Qualitative Analysis of Mothers' Decision-Making About Vaccines for Infants:

The Importance of Trust

Andrea L. Benin, Daryl J. Wisler-Scher, Eve Colson, Eugene D. Shapiro and Eric S.
Holmboe
Pediatrics 2006;117;1532
DOI: 10.1542/peds.2005-1728

The online version of this article, along with updated information and services, is located
on the World Wide Web at:
http://pediatrics.aappublications.org/content/117/5/1532.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
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rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Qualitative Analysis of Mothers’ Decision-Making About

Vaccines for Infants: The Importance of Trust
Andrea L. Benin, MDa,b, Daryl J. Wisler-Scher, MDb,c, Eve Colson, MDb, Eugene D. Shapiro, MDb,d, Eric S. Holmboe, MDe

aRobert Wood Johnson Clinical Scholars Program, bDepartment of Pediatrics, and dDepartment of Epidemiology and Public Health and
General Clinical Research Center, Yale University School of Medicine, New Haven, Connecticut; cDepartment of Pediatrics, School of
Medicine, Columbia University, New York, New York; eAmerican Board of Internal Medicine, Philadelphia, Pennsylvania

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
BACKGROUND. The high visibility of controversies regarding vaccination makes it
increasingly important to understand how parents decide whether to vaccinate their
www.pediatrics.org/cgi/doi/10.1542/
infants.
peds.2005-1728

OBJECTIVE. The purpose of this research was to investigate decision-making about doi:10.1542/peds.2005-1728
vaccinations for infants. Dr Benin is independent of any
commercial funder, had full access to all
DESIGN. We conducted qualitative, open-ended interviews. of the data in the study, and takes
responsibility for the integrity of the data
PARTICIPANTS. Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 and the accuracy of the data analysis.

months. Key Words

immunizations, vaccination, attitudes,

RESULTS. We addressed 3 topics: attitudes to vaccination, knowledge about vaccina-tion, parents, qualitative research

Accepted for publication Oct 17, 2005

and decision-making. Mothers who intended to have their infants vaccinated
Address correspondence to Andrea L.
(“vaccinators,” n 25) either agreed with or did not question vaccination or they accepted Benin, MD, 789 Howard Ave, New Haven,
vaccination but had significant concerns. Mothers who did not intend to vaccinate CT 06519. E-mail: andrea.benin@yale.edu

(“nonvaccinators,” n 8) either completely rejected vaccination or they purposely delayed PEDIATRICS (ISSN Numbers: Print, 0031-
4005; Online, 1098-4275). Copyright © 2006
vaccinating/chose only some vaccines. Knowledge about which vaccines are by the American Academy of Pediatrics
recommended for children was poor among both vaccinators and nonvaccinators. The
theme of trust in the medical profession was the central concept that underpinned all of the
themes about decision-making. Promoters of vaccination included trusting the
pediatrician, feeling satisfied by the pediatrician’s discussion about vaccines, not wanting
to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors
included feeling alienated by or unable to trust the pediatrician, having a trusting
relationship with an influential homeopath/naturopath or other person who did not believe
in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable
diseases are not serious, and feeling that since other children are vaccinated their child is
not at risk.

CONCLUSION. Trust or lack of trust and a relationship with a pediatrician or another

influential person were pivotal for decision-making of new mothers about vacci-

1532 BENIN et al
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nating their children. Attempts to work with mothers who are
concerned about vaccinating their infants should focus not
only on providing facts about vaccines but also on developing
trusting and positive relation-ships.
G IVEN THE HIGH visibility in the media of controver-
sies about vaccination of infants, it is important to understand
how parents decide whether to vaccinate their children to be
able to communicate appropriately with parents about
vaccinations.1–10 Previous studies have identified important
promoters and inhibiters of parents’ acceptance of vaccines. 11–
18 Promoters have in-cluded the desire to prevent disease, 11 a
belief in the social contract (the desire to help the community
by participating in herd immunity, also called “altruism”), 12
and the desire to do what is the cultural norm/what most other
people do (also called “bandwagoning”).12 Inhibitors have
included a fear of harming their child,18 adhering to a reversed
social contract (feeling that their unvaccinated child is not at
risk for disease, because most other children are vaccinated,
also called “free-riding”),12,15 a preference for making acts of
omission over acts of commission (preferring not to have
acted when there is any risk to the action),15,16,19 a perceived
ability to control their child’s susceptibility to and out-come
of the disease,15 a low perceived susceptibility to disease,18 a
belief that it is better to develop immunity from disease than
from vaccination,18 doubts about the reliability of information
about vaccines,15,18 and a fear
that too many immunizations may be dangerous. 11,18 Existing
studies11–18 have been largely quantitative or
based on hypothetical decision-making about vaccina-tion
and, thus, may not have adequately elicited the
comprehensive range of mothers’ attitudes in the way that a
qualitative study can. Qualitative research pro-vides a
framework for describing social phenomena, such as
comprehension and behaviors, that are based on complex
beliefs that may be difficult to measure in a standardized
quantitative manner.20–23 A qualitative ap-proach is based in
inductive reasoning whereby hypoth-eses are drawn from
observations (in contrast to deduc-tive or hypothesis-testing
methods).24 This approach allows for the generation of
hypotheses that can subse-quently be tested in a quantitative
manner.24 We sought to use qualitative methodology to
describe the full range of mothers’ attitudes about vaccinating
their children and the promoters and inhibitors of mothers’
acceptance of vaccinations during the time when mothers are
ac-tively deciding whether to vaccinate their infants.
METHODS
Study Design and Sample
The study was a qualitative study based on a 2-phase open-
ended interview of 33 postpartum mothers from
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May 2002 to July 2003. English-speaking mothers with
infants healthy enough to be in a level 1 nursery and who
delivered at the Yale-New Haven Hospital (New Haven, CT)
or who delivered at home in the care of 1 of 2 participating
midwifery practices in Connecticut were eligible for the
study. If hospitalized, mothers were ap-proached for inclusion
during their hospitalization at a time when they were not
receiving narcotic pain medi-cations or needing more than
routine medical care. Mothers who were recruited through
midwifery prac-tices were identified before their delivery;
after they delivered, the interviewer went to their homes to
per-form the interviews. We chose to interview mothers of
newborns, because parents face a decision about vacci-nation
against hepatitis B shortly after the birth of their child, and we
wanted them to be actively involved in the decision-making
process at the time of the interview. We also wanted to be
able to explore the degree to which mothers may make
decisions about vaccination while they are pregnant.
As is frequently done in qualitative research,20,22,25,26 we
used purposeful sampling with a random compo-nent. To
ensure saturation of themes related to non-vaccination and
trust, once we had interviewed 2 pilot mothers and 15
mothers selected randomly, we switched to a purposeful
sampling of black mothers and of mothers who did not want
to vaccinate their infants. Black mothers were sampled
randomly from mothers who delivered in the hospital and
who indicated on their admission sheet that they were black.
Mothers who did not want to vaccinate their infants were
referred by midwives or by pediatricians; all who were
referred were included. Only 2 mothers whom we approached
refused to participate; they refused because of inconvenient
tim-ing. This type of purposeful sampling is appropriate for
qualitative work, because the goal is to select informa-tion-
rich cases who will “illuminate the questions under study”
(not to select a probability-based sample).26
Mothers were enrolled until no new concepts were
identified by the additional interviews, that is, until the point
of “theoretical saturation,”22: (1) no new or rele-vant data
seem to emerge regarding a category, (2) the category is well
developed in terms of its properties and dimensions
demonstrating variation, and (3) the rela-tionships among
categories are well established and val-idated.22 The study
was approved by the Institutional Review Board at Yale
University School of Medicine. Informed consent was
obtained from all of the mothers before the interviews.
Data Collection
First Interview
For the first phase of the study, 1 author (A.L.B., a white,
female pediatrician), conducted in-depth, open-ended
interviews23,27,28 in person with postpartum moth-
PEDIATRICS Volume 117, Number 5, May 2006 1533
ers during their immediate postpartum period. The in-
terviewer was not involved in the medical care of the
participants. Open-ended questions assessed mothers’
attitudes about vaccination, their concerns about vacci-nation,
and the sources they used to obtain information about
vaccination. Questions included general questions about how
parents felt about vaccinating their infant, for example, “How
do you feel about vaccinating your in-fant?” “What do you
see as the benefits of vaccinating your new infant?” and
“What do you see as the risks of vaccinating your new
infant?” We also included several questions designed to elicit
how mothers obtained infor-mation about vaccines and how
they wanted to obtain information: “Where do you get
information about vac-cines?” and “What information do you
want about vac-cines?” Closed-ended questions elicited
information about demographics, number of children, plans
for vac-cination, general health practices, and knowledge
about vaccination.
Follow-up Interview
For the second phase of the study, the same interviewer
performed open-ended interviews by telephone when the
child was between 3 and 6 months old. The fol-low-up
interview reassessed knowledge and attitudes about
vaccination, as well as sources of information used. By the
time of follow-up, children should have received $1 set of
vaccinations if they were going to get them. Questions
focused on parents’ experiences related to vaccinating their
infants and their interactions with the medical system related
to vaccination. The main questions included, “Tell me about
your experience when you took your infant to the doctor to
get shots/ went for a checkup (for those refusing
vaccinations)?” “How did you feel about it?” “Did you have
any con-cerns? What were they?” and “Tell me how you felt
about the process of deciding whether to vaccinate.”
For both the first and the follow-up interviews, we used
standardized interview guides with probes and fol-low-up
questions to elicit detail and clarification. We audio taped all
of the interviews, including those by telephone, and the tapes
were transcribed in their en-tirety by an independent
transcriptionist.
Evaluation of Knowledge
Questions regarding knowledge about vaccines were asked
after both the first and the follow-up interviews. With the first
interview, 10 multiple-choice questions inquired about
common adverse effects of vaccines, about common
controversies about vaccines, and about which vaccines
parents had heard about and thought their child might either
get or have gotten. The focus of the questions was intended to
explore mothers’ recog-nition of the names of vaccines and
the diseases pre-vented. With the follow-up interview, a
subset of 6 of the 10 questions was repeated. Before asking
these ques-
1534 BENIN et al
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tions, without prompting, we asked mothers to list the names
of the vaccines their child had received. In addi-tion, as one
measure of how many mothers in this group held
misconceptions about vaccines, we counted how many
mothers spontaneously offered erroneous infor-mation during
the open-ended interviews.
Data Analysis
We analyzed transcribed data by using common coding
techniques for qualitative data and the methods of grounded
theory.20,22,23,26,27 In this process, we read the transcripts of the
interviews and identified themes within the mothers’ answers.
Using these themes that we identified, we generated a
structured classification of codes. We coded the data in a
series of iterative steps, and we revised and refined the code
structure multiple times as we developed new insights and
elicited new relationships between the themes present in the
moth-ers’ comments. To develop the code structure, 2 mem-
bers of the research team (A.L.B. and D.J.S.) indepen-dently
read each of the transcripts line-by-line, abstracted key
themes and ideas, and coded each of the transcripts. They
then met and assigned final codes through a negotiated
process. During its development, the code structure was
reviewed and refined multiple times by the full research team.
Once coded, we entered data into a software package
(NUD*IST, QSR N6, Don-caster, Victoria, Australia)
designed to manage unstruc-tured, qualitative data. This
software aids in the cata-loguing of and reporting of
supporting quotations. Interviews lasted between 30 minutes
and 2 hours.
After the analysis was completed in that the coding
structure and classification schema was fully developed and
all of the transcripts had been analyzed, 2 members of the
research team (A.L.B. and D.J.S.) independently reread all of
the transcripts, recoded them using the main subset of the
coding structure (56 codes), and classified mothers into
categories. The researchers then met and assigned final codes
and classification together, resolving differences through
negotiation. By this stage, independently, the researchers had
virtually complete agreement on coding and classification.
This recoding process provided a check of validity as a form
of “mul-tiple coding,” a technique by which independent re-
searchers code an interview so that coding strategies can be
cross-checked.29 To ensure that our analyses were systematic
and verifiable,20,23 we used interview guides, audio taping of
the interviews, and transcription by an independent
transcriptionist, as well as detailed docu-mentation of analytic
decisions and changes in the cod-ing structure.
As a way to characterize knowledge about vaccina-tion by
mothers in the study, we tallied correct responses and used
the Wilcoxon rank-sum test with a 2-tailed P value to
compare the median number of correct re-
sponses between each group of mothers and the group of
mothers who were vaccine acceptors.
RESULTS
We interviewed 33 mothers 19 to 43 years old (median: 32
years; interquartile range: 26 –35 years) from both suburban
and inner-city areas of Connecticut; 10 (33%) were
primigravida. The majority, 22 (67%), were white, 8 (30%)
were black, and 3 (9%) were Hispanic. Nine (30%) received
assistance from the Women, Infants, and Children program.
We were able to reach 19 (58%) for follow-up interviews.
Attitudes About Vaccination
Based on a combination of mothers’ actions and the attitudes
that they expressed during the interviews, we categorized
mothers into 2 main groups: “vaccinators” (n
25) or “nonvaccinators” (n 8; Fig 1). These catego-ries of
vaccinators and nonvaccinators were further sub-divided into
4 categories. Vaccinators were subdivided into: (1)
“accepters,” mothers who agreed with or did not question
vaccination (n 20); or (2) “vaccine-hes-itant mothers,”
mothers who accepted vaccination but had significant
concerns about vaccinating their infants (n 5). Nonvaccinators
were subclassified as (3) “late vaccinators,” mothers who
either purposely delayed vac-cinating or chose only some
vaccines (n 3); or (4) “rejecters,” mothers who completely
rejected vaccina-tion (n 5). These categories are depicted in
Fig 1 as occurring along a continuum, because mothers ex-
pressed ranges of attitudes that did not fit simply into discrete
categories but rather occurred along a spectrum.
Mothers who were categorized as vaccine-hesitant and
those who were categorized as late vaccinators com-prised the
middle of the continuum (Fig 1). These 2 groups of mothers
were very similar to each other with respect to their desire for
knowledge and their approach to obtaining information. We
chose the themes impor-tant to these mothers in the middle of
the continuum to be the focus of the data that we are reporting
here because they sought information from their pediatric
providers and because they expressed a clear interest in
obtaining information about vaccines. We hypothesize that
they are the most amenable to improved contact with
traditional pediatric and public health providers. In contrast,
mothers who were nonvaccinators on the far right end of the
spectrum seemed less amenable to, or
FIGURE 1
Attitudes about vaccination: a continuum.
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interested in, such contact; they cited, for example, that they
did not vaccinate because it says not to in the Bible or “to
keep their bloodline pure.”
Knowledge About Vaccination
Sixteen mothers spontaneously offered erroneous infor-
mation during the open-ended interviews (8 vaccinators and 8
nonvaccinators). Examples of erroneous informa-tion
included but were not limited to: a belief that their 3- to 6-
month-old infant had received vaccines against chicken pox,
smallpox, or measles, mumps, and rubella; a belief that they
themselves had received a vaccination against chicken pox as
a child and subsequently devel-oped disease with chickenpox
regardless of that vacci-nation; a belief that their infant could
become infected with the human immunodeficiency virus
from vaccines; a belief that vitamin K is a vaccine; and a
belief that infants develop influenza from the influenza
vaccine.
Mothers had poor knowledge about which vaccines
children receive. At the time of the first interview, only 2
mothers could identify even 1 of the vaccines that are
recommended at 2 months of age from a list of possible
vaccines that was included as part of the multiple-choice
questions that followed the interview (Tables 1 and 2). During
the follow-up interview, in response to the open-ended
question (ie, mothers received no prompting), “what vaccines
has your child received?” only 2 of the mothers who had
reported that they had vaccinated their infants could correctly
name $1 of the 5 vaccines their child would have received.
Mothers frequently named chicken pox and measles, mumps,
and rubella vaccines, vaccines that their child would not have
re-ceived because all of the interviews were done by 6 months
of age, and those vaccines are administered later.
In response to the closed-ended multiple-choice questions
that followed the first interview, mothers in this study who
were late vaccinators answered most of the 10 multiple-
choice questions correctly (median: 9; range: 6 –9; P .014
versus vaccine acceptors), mothers in this study who were
vaccine-hesitant answered a median of 6 correctly (range: 4 –
7; P .048 versus vaccine acceptors), mothers in this study who
were re-jecters answered a median 5.5 correctly (range: 1–9;
P
.93 versus vaccine acceptors), and mothers in this study who
were vaccine accepters answered the fewest ques-tions
correctly (median: 4; range: 2–9; reference group).
Domains Associated With Decision-Making About Vaccination
We identified 3 main domains related to decision-mak-ing
about vaccination: (1) mothers’ key sources of infor-mation,
(2) promoters of accepting vaccination, and (3) inhibitors of
accepting vaccination. We focused on how mothers’ attitudes
about vaccination aligned with these domains with particular
emphasis on the issues that
PEDIATRICS Volume 117, Number 5, May 2006 1535
 TABLE 1 Questions About Knowledge: First Interview (N 29)
Question (Correct Answer in Parentheses) No. With Each Answer
Correct Incorrect Not Sure
True/false
Any vaccination/shot can cause a bruise. (true) 18 4 7
Multiple choice (4 choices)
Which of these vaccines prevents meningitis? (Hib) 9 4 16
Which of these vaccines prevents whooping cough? (pertussis/DTaP) 11 5 9
Which of these is a proven adverse effect of the MMR vaccine? (fever) 17 3c 9
Which of these vaccines prevents liver damage and liver cancer? (HepB) 22 1 6
Which of these vaccines prevents a type of paralysis? (polio) 26 1 2
Which statement describes the rotavirus vaccine?a 5 1 22
Which statement describes thimerosal? 8 0 21
Multiple choice (choose all that apply from a list of 14 real vaccines and
1 false vaccine)
Choose vaccines typically given at 2 months of age (choosing any 2 8d 19
1 correctly without choosing an incorrect also)
Choose all vaccines heard of (choosing $5 real vaccines from list) 28b 0 0
Hib indicates Haemophilus influenzae serotype b vaccine; DTaP, diphtheria, tetanus, pertussis vaccine; HepB,
hepatitis B vaccine; MMR, measles, mumps, rubella vaccine.
an 28.
b One mother selected “none” and 2 selected the false vaccine in addition to
correct vaccines. c All 3 chose autism (2 were nonvaccinators).
d MMR (6), chickenpox (3), smallpox (3).

TABLE 2
Questions About Knowledge: Follow-up Interview (N
19)
Question (Correct Answer in Parentheses) No. With Each Answer
Correct Incorrect Not Sure
True/false
Any vaccine can cause a bruise? (True) 14 4 1
Multiple choice (4 choices)
Which of these vaccines prevents meningitis? 9 0 10
(Hib)
Which of these vaccines prevents whooping 10 0 9
cough? (pertussis/DTaP)
Which of these is a proven side effect of the 11 1a 7 FIGURE 2
MMR vaccine? (fever) Key sources of information about vaccination according to attitude about vaccination
Which of these vaccines prevents liver 16 0 3 (information most relevant for mothers who were vaccine-hesitant and late vaccinators).
damage and liver cancer? (HepB)
Which of these vaccines prevents a type of 17 0 2
paralysis? (polio)
Hib indicates Haemophilus influenzae serotype b vaccine; DTaP, diphtheria, tetanus,
ferred, trusted source of information was the pediatri-cian.
pertussis vaccine; HepB, hepatitis B vaccine; MMR, measles, mumps, rubella vaccine. For nonvaccinators, the preferred, trusted sources of
a
One chose autism. information were the homeopath or naturopath, the Internet,
books, and Mothering magazine. Mothering: The Magazine of
Natural Family Living is a bimonthly maga-zine that
were relevant to the mothers in the middle of the con-tinuum “celebrates the experience of parenthood as worthy of one’s
(Fig 1) because of their desire for more informa-tion and their best efforts and fosters awareness of the immense importance
expressed willingness to consider addi-tional discussion and value of parenthood and fam-ily life in the development
regarding vaccinations. We found that the themes elicited of the full human potential of parents and children.”30 It
from our conversations with mothers all revolved around the regularly includes articles both in favor of and opposed to
central concept of trust and whom mothers had decided to vaccination and is known to have a readership that includes a
trust regarding vaccina-tion. high propor-tion of nonvaccinators.15

As depicted in Fig 2, the preferred sources of infor-mation

Key Sources of Information
Fig 2 shows the key characteristics of mothers with regard to
sources of information about vaccination. For mothers who
were vaccinators and the subset of non-vaccinating mothers
who were late vaccinators, the pre-
among nonvaccinating mothers who were late vaccinators
overlapped with that of the vaccinators. These late
vaccinators often expressed conflicting feel-ings about how to
get their questions answered and

1536 BENIN et al
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whom to trust. For example, 1 mother who was a late
vaccinator described the many sources of information she had
tried and expressed her lack of satisfaction with the resulting
information:
“I’ve gotten some information from the baby care books….
From peers, too, friends…. Getting information
about why the vaccination schedule is the way it is, no one
can seem to really answer for me, even my doctor. I’ve asked
my doctors that question…. I really haven’t
gotten a really good answer…. I feel like I can’t get really
solid information.”
In direct contrast to how these mothers felt, those moth-ers
who were vaccinators had decided to trust the doc-tor. For
example, one mother said, “You know I really … feel that
I’ve made a decision to trust our pe-diatrician … So that, you
know, I’m kind of ceding the responsibility of getting more
information over to them, trusting her.” These mothers did
not want too much information, because they trusted the
doctor.
Because of the implications for planning the best tim-ing
for approaching mothers with information about vaccinations,
we questioned mothers about when they sought information
and when they made their decisions regarding vaccination.
Except for some mothers who were vaccine acceptors,
mothers sought information while they were pregnant and had
decided about whether to vaccinate during their pregnancy.
The fol-lowing is a quote from a woman discussing her desire
to have information prenatally.
“I think it should be prior [to delivery] because you never
know what’s going to happen…. So I think if you
have information beforehand…. It’s like, ‘OK, got the
information on this. I know it. If they come to me and ask me
if there’s something I want to do, I can make a decision.’ ”
Promoters of Accepting Vaccination
Overwhelmingly, we found that for vaccinators, the main
promoter of accepting vaccination was trusting the doctor
(Table 3). As one mother phrased it, “I don’t know enough
about how [vaccines] are put together and tested to have a
confidence level about that. But that’s where the doctors
come and you have to trust them.”
Another important promoter was feeling satisfied by the
pediatrician’s discussion about vaccination, which led to
trusting that pediatrician. In particular, vaccina-tors who were
vaccine-hesitant recounted positive, often lengthy discussions
with the pediatrician.
“[The pediatrician] respected the fact that … we wanted to sit
and talk for an hour and a half about vaccina-tions…. And he
stayed very late one night … it wasn’t
something that they could charge us for…. And it’s a
very busy practice. It wasn’t as if he needed to solicit our
business.”
Part of being able to trust their pediatrician was find-ing
that their pediatrician was able to answer their ques-
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TABLE 3 Promoters and Inhibitors of Accepting
Vaccination
Promoters of accepting vaccination
Vaccinators
Trusting the doctor
Feeling satisfied by the pediatrician’s discussion
Feeling that vaccinating is the cultural norm
Believing in the social contract
Having positive past experiences with
vaccines Wanting to prevent disease
Inhibitors of accepting vaccination
Vaccinators
Fearing mistakes being made
Both vaccinators and nonvaccinators
Believing children get the disease anyway (especially
chicken pox and influenza)
Believing that vaccine-preventable diseases are not so
bad (eg, chicken pox)
Nonvaccinators
Feeling alienated by and distrusting the pediatrician
Having a previous negative experience with the medical
establishment resulting in distrust
Having a trusting relationship with an influential naturopath/homeopath or
other person who supported not vaccinating
Distrusting the doctor’s information: doctor does not know
and does not have the time
Distrusting motives: vaccination is just a money-maker for
pediatricians and vaccine industry
Believing that diseases are not around, are not
serious, or are easily treatable
Worrying about permanent adverse effects (eg, autism)
Feeling that since other children are vaccinated their
child is not at risk (“reverse social contract”)
tions satisfactorily and completely. Mothers needed to feel as
though their pediatrician was knowledgeable and had all of
the relevant information.
Other promoters included a perception that vaccinat-ing
was a “cultural norm” and not wanting to depart from that
norm (also called “bandwagoning”12), believ-ing in the social
contract, mothers’ past experiences with diseases and
vaccines for themselves or for older chil-dren, and wanting to
prevent disease in their child (Ta-ble 3).
Inhibitors of Accepting Vaccination
Vaccinators and nonvaccinators expressed a fear of mis-takes
being made, and several mothers described in-stances when
their child had received the wrong vaccine and how this event
made them question their trust in the pediatrician. For both
vaccinators and nonvaccina-tors, inhibitors included the belief
that their child would get the diseases anyway, especially
chicken pox and influenza. Mothers also believed that
vaccine-prevent-able diseases are “not so bad”; a sizeable
number of mothers (12) cited chicken pox in this regard.
For nonvaccinators, the list of inhibitors to vaccina-tion
was lengthy. Inhibitors that were important to late vaccinators
are shown in Table 1. There were a number of other inhibitors
mentioned by only a few mothers or
PEDIATRICS Volume 117, Number 5, May 2006 1537
by those on the far end of the continuum that we have not
included here.
Most nonvaccinators expressed a sense of feeling alienated
by the pediatrician and/or the medical estab-lishment, for
example, “You just feel really painted into a corner and
there’s really no support in the medical community. I went
through … a dozen doctors who were just being like, ‘I will
not treat you if you’re not going to vaccinate your child.’ ”
Alienation was tightly tied to their loss of trust in the
pediatrician and the medical establishment. They were not
able to enter a trusting relationship, yet they clearly were
seeking such relationships with traditional pediatrics. Six of
the 8 nonvaccinators expressed a clear desire to have a trust-
ing relationship with a traditional pediatrician and had sought
such relationships but had been turned away. The following
are quotes from 2 different mothers.
“Because we wanted to find a pediatrician … I called 4
different pediatric groups that were listed in my medical
insurance book and all 4 of them said they would not see my
child…. I had nurses on the phone who would nor-
mally book appointments. My question was, ‘Do you have a
pediatrician who would be willing to discuss with us, to
vaccinate or not to vaccinate?’ She was like, ‘How could you
do that to your child?’ ”
“I’m very comfortable that they [the medical establish-ment]
have a wonderful place in what they’ve done and in what’s
possible and certainly would want to be an American citizen
with access to medical hospitals here … when it comes down
to it … I would love to have access to the health care that we
have here.”
Several nonvaccinating mothers distrusted traditional
medical care because of negative previous experiences with
the medical establishment in general, such as mis-diagnoses
or poor communication about a diagnosis. Instead,
nonvaccinating mothers ended up having a trusting
relationship with an influential naturopath or homeopath or
another person who supported not vac-cinating.
“I really trust my homeopath. She’s amazing … she is like
one of my number one sources on this topic. She … keeps
herself really updated in this since it’s her passion…. Her
clarity and the volume of information
that she has on antivaccination is so compelling that you want
to be like, ‘OK, I’ll never vaccinate. I’ll never, ever
vaccinate.’ ”
In direct contrast to this manner in which mothers who were
nonvaccinators felt that their homeopath ex-plained
immunizations with passion and expertise, these mothers
found that the doctors left them feeling as though they could
not trust the doctor’s information, the doctors did not have
adequate knowledge about vac-cines, and the doctors did not
have time to talk about vaccines. “But [the doctors] don’t
have the answers for me to these specific questions [about
vaccines]…. I like
them a lot, but I don’t think they have the time or the
motivation to find me the answers.”
1538 BENIN et al
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Many of these mothers distrusted the motives of pe-
diatricians and the medical establishment and explained that
vaccination was exclusively for making money for
pediatricians and the vaccine industry, as one mother
described:
“What I would like to see is that pediatricians are edu-cated
more on the potential detrimental side to the vac-cine program
and not financially rewarded for giving [vaccines]…. I mean,
in Connecticut, there’s a financial
reward given to pediatricians who have a full vaccine record.”
Inhibitors for nonvaccinators also included fears about
permanent adverse effects, such as autism, sudden in-fant
death syndrome, AIDS, and other immune diseases.
Moreover, nonvaccinators expressed a belief that vac-cine-
preventable diseases are nonexistent, are not seri-ous, and are
easily treatable.
“I’m not overly concerned with the incidence of these
diseases…. My infant is not at risk for tetanus right
now…. My doctor said that, if we lived on a farm, he
would recommend that she get tetanus right away. But we
don’t live on a farm…. And as far as the diphtheria,
there’s no diphtheria…. To give her diphtheria, it’s like
the same argument with the polio.”
What we have called the “reverse social contract” also acted
as an inhibitor: mothers felt that because most other children
are vaccinated, their child was not at risk for vaccine-
preventable diseases (also called “free-riding”12).
Qualities of Trustworthy Relationships
Both mothers who were vaccinators and those who were
nonvaccinators described qualities of a trustworthy health
care provider. These qualities included spending a long period
of time with them, discussing the subject of vaccines in a
passionate manner, having a large amount of scientific
information, using a “whole-person” ap-proach, behaving in a
manner that was not patronizing, and treating mothers/infants
as individuals with individ-ual needs.
DISCUSSION
We developed a schema classifying mothers’ attitudes to
vaccination and described their attitudes as existing along a
continuum: mothers were vaccine accepters, vaccine-hesitant,
late vaccinators, or vaccine rejecters, similar to a
conceptualization developed independently by Gust et al31 and
published after we completed our analysis. This
characterization of the continuum of atti-tudes to vaccination
can be used to help pediatricians formulate how to approach
individual patients and to help public health programs tailor
messages for the mothers in the middle of the continuum
(mothers who are vaccine-hesitant and late vaccinators).
These moth-ers in the middle of the continuum have
significant concerns about vaccination, are interested in
obtaining
information, and play an active role in deciding whether to
immunize their infants.
Trust or lack of trust and relationships were main
determinants of mothers’ decisions about vaccination; this
reliance on trust was especially impressive, because mothers
perceived that “diseases are not around” or are “not so bad,”
and they had little experience with vac-cine-preventable
diseases. Medical knowledge was not the main driver of
vaccination: mothers in this study who were most
knowledgeable about vaccination were those in the middle of
the continuum (possibly because they had the most concerns
and, accordingly, had sought out information).
Discussions about vaccination can be one of the first
opportunities to form a trusting relationship between parents
and pediatricians. Communication about risks and benefits of
vaccines has been the typical approach to this interaction 32,33
and is legally mandated.34,35 However, this communication
does not always meet parents’ needs, and the dialogue
between parents and pediatri-cians on this subject is not
always trusting and open, as evidenced by studies showing
that approximately one quarter of pediatricians do not allow
patients in their practice whose parents refused
vaccinations.36,37
Our findings indicate that relying only on dissemina-tion
of medical knowledge to parents in itself is not a satisfactory
approach to communication regarding vac-cines. Instead,
discussions with the mothers who were in the middle of the
continuum of attitudes to vaccination suggest that pediatric
health care providers may need to focus both on developing
trusting, open relationships and also on providing factual,
scientific information about vaccines and vaccine
controversies. As found in other studies, 11,17 mothers,
including many nonvaccina-tors, looked to their pediatric
providers for information about vaccines. Yet, when we spoke
with mothers who actively sought information from the
traditional medical establishment, there were clear differences
in the quality of the experiences with the pediatric-care
provider be-tween those mothers who chose to vaccinate
(mothers who were vaccine-hesitant) and those who did not
(mothers who were late vaccinators). Mothers who vac-
cinated had found a pediatric provider who could an-swer
their questions in detail and spend time with them. In contrast,
those who did not vaccinate had a pediatric provider who did
not know the answers to their ques-tions about vaccine
controversies, who could not spend time with them, or who
treated them condescendingly. Many of these mothers had
found a passionate, trust-worthy homeopath or naturopath
who could offer them detailed, scientifically based
information against vacci-nating.
Mothers identified as more trustworthy those rela-
tionships in which their providers expressed a passion about
vaccination, seemed knowledgeable, were able to offer
satisfactory answers to questions that were asked,
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did not act condescending or rushed, and treated them like an
individual. These factors fall into the domain of trust in
physicians that is referred to as “trust in compe-tence.”38–41
Perception of competence is a primary com-ponent of
patients’ trust in physicians; yet, because most patients cannot
directly assess their physician’s compe-tence, interpersonal
skills and communication style largely determine how
patients perceive their physician in this domain.39,41
Unfortunately there are little data on how to successfully
intervene to improve patients’ trust of physicians.40
Having a vaccine program that relies to such a large extent
on trust leaves it vulnerable. Trust can be fragile in the face of
scandals, conflicts of interest in the profes-sion, and
proliferation of negative information, even false negative
information.33 In lieu of trust alone, com-munication with
parents and the public about risks and benefits of vaccines has
been proposed as a means to strengthen immunization
activities.17,32,33,42,43 However, our data suggest that a more
complex picture of com-munication needs to be developed.
Although parents want to receive information on vaccination
from their pediatrician,11 pediatricians have very little time to
spend discussing vaccination.44,45 Moreover, it is hard to com-
municate about risk with patients,42,46 and, specifically, it is
hard to educate parents about vaccines.44,47,48 This study
provides a broader context through which to ap-proach
communication about vaccination. These moth-ers suggest
that developing trusting relationships regard-ing vaccination
may include not establishing policies of excluding
nonvaccinators from pediatric practices; hav-ing a detailed
understanding of vaccine controversies and scandals so that
when faced with concerned moth-ers who are in the middle of
the continuum, providers can address their needs for
information; being able to explain risks and benefits in clear
and simple terms, because most mothers have limited
recognition of the names and diseases that vaccines prevent;
and beginning the process of education about vaccination
during preg-nancy, because concerned mothers decide about
vacci-nation during their pregnancy. Many of these sugges-
tions have also been proposed by other authors, including the
recent statement from the American Acad-emy of Pediatrics
Committee on Bioethics.10,37,49–52 The question remains
unanswered as to how busy pediatric providers can have time
to follow these suggestions. It is possible that new Current
Procedural Terminology codes for counseling about
vaccination are a small step toward facilitating these efforts. 53
In addition, given the reliance of mothers on providers of
alternative medicine, pedia-tricians and the public health
community may consider forging alliances with these groups,
as well as with groups offering prenatal classes.
Our findings should be considered in light of limita-tions
to the study’s generalizability and validity. We relied on
information from a fairly modest sample of
PEDIATRICS Volume 117, Number 5, May 2006 1539
English-speaking mothers in 1 geographical area; thus, we
cannot ensure that these results would apply nation-wide.
Also, we cannot comment on the relative frequen-cies of
attitudes held by mothers, because, as is appro-priate for
qualitative research, we did not base the study on a random
sample of participants.23 We cannot ex-clude that there may
be alternate valid explanations of the data we collected; 26,54,55
however, we used method-ologic techniques that were
intended to enrich validity: purposeful sampling, grounded
theory, coding by 2 re-searchers, and a form of multiple
coding.26,29,54–58 More-over, our findings are both credible, as
well as consistent with those of published studies using varied
method-ologic approaches.26,29,31,54–58
We have not addressed the extent to which inher-ently
distrustful attitudes held by nonvaccinators before they
entered into a relationship with a pediatrician af-fected the
development of a trusting relationship. This issue is
particularly relevant because parents who are less confident
about vaccine safety may also be less apt to follow the advice
of their pediatrician in general.17 In-deed, we propose that
some mothers who were vaccine rejecters on the extreme
right of the continuum do hold inherent beliefs that lead them
to reject vaccination regardless of any interaction with a
health care provider. For example, these mothers told us that
they did not vaccinate “to keep their bloodline pure.” They
had low scores on the questions regarding knowledge about
vac-cinations suggesting that they had not sought informa-
tion about vaccines. Because we found that these moth-ers did
not seem amenable to discussing vaccination, we did not
concentrate this report on them. Instead we focused on
mothers, both vaccinators and nonvaccina-tors, in the middle
of the continuum, mothers who told us that they had sought
information from pediatric pro-viders, desired information
from pediatric providers, or desired to be included in the
mainstream medical sys-tem. Although some of these mothers
may be inherently distrustful of the medical system, we
hypothesize that they are interested in, and would benefit
from, being included in open discussions about vaccination.
In this study, we synthesized the factors found in previous
studies11–17,31,49,50 with newly found/emphasized factors and
placed them into a broad conceptual frame-work. These data
suggest that attempts to work with mothers who are
concerned about vaccinating their in-fants should focus on
developing positive relationships in addition to providing
facts about vaccines.
ACKNOWLEDGMENTS
This work was supported in part by a grant from the National
Institutes of Health (K24-AI01703), by the Yale General
Clinical Research Centers Program of the Na-tional Center
for Research Resources, National Institutes of Health (M01-
RR06022), and by the Robert Wood Johnson Clinical
Scholars Program.
1540 BENIN et al
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We thank the mothers who spent their precious post-
partum hours discussing vaccination with us, the mid-wives
who generously referred their patients to us, and Drs Marjorie
Rosenthal and Elizabeth Bradley for their thoughtful
comments.
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PEDIATRICS Volume 117, Number 5, May 2006 1541
Qualitative Analysis of Mothers' Decision-Making About Vaccines for Infants:
The Importance of Trust
Andrea L. Benin, Daryl J. Wisler-Scher, Eve Colson, Eugene D. Shapiro and Eric S.
Holmboe
Pediatrics 2006;117;1532
DOI: 10.1542/peds.2005-1728
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