“Do-it-yourself”: Vaccine rejection and complementary and alternative medicine (CAM)
Introduction
Acceptance of vaccination is a major driver of uptake, along with issues of access, affordability and awareness. Non-acceptance of vaccination is a phenomenon that concerns global agencies. In 2012, a World Health Organisation (WHO) working group was formed to address vaccine rejection – named ‘hesitancy’ – recommending expanded research to capture factors at individual, community, contextual and organizational levels (World Health Organisation, 2014). One factor that interrelates with individuals' vaccine rejection is use of complementary and alternative medicine (CAM) (Eve Dube et al., 2013, Wardle et al., 2016). A national survey of Australian parents found that obtaining information from alternative health practitioners was strongly associated with self-reported non-compliance with the vaccination schedule (Chow et al., 2017). However, despite an unequivocal correlation, there has been little research that probes or challenges assumptions about causality in either direction. Causality may be obscured due to confounding factors; for example, income, education, and distrust of the medical system are associated with both CAM use and vaccine rejection (Gaudino and Robison, 2012, Wardle et al., 2016). So, too, are high levels of agency and autonomy (Browne et al., 2015, Ernst, 2001). How, then, can we best understand the relationship between CAM use and vaccine hesitancy or rejection? How might this inform action by government, policymakers and health professionals who seek to address the latter via policy, practice or campaigns? This paper addresses this knowledge gap by exploring how vaccine rejecting and hesitant parents in two Australian cities present their use of CAM vis a vis their vaccination decisions.
Wardle et al. define complementary medicine as ‘a diverse group of healthcare practices not generally considered part of the conventional medical curriculum’ (2016, 2). Their literature review explored modalities including (but not limited to) acupuncture, aromatherapy, Chinese medicine, chiropractic, homeopathy and naturopathy. Pedersen (2013) describes alternative medicine as ‘treatment not usually offered within the ordinary health service and without public support or control, but offered on a fee-for-service basis by non-authorised practitioners with varying types of training and certification.’ (p.56). While Pedersen's definition makes a useful reference to the political economy of CAM – to which we will return – it is restrictive in focusing only on delivery by practitioners. By contrast, Wardle et al. (2016) distinguish between CAM as employed under the guidance of a specific practitioner, and CAM as self-prescribed and utilised, paying attention to both. The Cochrane collaboration definition extends to considering “accompanying theories and beliefs” that travel with “healing resources” outside the “politically dominant health system” (Zollman and Vickers, 1999, 693). We employ a very broad definition to describe both the modalities of specific practitioners and parent-directed use of supplements and traditional remedies. We focus specifically on parental perceptions and experiences of CAM, whilst recognising that parents undertake a much wider variety of activities to promote the health and wellbeing of their children. Finally, although CAM and biomedicine are distinct paradigms (or, as we will go on to characterize them, part of distinct expert systems), CAM is often a supplemental form of health care, rather than an alternative; many CAM users also use biomedicine (Browne et al., 2015, Stokley et al., 2008). An Australian study found that 69% of a representative sample had visited a CAM provider in the last 12 months (Xue et al., 2007), yet we know from Australia's vaccination coverage of 93% that most of the parents amongst this sample would still be vaccinating their children. Nevertheless, Australian data clearly shows that seeking vaccination information from CAM providers makes parents more likely to be vaccine hesitant or refusers (Chow et al., 2017), hence the relationship invites deeper analysis.
A spectrum of vaccine acceptance extends from active demand and full vaccination to complete rejection of all vaccines. Vaccine hesitancy falls in the middle, where people may experience doubt and uncertainty and either fully or partially vaccinate. Parents in this study range from vaccine hesitant to vaccine rejecting. In a previous paper, we analysed how such parents view and (dis)trust expert systems pertaining to vaccination. This amounted to, in many cases, a rejection of Western medical epistemology itself and, consequently, some or all vaccines (Attwell et al., 2017). This article explores the flipside of this. Intimate with parents' distrust, we instead seek to understand their trust in alternative modalities. Accordingly, we have reanalysed the data to investigate how and why parents used CAM, why they considered it beneficial or trustworthy (unlike Western medicine) and how – if at all – they digested the notion that CAM, like pharmaceutical companies, operates for-profit. We explore these factors in relation to individual parents’ rejection of some or all scheduled vaccines.
Section snippets
Methods
Data were collected in Fremantle, Western Australia (WA) and Adelaide, South Australia (SA). The data arose from the collation of two, originally independent qualitative research projects, conducted by researchers who subsequently joined forces after identifying common project aims and methods (during the final phase of data collection in SA). Both studies employed semi-structured interviews with parents who were not vaccinating, partially vaccinating or had delayed some vaccinations for their
Results
In total, 29 parents were interviewed: 9 from WA (by KA) and 20 from SA (by PR). The majority were women (n=26). The age range was 25–50 years; 19 were between 36 and 42. Over half of the parents held a university qualification. Participants included 13 parents who had never vaccinated (NV), 5 who had ceased (CV), 7 who were delaying or partially vaccinating – ‘incompletely vaccinated’ (IV), and 4 who had delayed, but who were now up-to-date (V). Three participants were qualified or student CAM
Discussion
The relationship between CAM and vaccine refusal is not linear. While Navin (2016) suggests that vaccine rejecters replace biomedical expertise with more appealing and aligned CAM providers, it would be inaccurate to assume that CAM therefore neatly replaces vaccination. Some participants did not mention CAM at all in terms of their vaccination decision-making – and this included rejecters of all vaccines – while others rejected particular modalities. For those parents who embraced it, however,
Conclusion
This article sought to understand the relationship between CAM use and vaccine hesitancy or refusal, considering CAM as part of an expert system running counter to Western medical epistemology. We found a symbiotic relationship between CAM and vaccine rejection – for DIY-minded parents who value their agency and ‘reify the natural,’ the two practices prove interactive and complementary, but neither is responsible for the other. CAM was not a replacement for vaccination; instead, it was a
Acknowledgements
Expert advice was sought from Jon Wardle, author of the review discussed here. The Fremantle data was gathered by Katie Attwell while working for the Immunisation Alliance of Western Australia, a not-for-profit immunisation advocacy organisation. The Alliance received funding from Sanofi Pasteur in the form of a $20,000 unrestricted grant to develop and evaluate the I Immunise campaign, which itself was funded by the Department of Health, Western Australia and is described in a separate paper (
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