discussions were tape recorded and tran-cribed. Transcriptions were checked to correct for inaccu-acies. Transcriptions were coded with the assistance of theualitative analysis software NUD*IST 4 which allows forarking and subsequent retrieval of text according to a par-

icular theme. Thematic analysis was used. Coding attemptedo identify emerging themes which were then organised intocoherent hierarchical scheme. A priori interests were alsooted, including evidence of anticipatory regret, and omissionias [12]. We also approached analysis with theories of mediaeception and persuasion in mind [13]. Without having seenhe existing codes, the co-authors read two transcripts andiscussed emerging themes with the first author. The existingoding structure was modified. After initial coding, instanceshich contradicted emerging tendencies were purposively

ought [14]. Once indicative quotes were identified, the sur-ounding discussions from which they came were re-read inn attempt to ensure statements were not taken out of context.he group dynamics in which the statements occurred werelso considered [15].

.4. Ethical considerations

The University of Sydney Human Ethics Committee andthics committees for the Central, Northern and Western Syd-

7 cine 24 (2006) 7238–7245

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Why do we not know about these things?Like immunisation, immunisation, immunisa-tion, but very little on the side effects and youknow, “Your child may be that one who getsbrain damage”. My little girl is 3 and no-one’sever said to me, “If you immunise her she mightbe the one who gets brain damage” (Group 6,low income area).Mitigating anti-vaccination impactI’ve known thousands of people who’ve had this(vaccine), and I’ve never ever heard of anyonehaving brain damage. But I have heard of othershaving, you know, whooping cough and what-ever else (Group 6, low income area).I mean there’s ALWAYS a chance of somethinglike that. Even if it’s walking out on the road andgetting hit by a car or getting the amniocentesiswhen I was pregnant, whatever. There’s alwaysa chance that . . . and if it does, it happens. It wasfated to be and you live with the consequences(Group 1, suburban middle income area).Regret from omission and commission. . .the GUILT that I would feel, because I hadnot immunised my old child to prevent herfrom passing that disease onto my son whoultimately died of that disease. The guilt thatI would feel! (Group 5, inner-urban middleincome area)It wasn,t the fact that he got hit by a bus, oryou know, a strike of lightning, “I took him tothe doctor and I stood there while he had the

240 J. Leask et al. / Vac

ey Area Health Services approved the project. We undertooknumber of measures to avoid the video prompts introducingew arguments against vaccination that might undermine par-icipant’s initial confidence in immunisation. This includedhowing another video to each group at the end of each ses-ion which was primarily supportive of vaccination (Video); circulating a booklet, Understanding Childhood Immu-isation; and giving the telephone number of an immuni-ation expert (MB) who could address any new concernsarents might have. Also, a day or two after each groupet, each mother was telephoned for further discussion and

ebriefing.

. Results

.1. Participants

A total of 37 mothers attended six focus groups of betweenour and eight participants. Their mean age was 32 years withhe majority (78%) born in Australia and the remainder fromhe UK, New Zealand and India. Thirty-nine per cent hadwo or more children while the remainder had recently givenirth to their first child. Most participants (61%) had tertiaryducation. All claimed their children to be fully vaccinated forheir age. The following analysis includes indicative quotesor each theme (Box 1).

.2. Strong support for vaccination

Prior to seeing the videos, initial discussion about immuni-ation reflected the women’s strong validation of the practice.

ost mothers spoke of vaccine preventable diseases as threat-ning and frightening. They expressed their fear particularlyn terms of new diseases, a sense that there are more germsowadays, along with a pervading sense that germs from for-

Box 1: Indicative quotes from focusgroupsStrong support for vaccination – fear ofdisease. . .things like sort of migrants and differentnationalities and people from other countriescoming in that [mean] your child is at risk ofcatching something if you don’t have themimmunised. (Group 2, suburban middle incomearea)Shock from anti vaccination messagesI’m a real sucker for those sort of things. I wasstarting to cry when I was looking at. . . that isan unfortunate thing of public health measuresthat some individuals - God forbid that it’s myindividual – will suffer (Group 5, inner-urbanmiddle income area).

injection” (Group 4, suburban middle incomearea).Core influences: doctors, social networksand seeing the diseases. . .if I had just seen that and not read anything,or had no outside influences, I would proba-bly say, ‘No I don’t want her vaccinated’, butI’ve had the other influences and I’d decided theother way (Group 2, suburban middle incomearea).“I’ve got a fair amount of faith in my doctorand I tend to trust what she says and trust heropinion, so I think that I would believe what shewould say before I’d believe anything I saw onTV (Group 4, suburban middle income area).I think it’s actually REALLY hard to know how tobalance it. . .You get that much information, inthe end you have to decide where your confi-dence lies. Who can I really trust? That’s hard(Group 1, suburban middle income area).Yes, well if it is a group that are anti-immunisation, well, they would say thatwouldn’t they. . .. But if you feel there’s some

J. Leask et al. / Vaccine 24

professional independence, you are more likelyto listen to it (Group 5, inner-urban middleincome area).Until you actually go to another country and seethe consequences, and see the dreadful, dread-

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ful, diseases. . . (Group 3 suburban high incomearea).

ign and exotic lands posed an unknown threat. Diseases suchs tuberculosis, influenza, Ebola virus and AIDS were oftenentioned in the context of wanting to find ways to protect

hildren.Repeating a popular discourse in the print media, some

ave tales from the war – romanticizing the generations whoould appreciate the value of vaccines [4]. Also, vaccina-ion was venerated as a practice through which women could

anifest nurturing and notions of being a good mother “likelioness with a cub”, as one mother put it. Vaccination wasften discussed as an unremarkable, normal part of life, rein-orced in many different contexts including the health carenvironment and the family. Many women said “it’s justomething you do” and spoke of vaccinating their own chil-ren almost to maintain a family tradition. Those who spokef vaccination as normal and automatic expressed surprisehat some people were opposed to the practice.

In the context of vaccines being seen as important, partic-pants spoke of injection pain, and minor reactions as trivial

atters.At a time when the acellular pertussis vaccine had recently

uperceded whole cell vaccine, new vaccines featured promi-ently in the discussions. Participants were keen to determinehether their child was receiving the latest and safest vaccine

nd many voiced reassurance in having a safer vaccine avail-ble, almost as a panacea for any emerging concern aboutaccine safety.

Despite a resounding support for vaccination, someomen expressed reservations. A prominent concern was the

ffect on the vulnerable baby’s immunity, one describing its creating “a little war in their blood system”. Participantsften alluded to the vulnerability of infants.

However, in the spirit of a resoundingly positive moodbout vaccination, some groups eagerly labeled thosepposed to vaccination as “burn your bra types”, “hysteri-al”, “new agers”, “alternative lifestylers”, “naturals”, or aseople who “go against it for rebellion’s sake” or even aseople associated with “ethnic” groups.

.3. Shock from anti vaccination messages

The video skeptical of vaccinations was shown (Video 1

see Methods). It rapidly stripped away the initial bravado

stablished in most of the groups. In summary, most moth-rs were initially disturbed and shocked by the video, par-icularly by the visual impact of disabled children. Many

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howed a complete acceptance of the programme’s latenteaning. They spoke of being surprised that vaccination car-

ied such risks and anger at not having been warned abouthem previously. Those who expressed a stronger responseppeared shocked with downcast facial expressions and evenrying.

A few women became angry soon after seeing theegment. Many however, expressed immediate resistanceo the messages, particularly in groups where immunis-ng was established as a socially desirable practice. Also,

any groups soon voiced their general scepticism of mediaensationalism and the propensity to propagate negativetories.

.4. Mitigating anti-vaccination impact

Mothers used a number of ways to put what they per-eived as “anti-vaccination” messages into context. Thisften included a simple risk-benefit equation, sometimesrawing on analogies to make their point. Beyond employ-ng rational logic, trusting the person who conveyed thenformation was important along with personal experiencesith vaccine-preventable diseases which they employed to

upport their rejection of the anti-vaccine information. Thenticipation of regret at their unvaccinated child acquiringvaccine-preventable disease arose repeatedly. The mothers

poke of “never being able to forgive themselves” and theirguilt” if their child was unvaccinated and got the disease.

few talked of the reverse situation where, in taking theirhild to be immunised, their actions meant that the child wasamaged.

.5. Core influences: doctors, social networks andeeing the diseases

Mothers elucidated the things that made vaccination worthhe apparent risk introduced from video 1. These includedrust in doctors, personal experiences with diseases, and theeinforcement of vaccination through social networks.

The concept of trust arose repeatedly, particularly in rela-ion to doctors. The family doctor appeared to be an integraloint of reference in vaccination decisions and the negotiationf risk messages. Participants valued doctors who took theime to explain procedures and discuss risks. Some conveyedheir own very positive experiences with their doctors, andthers voiced disapproval of doctors who seemed unwillingo discuss vaccination, feeling they might dislike the chal-enge to his or her authority. Those more sceptical of medicalnowledge alluded to difficulties with trust.

However, the generally strong trust of doctors andcceptance of medical knowledge meant that hearing anti-accination arguments from doctors in video 3 was more

isturbing for participants. There was also discussion aboutovernment where some expressed skepticism that the “gov-rnment is only telling you what they WANT you to know”,hile others found it hard to see why the government would

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242 J. Leask et al. / Vac

ay large amounts for immunisation programmes withoutood reason. Indeed, most discussion evinced a strong degreef trust in vaccination polices and the health authorities whoake them.Many participants spoke of personal experiences with

accine preventable diseases as important in their ultimateesolve. They knew, or were, health professionals who gaveccounts of children with, say, pertussis. Stories from non-ealth professionals about the horror of vaccine preventableisease included a false positive Hepatitis B diagnosis, traveln Africa and a pertussis scare in the maternity unit. Duringhese narratives, group members became uncharacteristicallyuiet with facial expressions and exclamations reflecting theacredness with which they held the stories. For those withoutuch experiences to draw upon, the media provided vicariousxperiences. Every group recalled an advertisement featur-ng a child with pertussis shown during a national pertussisaccination campaign as “shocking” and “devastating”.

Many mothers’ own attempts to reassure themselves aboutaccination also involved the influence of parents, partner,riends and other social networks. Their own mothers rein-orced the importance of vaccination along with siblingsho were health professionals. During the post-group inter-iews, some women reported they had gone home and spokenith their partner, sister, and/or mother about the issue. It

ppeared that these conversations reassured participants dis-urbed by the new information about vaccines encounteredia the videos and were an important way to return to formerlystablished views. During these interviews, the mothers whoad appeared unsettled during the focus groups appeareduch more resolved about the issue and in favour of vac-

ination.Every group raised the benefit that vaccination brings to

he wider community. Participants frequently described thedea that immunisation was a social responsibility. This wasither conveyed as one’s own contribution to reducing risk inhe broader community or as an expectation that other parentsould do the same. They spoke of mothers who did not have

heir children immunised as being “very irresponsible” andequiring “common courtesy” to avoid passing on disease.his also translated into a concern among a few mothers that

he television prompts might dissuade some mothers fromaccinating.

At the end of each group session, participants watched anxcerpt from a popular current affairs television programmehich was primarily supportive of vaccination (Video 2).he content was accepted with relief by most participantsespite many having earlier expressed their scepticism abouttabloid” television. Some expressed relief at having it rein-orce their predispositions. It seemed that when their formerlynquestioned beliefs about the overall value of vaccina-ion were challenged, participants were relieved to grasp

t something which reassured them. After viewing video, participants spoke of being reassured by a doctor whoeemed to them, confident, “because when someone believesn something, you believe in it too”. Many seemed eager

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or a voice that legitimised their own initial support ofaccination.

. Discussion

This study aimed to explore how mothers of infantsespond to competing media messages about vaccine safety.

e found the television vignettes useful in triggering dis-ussions and mirroring discussions that might occur in otherroup environments such as playgroups and new mothersroups.

When their existing beliefs about vaccine safety were chal-enged by our videos, mothers’ defenses typically ran theollowing course. First, they were surprised by their lack ofxposure to anti vaccination material. Their disbelief washen supported by recourse to authority (their own doctorsnd family and friends in their social network). They thenesorted to type-casting or stereotyping anti vaccinators (e.g.,bra burners”). This was followed by asserting statementsbout the social responsibility and control over disease thatas seen to characterise their own good parenting practices.Those who had previously only seen vaccination as ben-

ficial expressed surprise, fear and anger at not feeling fullynformed of risks. This led many to initially question theirwn unthinking adoption of the practice. The core claim bynti-vaccinationists that parents should be fully informed inecisions about their child’s health clearly had some reso-ance for parents who do not want to feel they are careless inhoices about their child’s health. If parents have already beennformed by their providers about risks, emotive press storiesbout vaccine-damaged children are likely to have less swayecause parents have a supportive reference point with whicho interpret them. This concept is supported by the process ofpsychological inoculation” advanced by McGuire [16].

However, parents asserted their belief in vaccinationecause it represented a point at which they could exerciseontrol over communicable diseases seen as frightening andard to control. Indeed, vaccination appeared to symboliseblanket of protection, as if the newer exotic diseases likeIDS and Ebola which some mothers spoke of, were some-ow being kept at bay by immunising their children againsteasles or pertussis. Trust in health professionals, particu-

arly doctors, was fundamental for the mothers in this study.n deciding whether to believe a message, they first took notef whether the informant was medically trained. From theiraccine providers, mothers tended to want a person who wasbreast of current recommendations and willing to discussaccine risk and benefit. The notion of being an informedecision maker appeared important to many women. Theylso wanted to be entrusted themselves with information fromealth professionals about vaccine risk – an exchange of trust

here mothers wanted to be regarded as competent decisionakers.Immunisation is a social practice [17] and in this study,

accination was a vehicle for expressing wider social norms

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nd values. Some mothers revealed some prejudices in rela-ion to multiculturalism, their beliefs about what constitutedood parenting, and the deviant behaviour of rejecting vac-ination. Interviewing in the social context revealed howroups maintain their own boundaries and delineate whatharacterises other in relation to self or us. Here, vaccinationas socially reinforced through scorn for vaccine defaulters,

ype-casting of parents who do not vaccinate their childrennd veneration of the mother-as-protector role through adher-nce. Interestingly, some women participating in the studyxpressed concern within the groups and in the follow upnterviews, that exposure to the videos might have temptedthers in the group to reject vaccination. This revealed thatike health professionals, mothers can also share concernbout the potential effect of anti-vaccine discourse on par-nts.

In this study, a parent’s decision not to vaccinate a childas recognised as a decision which had implications for oth-

rs [17]. Insights into how community benefit is understoodnd might be framed are important when, as vaccination’success leads to disease control, community benefit rises inmportance over individual benefit [18]. The ways that studyarticipants acknowledged community benefit suggest thatresenting vaccination as a social good might be a worth-hile and possibly overlooked strategy.Parents in this study were impressed by new vaccines and

heir potential. Generally, the mothers did not recoil fromaccination after hearing of the ills vaccines were alleged toause. Instead, their response was a demand for the best andatest model vaccine. The feeling of doing something abouthe perceived risk was better than doing nothing. Here thexperience with the MMR vaccine controversy in the UK mayffer parallel insights. Andrew Wakefield, during a press con-erence following the publication of his Lancet paper alleginghe MMR vaccine was linked to autism [19], mentioned theossibility of separate antigens being safer than the currentombined vaccine, although it lacked an evidence base [20].

hat appeared initially as a peripheral issue then became theocal point for news reports and parents unhappy at not beingble to access separate vaccines.

Wakefield’s suggestion that separate antigens promisedrotection from autism while still giving parents the sensehey were also protecting their children from measles, mumpsnd rubella, provided them with a perception of the best ofoth worlds. Parents leapt upon the idea of a regime of vac-ination perceived as safer and of a higher order technology,espite a lack of evidence for this.

Hence, there may be a psychology behind the demandor separate antigens that might be being unrecognised andntapped at present. In an environment increasingly seens high-threat by parents, a new respect for safety (how-ver inconvenient, given the number of vaccinations) may

e emerging [21].

Many aspects of this study’s findings have been repro-uced in other research examining how parents respond toedia messages about the measles-mumps-rubella vacci-

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ation and its unproved link to autism and bowel disease22]. Although vaccinating a child remains a technicallyational practice, this study revealed decision processes thatere far from rational in this scientific sense. Decisions

ppropriated wider issues giving them Plough and Krim-ky’s cultural rationality – a concept which has been used toescribe the interplay between cognitive, emotional, social,ultural and spiritual factors in decision making [23,24].hile technical rationality “rests on explicitly defined sets

f principles and scientific norms”, cultural rationality isharacterised by trust in political culture and democraticrocess and appeal to folk wisdom, peer groups, and tra-itions [23]. Using technical rationality, vaccination expertsase their assessments on technical knowledge and resultsrom epidemiological studies but, as noted, individual parentsay find their personal experience with vaccines or advice

rom family members much more fundamental in decisionaking.In the medical literature, suggested responses to erro-

eous beliefs about vaccination reflect the assumption thatpublic reiteration of “the facts”, provision of accurateell referenced statistics, and quantifiable risks and ben-

fits should alone reassure parents [25–27]. Indeed, factsn their own might have the opposite effect of polaris-ng people into existing positions where those support-ve of vaccination have their beliefs confirmed and thosepposed become more entrenched and committed. Meszarosnd colleagues presented parents opposed to the DPT vac-ine with carefully prepared factual information about risksnd benefits. These parents became more committed toheir antipathetic position. Their response was moderated byheir underlying values about death and chronic disability28].

Mothers in this study reflected a generally positive attitudeo immunisation. Our recruitment procedure was intendedo screen out mothers opposed to immunisation but noneere identified. This finding is supported by quantitative

esearch suggesting strong support for vaccination in Aus-ralia where vaccine controversies have been less prominenthan say, the UK [29]. The sample focused on tertiary edu-ated women, from a largely Anglo-Celtic background, ableo communicate in English who were primarily supportive ofmmunisation. This limits the generalisablity of our study.ut interestingly, qualitative research from Australia sug-ests those who question vaccination also tend to be fromhis demographic group [8]. In addition, parental attitudes areynamic in terms of individual change over time and attitu-inal shifts in new cohorts during controversies. Recruitingothers largely supportive of immunisation allowed us to

iew a microcosm of how parents might change their viewsn larger scale debates about immunisation such as MMR. Inublic health terms, it is these swinging voters who are likely

o be more significant in taking vaccination rates well belowarget levels.

Our decision to not screen out mothers who were healthrofessionals may be seen as ‘biasing’ the groups. We argue,

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owever, that since these women are also mothers they legiti-ately represent the diversity among women deciding about

mmunisation, being influenced by the media and influencingther mothers, perhaps disproportionately.

The focus group method cannot provide a systematicccount of the knowledge and perceptions of each individ-al since dominant members can drown out quieter ones.owever, focus groups, unlike individual interviews, allow

esearchers to observe the interactive and social nature of theopic of interest [30,31]. They can also inform research of a

ore systematic nature such as surveys.

. Recommendations

Experts often attempt to convince parents of the safetyf vaccines using facts alone. However, this strategy failso account for the wider values and discourses that informhe practice. What is needed perhaps is a less a focus on theontent of information which assumes people, once given theacts, will not be influenced by anti-immunisation rhetoric,o a stronger focus on matters of process which aim towards

aintaining trust and public confidence, particularly in healthrofessionals.

Public advocates of vaccination need to account for thenderlying levels on which debates about vaccine safety oper-te. This might involve identifying and naming the core issuesn each new debate (e.g., choice for parents, grief over autism,erception of uncaring doctors) and addressing public con-erns at this level while also addressing the factual details.

In this study, self reassurance revolved around a desiremong mothers to protect their children from infectiousiseases. In public debates about vaccination, vaccine-reventable diseases too often are ignored in the scram-le to defend vaccines. While remaining transparent on thessue of vaccine safety, vaccine advocates need to frameebates in terms of disease prevention. Stories of disease-ffected children need to re-enter the public discourse viaealth professionals, people who have experienced the dis-ases and via campaigns. In this way, debates can begin toe reframed from the powerful discourses appropriated innti-vaccination rhetoric to the equally powerful discoursesnderlying infectious disease prevention.

cknowledgements

The authors would like to thank Margaret Gibbons fromestern Sydney Area Health Service, Julie Rogers fromorthern Sydney Area Health Service, and Robin White

rom Central Sydney Area Health Service who provided sup-ort to undertake the study Rosemary Brand transcribed the

nterview tapes and Margaret Holm provided for editorialssistance. Lastly we are grateful to the women who pro-ided their time and enthusiasm to participate in the focusroups.

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This study was funded under a project grant from theustralian National Health and Medical Research Council

NHMRC).NCIRS is supported by The Australian Government

epartment of Health and Ageing, The NSW Departmentf Health and The Children’s Hospital at Westmead.

Penelope Hawe is a Senior Scholar of the Alberta Heritageoundation for Medical Research.

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