Decision Making Processes Underlying Avoidance of Mandatory Child Vaccination in Croatia - A Qualitative Study

"Generally, healthcare workers should develop a relationship of trust and stronger bonds with the patients which would provide a safe environment to discuss various issues related to vaccine hesitancy..."

Despite mandatory vaccination in Croatia, infectious outbreaks still occur; there seems to be a gap in literature that would explain why such endeavours are failing. Thus, this study's aims were, first, to investigate cognitive processes underlying vaccine hesitant parents' decision making, specifically focusing on hypothetical situations in which they would reconsider vaccinating, and, second, to investigate their behaviours and strategies by which they avoid mandatory vaccination and deal with potential consequences.

In September and October 2018, the researchers conducted 25 semi-structured interviews with Croatian parents or caregivers with at least one child for whom they refused all or some mandatory vaccinations or who changed or intended to change their children's routine vaccine schedule.

Main themes to emerge include:

• Decision-making on vaccination and hesitancy - Interviews highlighted the fact that the vaccine decision-making process is complex, time-consuming, primarily driven by emotional factors, and sensitive to social influences and pressures. Participants related emotions and intuition to the fear of vaccine side effects and a strong desire to protect their child, commonly labelling their decision as "instinctive". Participants also described the strong impact of social connections: They are sensitive to complex dyadic spouse relations (e.g., a pro-vaccine parent being nudged by their anti-vaccine spouse) and by the influence of relevant information sources, including their doctors. Specifically, the majority of these vaccine-refusing parents search for information on various anti-vaccine media. Some parents held initial positive attitudes towards vaccination that were challenged by negative events that raised doubts about vaccines. Parents also reported unprofessional communication from clinicians, including being ridiculed after asking questions about vaccines.
• Reflection and justification of the decision not to vaccinate - It may be postulated that parents' intuitions moved them in direction of opposing vaccines, which then motivated justifications of why vaccines are bad. These justification were found to be related to their general worldview, as well as moral and religious beliefs. More than half of the participants also adhered to some form of conspiracy belief. The researchers hypothesise that relying on an experiential style of reasoning (vs. an analytically rational one) makes individuals more susceptible to endorsing statements that are not well thought through. Some of the participants engaged in social comparison and looked at vaccine attitudes as a social issue that polarises people into pro- or anti-vaccine groups and distanced themselves from being a member of either of these.
• Vaccination avoidance behaviour - Parents avoid mandatory child vaccination with strategies including: straightforward rejection, rejection justified by related and unrelated child health issues, malingering, disappearing in the system, stalling in hope the issue will disappear, emigration, and not having more children. Parents varied in their openness of communicating the decision to clinicians; some stated they were straightforward and honest in refusing vaccination and communicating that refusal to their health professionals openly. The results also suggest that some clinicians tolerate - or even share - parents' vaccination hesitancy or have loose relationships to their patients that then contributes to easier avoidance. Within a broader European qualitative study on vaccine hesitancy, healthcare workers interviewed in Croatia reported a need for improving their training about vaccines and better communication with patients. In the same study, a minority of the interviewees reported not feeling comfortable addressing vaccine hesitancy and sharing the same doubts about vaccine as parents do. Therefore, the researchers suggest, avoidance strategies used by parents may be directly related to the communication skills and attitudes towards vaccination of healthcare workers.
• Dealing with the outcome and reconsidering vaccination - When asked how they cope with the risk of their child being infected with a disease, several participants seemed to lack any strategies for dealing with the risk and even reported they have never considered it. Many stated they relied on keeping the body and immune system strong. Those who were willing to reconsider vaccinating their children said they would do so only under specific conditions, which might be beneficial in tailoring interventions aimed at promoting vaccination rates, e.g. being given absolute assurance on safety, having benefits clearly presented to them, or having alternative vaccines available.

The researchers offer (in Figure 2 in the paper) a graphical representation of these themes. The themes are arranged in a set of tentative relationships, whereby the circle sizes represent relative frequencies of identified themes, while full arrows indicate direct (and broken arrows potential or probable) influences between them. In short, the model suggests that decision-making is directly related to reflection on the decision as a two-way feedback loop. The relationship between decision-making and avoidance behaviour goes only one way - i.e., the decision, although it need not be rational or even a conscious one, leads to the behaviour. Once behaviour is executed, it can lead to further reflection (or rationalisation), thus closing the loop. It can also lead to dealing with the outcome (of non-vaccinating), real or imagined, which can, in turn, lead to reconsidering vaccination and/or reflection on the decision. All that can subsequently inform decision-making and lead to a new decision-reflection-decision-behaviour loop.

Next, the researchers outline several directions for future studies on vaccine hesitancy and avoidance. For example, it could be instructive to investigate in more detail the frequency of non-professional behaviour of healthcare workers toward hesitant parents, as well as related group processes of stereotyping such parents.

Finally, they propose practical guidelines that may help the development of public policies aimed at increasing vaccination rates (see also Table 2 in the paper). For instance, given that the health professionals influence patient vaccination uptake, practitioners could work on fostering better communication between patients and health professionals. "Talking about potential vaccine side-effects and acknowledging adverse events when they happen may enhance a positive and trusting patient-doctor relationship in addressing issues related to vaccines. Healthcare workers should also be more mindful to the parents' period of entering the decision-making process in which they are particularly sensitive to other peoples' influences."

In conclusion: "Overall, the results of the present study demonstrate complex and interrelated contributors to vaccine hesitancy as well as different trajectories in which people from different backgrounds reach the same decision. They suggest that vaccine hesitant parents often rely on emotions and intuition [and] are prone to cognitive biases and conspiracy ideation....Furthermore, the mandatory nature of immunization does not seem to be a sole sufficient strategy for addressing hesitancy, as many flaws in the patient-doctor relation were identified, especially related to triggering hesitancy and behavioral strategies of vaccination avoidance."