Caregivers’ perceptions on routine childhood vaccination: A qualitative study on vaccine hesitancy in a South Brazil state capital

ABSTRACT

Immunization programs worldwide have been facing challenges in keeping vaccination coverage high. Even though universally known for its robust National Immunization Program, Brazil has also faced significant challenges regarding vaccination coverage. One of the reasons for this is vaccine hesitancy, a complex, multi-causal, and context-specific phenomenon. This qualitative study aims to understand the factors associated with decision-making and the drivers of vaccine hesitancy in Florianopolis, Santa Catarina state capital, regarding caregivers’ perceptions of routine childhood vaccination. In-depth interviews were conducted in the Capital city of Santa Catarina State. Families with children up to 6 years old were included. Data were analyzed based on thematic content analysis. Twenty-nine caregivers in 18 families were interviewed. These caregivers were mainly mothers and fathers. Three themes emerged: 1. Access to information and the decision-making process, where we discuss the role of social circles, healthcare workers, and the internet; 2. Individual-institutions power relationships: Perceptions about the State’s role and the Health institutions: 3. Reasons and motivations: The senses and meanings behind non-vaccination, where we discuss the drivers of vaccine hesitancy related to risk perception, caregivers’ opinions on the medical-pharmaceutical industry, vaccines’ composition and their side effects, families’ lifestyles and worldviews, and the childhood routine vaccination schedule. The results of this study reaffirm the complexity of the decision-making process in childhood vaccination and further enable a better contextual understanding of the complex and challenging phenomenon of vaccine hesitancy.

KEYWORDS:

• Vaccination
• immunization
• vaccine hesitancy
• childhood health
• qualitative research
• Brazil

Introduction

Vaccination is one of the most successful public health interventions in human history. Despite this, immunization programs worldwide have faced challenges keeping vaccination coverage high and equitable.¹ Vaccination coverage had been falling in many parts of the world even before the COVID-19 pandemic. The reasons are diverse, ranging from issues related to local health systems and difficulties of access, among others.² The World Health Organization (WHO) and its expert groups have devoted themselves more keenly to vaccine hesitancy for over a decade. WHO first defined vaccine hesitancy in 2012 as the delay in acceptance or the refusal of vaccination despite the availability of vaccination services.³ More recently, the concept has been rethought, most notably by the WHO Working Group on Behavioral and Social Drivers of Vaccination, which defined vaccine hesitancy in 2022 as “a motivational state of being conflicted about, or opposed to, getting vaccinated; this includes intentions and willingness.”⁴

Brazil is universally known for its robust National Immunization Program, created in 1973, even before the creation of the Unified National Health System.⁵ With a vast vaccination schedule, especially for children, Brazil has consolidated an immunization culture, that is, the naturalization of childhood vaccination as a fundamental part of the parental care role.⁶ Besides producing most of its vaccines, the country is also responsible for exporting vaccines worldwide, such as the yellow fever vaccine.⁷

Nevertheless, in line with global trends, Brazil has also faced significant challenges in maintaining vaccination coverage. Some of the reasons for this are the challenges posed by the underfunding of the health system, the weakening of public health policies, and vaccine hesitancy.^8,9

Vaccine hesitancy is a context-specific phenomenon and relates to each locality’s history, time, and culture. It is known that the meanings attributed to vaccination, and especially to vaccine refusal, are not homogeneous throughout the world.¹⁰ Studies prior to the COVID-19 pandemic pointed to some reasons found in both high-income and low and middle-income countries, such as doubts about the actual efficacy and safety of vaccines; questioning the financial gain and commercial interest of the pharmaceutical industry, criticism of the composition of vaccines and their mechanism of action; and fear of adverse effects. Also, false beliefs about vaccines and vaccination, for example, the belief that immunity acquired by infection is better than that generated by the vaccine, and the belief that lifestyle habits (such as healthy eating, for example) are protective against all vaccine-preventable diseases, thus dismissing the need for prevention through vaccination.^11–15 In the context of the global south, influences of the historical and social background of these nations on caregivers’ confidence are observed, as well as issues related to access to vaccines and health facilities In the context of the global south, influences of these nations’ historical and social backgrounds on caregivers’ confidence and issues related to access to vaccines and health facilities are observed.¹³

Understanding the drivers of vaccine hesitancy in the particular contexts of the global south, in low and middle-income countries, is an essential step toward overcoming the one-size-fits-all model.¹³ Also, the COVID-19 pandemic has highlighted the debates and tensions around vaccines. That means empirical research conducted in the pandemic context could help analyze childhood vaccine hesitancy through a new lens. Therefore, this research aimed to investigate the perceptions attributed to routine childhood vaccines by caregivers of young children in Brazil. In this sense, it is important to introduce the “caregiver” category because in Brazil the family constitution is not only represented by the mother and father, who would traditionally be responsible for looking after children, but the role of this responsibility is shared between different people and, furthermore, the idea of “caregivers” takes into account the different family arrangements present in the composition of the country’s domestic units.

Materials and methods

This qualitative study was conducted in Brazil between March 2021 and April 2022. We used in-depth interviews to explore the opinions and understandings of Brazilian caregivers of young children about routine childhood vaccines.

Study sites

The project occurred in one Brazilian municipality’s capital city, Florianopolis (State of Santa Catarina, in the southern region of Brazil). Florianopolis has a high Human Development Index (HDI; 0.847), a low infant mortality rate (7.78 per 1,000 live births-year), and a high percentage of proper water sanitation (87.8%). Most inhabitants in Florianopolis are white (84.8%).^16,17

Florianopolis has recently registered lower than recommended vaccination coverage levels for childhood schedule.¹⁸ In this city, childhood vaccination coverage is lower among families with higher income and education level.¹⁹

Inclusion criteria

Families invited to participate in the study were those living in Florianopolis with children up to six years old. We selected families with distinct behaviors regarding childhood routine immunization: families with (1) wholly or (2) partially vaccinated children, the latter comprising the group that selected some vaccines, as well as with (3) unvaccinated children. This criterion was implemented for all the behaviors to be represented.¹⁹ We separately interviewed two family members identified as the principal caregivers of the children, i.e., those responsible for their daily care and decision-making regarding their health. In some families, it was only possible to interview one of the principal caregivers (usually the mother) because the other caregiver was unavailable or did not respond to contact attempts.

Diversity was the prime consideration in the selection of families included in the study. Participants with different characteristics, such as socioeconomic levels, racial groups, levels of education, and residence in different neighborhoods of the two cities were specifically targeted for inclusion when possible. In this sense, as much research suggests, in qualitative studies like ours, what is crucial is the sample quality and not necessarily its quantity.²⁰

Sampling and recruitment

Participants were recruited using snowball sampling,²¹ a strategy that facilitates the inclusion of hard-to-reach populations, such as families that select, postpone, or do not vaccinate their children. Starting from initial sources, each family as indicated others to participate in the study. The initial interviewees were families with no relation to the researchers, indicated by people from the personal and professional circles of the study investigators. Figure 1 details the steps undertaken to reach the final sample.

Figure 1. Flowchart of snowball sampling in Florianopolis (SC).

Data collection

We extracted empirical data from in-depth interviews.^22,23 One trained, experienced researcher, the first author, conducted the interviews in Portuguese using a pre-established and tested script (supplementary file 1).

Due to the COVID-19 pandemic, the first author conducted interviews virtually or in person, according to the participant’s preference. Eventually, only one interview occurred in person at the interviewee’s home (respecting existing COVID-19 protocols); all others took place in a virtual environment using the Zoom® platform.

The interviews lasted from 18 to 108 minutes (mean 48.1 minutes). All interviews were fully audio-recorded and transcribed by the manuscript’s first author. The names of all interviewees were replaced by codes to protect participants’ anonymity. The second author revised the transcriptions, and the first, second, and third authors discussed and interpreted the data – the fourth independently revised all the processes to guarantee the best accuracy and objectivity.

The fieldwork in Florianopolis took place between March and June 2021. The final number of interviews conducted in the city was determined based on the information produced during data collection, according to the saturation criterion regarding each question in combination with the complete interviews.²³

Data analysis

We evaluated and interpreted the interviews using thematic content analysis,²⁴ focusing on the content of caregivers’ narratives and contextual meaning. After an immersive reading of the transcriptions, highlighting the meaning units, we listed the codes. There was no duplicate coding. A spreadsheet was used to list the codes after abstracting participants’ accounts and for grouping codes into categories from which the themes emerged. We used the step-by-step theme development proposed by Vaismoradi and team²⁵ and the iterative categorization technique proposed by Neale.²⁶ We carried out the final synthesis of relating themes to established knowledge.²⁵ All data were produced and analyzed in Portuguese, with quotes selected to illustrate categories in the results section which were later translated into English.

Ethical statement

The was approved by the Ethics Review Board at the University of Sao Paulo (CAAE nº 37536320.2.0000.0068). All participants signed an informed consent form. Codes were assigned to the participants to ensure anonymity – a number was identified for each family. The participants’ codes are formed by the family number followed by the initial letter of the kinship (M = mother; F = father; A = auntie; G = grandmother). It is important to note that the Brazilian ethics committee does not allow interviewees to be compensated through direct gains.

On the other hand, they can be compensated through indirect returns, such as benefitting from the research. In addition, participants can refuse to continue taking part at any time during the research. If the research is terminated, they can request that their data be withdrawn from the study at any time.

Results

We interviewed, in total, 29 caregivers in 18 families. These caregivers were mothers (n = 16) and fathers (n = 13). Table 1 [at the end of the article] shows the demographic characteristics of all interviewees.

Table 1. Participants’ sociodemographic characteristics in Florianopolis (SC).

	Code	Age	Skin color	Occupation	Social class	Children’s age**	Position on vaccines
Fully vaccinated children	01 M	40	White	Professor	Middle/B2	4y3m 6y11m	–
	01 F	45	Black	Teacher	Middle/B1
	02 M	35	White	Teacher	Middle/C1	1y7m 14y7m	–
	02 F	34	White	Lighting technician	Middle/B2
	03F	26	Black	Software vendor	Lower/C2	6y, 5y, 4y	–
	04 M	32	Black	Professor	Middle/A	1y2m	–
	04 F	37	Black	Engineer	Middle/C1
	05 M	40	White	Tourismologist	Middle/B1	11 m	–
	06 F	37	White	Data analyst	Middle/B2	2y7m 16y9m	–
	06 M	39	White	Historian	Middle/B2
Delay or refusal of vaccines despite availability	07 M	31	White	Doula	Middle/B2	2y10m 13y11m	Unvaccinated for HPV (oldest child) and rotavirus (youngest one).
	07 F	36	White	Civil police	Middle/A
	08 M	43	White	Engineer	Middle/B2	4y2m	Selected or postponed some vaccines.
	08 F	37	Brown	Professor	Middle/B1
	09 M	42	White	Researcher	Middle/A	5y	Selected or postponed some vaccines.
	09 F	43	N/D	Administrator	Middle/A
	10 M	34	White	Cultural producer	Middle/B2	1y, 3y3m, 12y11m	Youngest child: unvaccinated; 3y child: unvaccinated up to 1 year old (vaccines fully postponed).
	11 M	42	White	Architect	Middle/B2	4y5m	Selected or postponed some vaccines.
	11 F	39	White	Trade representative	Middle/C1
	12 M	38	White	Teacher	Middle/B1	5y6m	Unvaccinated up to 3 years old. After this age, selected or postponed some vaccines.
	12 F	43	White	Writer	Middle/B1
	13 M	30	White	Student	Middle/C2	6y	Unvaccinated.
	14 M	24	White	Autonomous	Middle/C2	2y5m	Selected some vaccines. Do not vaccinate on mass vaccination campaigns.
	14 F	26	White	Craftsman	Middle/C2
	15 M	43	White	Autonomous	Middle/B2	4y11m	Unvaccinated.
	15 F	53	White	Therapist	Middle/B2
	16 F	33	White	Doctor	Middle/B2	3y11m 5y9m	Selected or postponed some vaccines.
	17 M	37	White	Housewife	Lower/C2	4y6m	Vaccinated exclusively BCG due to maternity hospital’s obligation.
	18 M	34	Yellow	Autonomous/Therapist	Middle/B2	3y9m	Unvaccinated.

N/D = Not declared.

*Social class self-declared by the interviewee (upper, middle or lower class)/Social stratum defined by the ABEP score (“Brazil economic classification criterion”).

**Children’s age at time of interview, in years (y) and months (m).

Among the 18 families interviewed in Florianopolis, six fully vaccinated their children and showed high confidence in the vaccines. Therefore, to analyze vaccine hesitancy, we use data from the interviews conducted with the hesitant families of the city, that is, 19 caregivers in 12 families. These caregivers were mothers (n = 11) and fathers (n = 8).

Access to information and the decision making process

The role of social circles

The primary source of doubts regarding vaccine information mentioned by the hesitant caregivers was the social circles in which they are nested.²⁷ These are mainly prenatal groups and parents and school groups.

Through these circles, families acquire those doubts about vaccination and continue to obtain information for decision-making during the vaccination process. It is noteworthy that caregivers point out Florianopolis as a place where vaccine questioning is culturally naturalized and accepted, which makes them feel respected in their decisions and less judged for not following what would supposedly be expected or hegemonic.

Influence of friends who already had older children and who were not vaccinated, also influenced me, seeing many very healthy children without any vaccine. (18 M)

Oh [my source of information] was other mothers. We had a group there, and we were constantly exchanging information, you know. I remember that is how it was, that is how we found out. (10 M)

He studies at a Waldorf school too, right […] So we live where this is relatively common, right? (15F)

The role of healthcare workers

Healthcare workers, especially pediatricians and those linked to natural childbirth groups (mainly home-delivery childbirth ones), are pointed out as essential sources of information for decision-making. These professionals often assist the caregivers deciding of which vaccines (not) to take.

The information came to me through the midwives and my friends with children. (14 M)

So, I think the influence was a bit like this: I think those doctors who surrounded us are people who work in the Unified Health System and are aware of the country’s background. Moreover, if they tell us, ‘Oh okay, there are some [vaccines] that you do not need in this case, but like, after the first year, when he is stronger,’ then I trust them.(08F)

So, I trust him [pediatrician] a lot. And then there were a couple of vaccines that he indicated, and I said, ‘Did you vaccinate your son?,’ and then he got slightly embarrassed to lie to me, he said no, and then I did not [laughs]. (09 M)

The role of the internet

The internet was widely mentioned as a possible source of information, but the opinions were quite divergent. For most families, the internet is not a reliable environment to seek vaccine information. Even when they do, they try to confirm the information they find.

Whenever I went to search through technological means, I did not feel secure with the information I had. So, for me, it was much more reliable; it was much safer to talk to people than research it because even though it was a scientific article, I did not feel sure that that information was accurate, you know? (13 M)

It is just that the information I seek I search on the internet, right? Open media is pro-vaccine, right? At least, that is what I see. (15F)

There is a group on Facebook against vaccines, against vaccination, and sometimes they bring some information there, and I look it up, right? Sometimes, it comes as a booklet, sometimes as a meme, you know, which is something you cannot trust, but that serves as a trigger for my search because it is very difficult to search in Google. (17 M)

Individual-institutions power relationships

The interviewed families present various criticisms about the irreducibility and inflexibility of institutions in the face of their doubts about vaccination. In addition, the “unquestionable” character attributed to vaccines by the healthcare providers is mentioned as a barrier to successful discussions about vaccines with them. The families feel that healthcare workers stand in a position of insurmountable moral superiority – and they question this status. The criticism of vaccines is also a critique of power relations established in the healthcare provider-patient relationship.

I also felt that in the hospital, the pediatricians are like that, in that very unpleasant sense, because they do not enter into conversation; they are in charge; this is something that: no, the parents are in charge. This is our right. (11F)

In the hospital itself, there was this violent pressure, right? We had to sign a term at the hospital saying that the social worker was going to come here later, that we were going to be sued and stuff, something horrible like that. Taking away the right that I understand I have as a citizen. I am taking away my citizenship [laughs]. Because it is my decision, not another person’s decision, you know? (15F)

There seems to be a wall that transforms all SUS [Brazilian Public Unified Health System] procedures into something highly unquestionable. As a patient, I cannot question things there […]. A simple query, which is not disrespectful, is seen as disrespectful, and there is already a barrier. (17 M)

Reasons and motivations: the senses and meanings behind non-vaccination

Reasons related to risk perception: the risk-benefit scale

Among the interviewed families, the element that most stands out in decision-making for (not) vaccinating is the relationship between perceived risk and benefit. The decision assesses the highest risk to the children: the disease or the vaccine. That is, the more the risk of getting sick or the perceived severity of the disease is understood as low, the more possible adverse effects of vaccines are considered. Moreover, they also consider whether the diseases are contagious before making their choices.

I will always do the like this: Will it make it worse to take it or not? Did you understand? So, putting it on the scale, I prefer not to. (09 M)

Many of these diseases before, in the year 1900, were at much higher risk; the chances of getting them were much higher, so it made some sense; the balance had to stabilize one way or the other, so risk-benefit was different from today. Today, in the year 2021, risk-benefit is different. So, I prioritize my mental and overall health and minimize the chances of catching something that’s almost gone. (12F)

You have two options: you buy the risk of giving the vaccines and your child having sequelae and blah, blah, blah, and you have the other option, which is not giving them and also taking the risk of your child having complications and da da… And then, I put what I would handle on the scale. Which decision I can handle, right? (13 M)

Reasons related to caregivers’ opinions on the medical-pharmaceutical industry

Criticism of the medical-pharmaceutical industry and perceived profit prioritization over health is another strong reason for deciding not to vaccinate. In this same context, vaccines considered “new” are viewed with suspicion, as they are thought to have been developed and added to the vaccination schedule only to generate more profit for this industry.

I do not trust the pharmaceutical industry. I do not trust it, and it is not anti-science; on the contrary, it is not. I think science has its role, but who finances it, who has money to finance it, are a bunch of …. [expletive] (13 M)

I have this prejudice because of the money that revolves around medicine and health in Brazil, you know? If I lived in Cuba and they said I would have to take medicine, I would, you know? (08 M)

I have more confidence in those post-war vaccines because I understand that, at that moment, there was a more humanitarian task force to try to create a world with fewer deaths, you know? Now these new types of [vaccines, like] H1N1, HPV, rotavirus, things like that, these I think are a small quantity of an invention by the pharmaceutical industry, I do not know. [if I have confidence in them] (09 M)

Reasons related to vaccines’ composition and their side effects

The fear of possible adverse effects and long-term vaccine sequelae is another crucial reason for delaying or refusing vaccines. The main criticism by these families is the composition of vaccines, i.e., they believe that excipients would be harmful to the human body, especially the “heavy metals,” which they say could impair the children’s development, as half of the respondents mentioned. These families compare vaccines to contamination, which would cause a disequilibrium in the children’s bodies. Again, the “new” vaccines are highlighted, as their short- and long-term effects would be even less known than those consolidated in the children’s vaccine schedule for decades.

So, I am very afraid because I do not know what the complications would be. Much of what we have today as adults is due to many things that were even injected into us as children. I do not doubt that there several diseases appear in adults because of that, you know? (13 M)

They put these heavy metals to preserve whatever is in the vaccine, viruses, bacteria, whatever. However, this is a heavy metal, so it has or could have negative consequences on the neurological system and health in general. […] I asked all the health centers, and I went to private pharmacies looking for the same version of the vaccine, but without that metal that they use for this, it does not exist. If the labs make a version that maybe lasts less but does not have that crap inside, I think a lot more people would vaccinate because argument number one would disappear. (12F)

My fear with vaccines has always been the excipients. There is a lack of information about this and the refusal to show the participants. I find it very strange that you refuse. (17 M)

Reasons related to caregivers’ lifestyle and worldview

The worldview and lifestyle of interviewed families relate directly to perceptions and decisions regarding vaccines. The idea that vaccines “contaminate” the body is linked to a lifestyle that seeks to be as natural as possible, free from allopathic medicines. Thus, these caregivers believe that access to a good diet and quality of life would protect the children from vaccine-preventable diseases. Therefore, the children’s immune system could develop all its potential without external interference, which is the vaccine.

I was coming from a very natural lifestyle, wild even, you know, having had a very wild birth and going into nature for a while, and then, in that reality, the vaccine seemed very artificial, right? An interference … I do not know … it made no sense. Also, I did not want this interference so soon in my daughter’s body; I see the vaccine as something violent… and also the fear inside me of “wow, what about getting vaccinated?” as if it were a before and an after, “it got contaminated and now it is a path that has no return,” there is no way to “devaccinate” a body. (18 M)

So, for me, vaccination is a disrespect for your own body because you give something that your body already produces, that your body already makes, the function of the immune system you already got for free, so why do that? (11F)

Reasons related to the childhood routine vaccination schedule

Those families who choose to make their vaccination schedule to postpone some vaccine doses criticize mainly the high number of vaccines and doses that the children are supposed to take early in life, and they also criticize the age of commencement of vaccination. Vaccinating the baby at the time of birth and in the first months of life is viewed as something violent by some of these caregivers.

The nurse, the person who was there at the health Center, wanted to give 5 and 6 vaccines on the same day. I said, “No, wait a moment; how will you give five vaccines?” Each one will activate their immune system; the body will need that energy, it will need to gain that balance, that harmony again, it is a lot to give five vaccines on the same day. I thought it was aggressive not to consider this, that it is not a calendar but a person. (12F)

If vaccines were given at an older age, I would give them all without hesitating. […] So, the big problem with the vaccine is age. You know you must get many vaccines when you are a baby? (08 M)

Discussion

Our results show that the decision-making process regarding childhood vaccination is complex and involves several factors, influences, and information sources. Contact with other hesitant families proved to be the main trigger for questioning routine vaccination, social circles proved to be the primary source of information used to answer those questions and maintain positions. We also found that the role of healthcare professionals was highlighted, especially those linked to natural childbirth groups, complementary and alternative medicine (CAM), and allopathic pediatricians. Regarding the literature, similar findings have already been reported both in Brazil and the world, and reinforce the role that healthcare professionals play in encouraging non-vaccination, especially those linked to rationalities such as homeopathy and anthroposophy.^14,28–30

About the Internet, other findings unveiled how the different platforms play an essential role in the dissemination of health information and, thanks to the advance of virtual tools, there is little control over what is disseminated.² Various studies have already demonstrated the role of the Internet in opinion formation about vaccines and vaccine hesitancy.³¹ Individuals who cite the internet as a primary source of information to learn about vaccines are more likely to refuse or delay vaccination.³² Wilson and Wiysonge³³ also demonstrated that misinformation disseminated by social media directly impacts vaccination coverage.

However, our results bring something new to this literature: the Internet, contrary to what has been taken for granted, is seen by only some of the hesitant families we interviewed as the leading and most reliable source of information. These vaccine-hesitant families reinforce their awareness that the virtual environment is unreliable and, therefore, even when they use it, they try to confirm the information from other sources. We believe that this finding is due to the context in which the research was conducted: COVID-19 the pandemic was accompanied by an infodemic, leading to a truth crisis.³⁴ In our research, we understand infodemic³⁵ as a form of a social dynamic where narratives and moods in social media related to COVID-19 emerge, are communicated, and spread, generally creating confusion and disorder. We coincide with other investigations that the excess of information produced and shared leads to the feeling that one does not know whom to trust,³⁶ a feeling reported by our study’s interviewees. Thus, the Brazilian local social and political context³⁷ may have influenced the caregivers’ opinion about the reliability of the Internet.

Our data also points out that the individual-family-institution relationship has also been shown to play an essential role in the meanings attributed to childhood vaccination. As other studies show, many of the hesitant families are not anti-vaccine but anti-establishment,^32,36 and the interviewed families in our study reinforce this positioning.

The ideas of individual freedom and autonomy are increasingly advocated in Brazil, especially by the middle and upper-class and highly-educated families.^38,39 In this research, it was also found that the hesitant families were mainly middle and upper- class. Also, the families studied, described by Kuan,⁴⁰ with a large amount of social capital, feel authorized to question and criticize policies. Besides that, they feel like having the necessary resources to maintain their children’s health regardless of the vaccination status, as other authors indicate.^30,40,41

Framed by what Reich calls neoliberal mothering or individualist parenting,⁴¹ the premise of the uniqueness of each child/individual leads to tailored caring. In this context, universal interventions like vaccination are perceived as problematic.⁴² In our research, we find that nearly all the mothers interviewed are moving toward customization of health with individualized services, which are unsustainable from the collective and epidemiological point of view.^30,43,44

Our results also showed that the relationship between individuals and health services/professionals is often conflictive and based on a hierarchical power relationship. The “contemporary parental norms”⁴⁰ include the active caregivers’ participation in the children’s health. The idea of following the health professionals’ guidelines passively is avoided, whereas the families interweaved consume information and make active informed decisions.

In Brazil, the strong immunization culture initially built by the National Immunization Program’s success made childhood vaccination unquestionable.⁸ The vaccination practice was moralized; that is, the meaning of care was attributed to those who vaccinate, and the meaning of negligence to those who hesitate. This process makes the dialogue between health professionals and hesitant families demanding since the more one moralizes a truth, the more difficult it is to interact with someone who disagrees.⁴⁵ Thus, vaccination has become a topic with no space for debate, generating a ‘dialogical vacuum or abyss’: caregivers with doubts or questioning find open doors to dialogue with other non-vaccinating caregivers or with CAM doctors that contraindicate vaccination.^14,30

On the other hand, due to the immunization culture in Brazil, even health professionals very often do not feel able to discuss vaccines, as they have only learned that this is the right thing to do.⁴⁶ The COVID-19 pandemic has made this scenario even more complex, demonstrating how healthcare professionals are susceptible to misinformation and conspiracy theories.⁴⁷ Both health professionals and caregivers seem to wish to be better informed about vaccines.^40,46,47

Finally, the reasons mentioned by caregivers for not vaccinating were quite diverse and generally aligned with the reasons found by other researchers in the Global South context.^13,15 As categorized by Oduwole and team,² we also found drivers related to three broad levels: the level of the individual, the social/contextual level, and the level of vaccine administration.

Risk perception was presented as the primary driver of vaccine hesitancy. Due to the success of vaccines and the control of vaccine-preventable diseases (VPD), vaccine adverse effects are now perceived as more significant than the harm of the diseases.^2,30,40 Emotional appeals have more impact on decision-making than scientific statements about probabilities and risks.³⁰

Barbieri’s study¹⁴ showed that all Brazilian families interviewed attribute their vaccination decision-making to parental care and protection. Families that vaccinate their children consider that protecting means vaccinating, whereas hesitant families consider that they should protect their children from the vaccines.³⁸ It is essential to understand this paradigm shift in order to address these families’ fears correctly. Also, the communication on vaccines should be transparent in presenting both the benefits and the risks, disclosing potential side effects.³⁰

Some strongly emphasized reasons mentioned by the interviewed families should be considered with special attention, as they seem to have been heightened by the COVID-19 pandemic. Criticism of the pharmaceutical industry and fear of the composition of vaccines, for example, stand out among the results. The distrust of the pharmaceutical industry is widely described in the non-vaccination literature, as its influence on government policies and medical research is perceived as unfavorable.^15,30,38 Considering that rumors and conspiracy theories are common in times of acute social uncertainty, the COVID-19 pandemic brought even more narratives to this scenario. These beliefs should be read as expressions of widespread fears and anxieties.³⁶ The background of distrust and uncertainty may further reinforce these beliefs, being able to impact children’s vaccination coverage in Brazil.⁴⁸

It is critical to highlight that deciding not to vaccinate is not only about the vaccines themselves. Often, this decision informs a way of seeing the world. Lifestyle and worldview relate directly to health choices, and, for many families, the option not to vaccinate is only part of a package of choices for a “natural” life.^14,30,40 The conception that the children’s body is pure and should be protected from ‘contamination,’ for example, has already been described before.⁴⁹ Understanding that each social group’s notions of health are steeped in their experiences and representations of the world is essential for successful immunization programs.^4,13

Limitations

This study has limitations. The protocol was designed before the onset of the COVID-19 pandemic and aimed to investigate vaccine hesitancy in the context of routine childhood vaccination. The pandemic scenario had to be adapted into the initial design. Most interviews were conducted remotely through video calls, which may have interfered with the quality of interviewer-interviewee interaction. Sometimes, the second caregiver was unavailable to participate in the study. However, this limitation is unlikely to impact our main results, as we found no significant disagreements between the primary caregivers in most families. The study was conducted by researchers from academic institutions, which may have inhibited more radical anti-science expressions. The other article authors constantly revised the objectiveness. It is important to note that this research was carried out in the context of a national government that denied the existence of the pandemic, denied vaccines as a crucial element for health, and was never able to establish an epidemiological contingency plan at a national level. More than 700,000 deaths were the consequence of this policy.

Conclusion

The results of this study reaffirm the complexity of the decision-making process in childhood vaccination. The role of social circles and healthcare professionals in this process was evident. The unanimity in considering the Internet unreliable emerges as an important finding and should be considered in future research and public policies. In this sense, we established institutional contacts with the local health authorities to show them these results. It also highlights the fragility of the family-health professional relationship, which is essential for effective communication in health and should be at the center of immunization policies. Finally, the results show that the vaccine hesitancy drivers in Florianopolis are generally aligned with those found worldwide.

This work has the strength of understanding a complex phenomenon from the perspective of a diverse range of caregivers. Father’s opinions and experiences, for example, are barely investigated in research on children’s health care. In addition, the research was conducted in two very distinct Brazilian regions with different socioeconomic and cultural settings. This diversity is necessary to understand diverse contextual aspects, considering the complexity of the phenomenon, the great Brazilian territorial dimension, and the regional particularities.

This study was conducted during the COVID-19 pandemic, which must be considered in interpreting the findings. In this sense, it is vital that this research is exposed in the Brazilian context so that health professionals and non professionals are aware of the consequences of the absence of public health policies.

Thus, its results may contribute to reflections on the impact of the pandemic on caregivers’ opinions and meanings about childhood vaccination. Finally, qualitative studies in health enable a better understanding of complex and challenging phenomena such as vaccine hesitancy. Findings such as those pointed out here can contribute to planning and implementing appropriate government strategies to increase vaccination coverage.

Acknowledgments

The corresponding author would like to acknowledge all the research participants for their willingness to contribute to this study and the South African Medical Research Council through Cochrane South Africa for supporting this article’s publication.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2298562.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.