Initially 28 orthodox protestant families were approached, one family did not participate because of practical constraints. From 27 families, we interviewed one or both parents: 21 mothers, 3 fathers, and 3 couples. The families belonged to various denominations and 13 families started vaccinating their children. Further details are shown in Table .
Characteristics of orthodox protestant parents participating in study
The decision-making process: tradition versus deliberate choice
The majority of parents decided around the birth of their first child on whether or not they would take part in the National Immunization Program. With regard to the vaccination decision-making process, two subgroups of parents could be distinguished: parents who followed tradition versus parents who made a deliberate choice.
The parents who followed tradition did not go through an explicit decision-making process. They hardly discussed the topic of vaccination and simply did the same as their parents. If they came from a non-vaccinating family, they refused vaccination; if they came from a vaccinating family, they agreed to vaccination.
"“We were both a member of the same type of congregation; that makes difference. You have been given the same values. It was no longer a point of discussion.” (Respondent 5, traditionally non-vaccinating family)"
"“Yes, did we really think about it? We didn’t really consciously think about it because both of us have also been vaccinated. You just continue on, really … I wouldn’t know of anyone in my family who hasn’t done it.”(Respondent 11, traditionally vaccinating family)"
Those parents who made a deliberate choice considered both to vaccinate and not to vaccinate. Although the man is the head of the family in orthodox Protestantism, in the cases in our study of making a deliberate decision, the decision was mostly made by the two parents after lengthy discussion. Some of the couples making a deliberate choice first discussed the topic with their parents or asked their friends’ opinion. None of the participants making a deliberate choice discussed the topic with the religious leaders of their churches. Personal religious experiences were sometimes reported to play an important role in their final decisions, however. Many of the parents making a deliberate choice prayed to God to help them with their decision and some reported having received a sign from God.
"“… I thus put my bible down on the seat of the car and, just before I got to the Public Health Building, I opened up the bible and there it stood, that the stuff that is given may be used. Things were clear for me then.” (Respondent 13)"
For both parents who followed tradition and parents who made a deliberate choice, the vaccination decision was made for all children to come. Although some parents reported reconsidering the decision with the birth of every new child, this did not lead to a different decision. Moreover, all of the parents agreed that the parents are responsible for the vaccination decisions as long as the children live in their homes; the children take on responsibility when they come of age and marry.
The final decision: four subgroups of parents and their arguments
When the nature of the vaccination decision-making process is considered together with the final outcome regarding participation in the National Immunization Program (i.e., vaccination) or not, four subgroups of orthodox protestant parents could be distinguished:
1) parents who followed tradition and refused vaccination,
2) parents who made a deliberate choice and decided against vaccination,
3) parents who made a deliberate choice and decided in favor of vaccination, and
4) parents who followed tradition and agreed to vaccination.
The characteristics of the respondents in each subgroup are summarized in Table .
The subgroups are described in more detail below.
Traditionally non-vaccinating parents
The traditionally non-vaccinating parents all belonged to denominations with low vaccination coverage. They referred to religious doctrine to explain their refusal of vaccination. Man should not interfere with divine providence and man cannot interfere with divine providence because God is almighty. The timing of a medical intervention is of critical importance for them: Preventive measures are not accepted while curative and palliative measures often are.
"“Whether I have my children vaccinated or not does not matter to me because I don’t believe in it. I believe that if God wants to spare my children from an accident, then He will spare them from it.” (Respondent 1)"
"“This is even strengthened by all that I have been through….You can simply see that you have nothing to say.” (Respondent 26)"
"“Because we believe that there is a God who steers our lives and leads us and that we should not get ahead of his deeds. We cannot predict what he brings or does not bring upon us.” (Respondent 16)"
Tetanus post-exposure prophylaxis was typically considered a cure and thus accepted by these parents. Some of the traditional non-vaccinating parents in our study therefore also accepted polio vaccination in the case of an epidemic. When faced with immediate danger, vaccination was no longer considered preventive by them.
"“I can remember when polio was rampant; you could be given a sugar cube with the virus, that is what they recommended and many of us — including myself — swallowed such a cube. But there was a real danger then. And that’s something different, in my opinion.”(Respondent 24)"
Apart from their religious objections, the traditionally non-vaccinating parents sometimes had concerns about vaccine safety and particularly about the disease-inducing properties of vaccines, however they reported these concerns were not decisive. They were still used to the presence of infectious childhood diseases like mumps and measles, which they did not consider very serious.
"“You don’t have any complaint or any disease. And then you inject something that makes your child sick.” (Respondent 16)"
"“But a childhood disease…to immunize against it? Looking at the children, they simply come down with it. I also had it earlier myself. And you get over it; it’s just part of things.” (Respondent 9)"
Deliberately non-vaccinating parents
Deliberately non-vaccinating parents often live in a community with both vaccinating and non-vaccinating orthodox Protestants, for example, one of the spouses has been vaccinated while the other has not. These parents also used predominantly religious arguments but mostly in connection with their trust in God. Even if God sends a disease, he has a purpose for it. The personal relationship with God plays a major role in the decision to not vaccinate; the parents put all their trust in God. Such experiences as life-threatening diseases only enhance one’s relationship with God. Deliberately non-vaccinating parents stress the significance of the disease rather than deny the medical effectiveness of vaccination.
"“I know for sure that God cares for me. And that the things He sends me, that may also be disease, that He will help me to cope with it.” (Respondent 23)"
"“I mean, I say to myself afterwards — I hope that I never have to go through this again — but it has been really good for our family, our marriage, but also our religious life. Through this we live closer to God.” (Respondent 10)"
"“And purely without looking at the bible, I have to say that it looks like the vaccination program has had paid off as far as the immunization goes.”(Respondent 23)"
In contrast to the other deliberately non-vaccinating parents, one orthodox protestant couple – both from a traditionally vaccinating background- decided against vaccination of their children for non-religious reasons; they were convinced that vaccines could have major side-effects and therefore preferred their children to acquire immunity by conquering infections with the aid of homeopathy.
Deliberately vaccinating parents
The deliberately vaccinating parents were mostly not vaccinated themselves. After lengthy discussions, they decided to break with a longstanding tradition in their families.Although they cite the medical benefits of vaccination, they used predominantly religious arguments to justify their decision to vaccinate. They consider vaccination a gift from God to be used in gratitude. However, in the interviews, they elaborated more on the counterarguments to the religious objections to vaccination than on their own arguments in favor of vaccination. These parents reported that, after thinking things over, they could not see any good reason to not vaccinate.
"“Yes, you may use the means that are there and I am convinced that it says in the bible that the Lord Jesus himself also says at a given point that … you have flat roofs in Israel, and then he says that fences should be put around them because otherwise they fall off.” (Respondent 7)"
"“For me, the Lord is not bound to vaccination. Then I would think of God in much too little terms. If he was bound to vaccination. If he really wants something to happen to us, then he is not dependent on vaccination.”(Respondent 13)"
"“I simply lack the faith; I don’t have it. When you hear some stories or read some books, they have such a faith…But that faith, I don’t have it.” (Respondent 22)"
"“Because you want to protect your children against everything…” (Respondent 8)"
Traditionally vaccinating parents
Traditionally vaccinating parents were vaccinated themselves and did not see any religious objections to vaccination. They did not relate the issue of vaccination to their belief in God. Medical arguments were used to justify their decision. If they had any doubts about vaccination, these concerned the possible adverse effects of the immunization itself.
"“I cannot say that I know someone who does not do it. I have the idea that by us in the church, certainly here, that it’s simply accepted….I also cannot think up any arguments for why it should not be allowed.”(Respondent 15)"
"“I have also thus seen that you should not underestimate these illnesses….but I think then, well, what does it do with the immune system of your child?”(Respondent 9)"
Many orthodox protestant parents feared to regret their decision on vaccination in future. The traditionally and deliberately non-vaccinating parents both considered epidemics — and particularly polio epidemics — to be an ordeal and feared that their faith would not be sufficiently strong to endure it. But most of all, they feared their children possibly becoming severely ill and dying.
"[In case of a polio epidemic] I think that I would end up in a real dip. The struggle then begins. Maybe I should have [vaccinated them]; then they would have maybe [not have become ill]…(Respondent 1, traditionally non-vaccinating family)"
"[In case of a polio epidemic] I would really find it horrible if one of my children or my husband would get it, I really would. I cannot bear to think of it. And I count on being spared of this. I would try to explain later to my child why I didn’t do it, purely on the basis of faith. (Respondent 10, deliberately non-vaccinating family)"
On the other hand “first generation” deliberately vaccinating parents feared the adverse effects of vaccination as these are taken as a sign from God that they have made the wrong decision. Two deliberately vaccinating parents, for example, stopped the vaccination series when unexpected medical events arose. In one case, the daughter still came down with the measles after being vaccinated. In the other case, serious adverse effects arose but were later found to be the symptoms of an underlying disease. In light of apparent adverse vaccination effects, the mother did not dare to continue vaccination. In her opinion and in response to her prayers, she had received a sign from God to stop vaccination.
"“Imagine that the decision is wrong. Just a bit of fear, because you made a decision on rational grounds but more than just the rational may be at play. You read, of course, about the possible effects and, certainly when I first had her vaccinated, I found it scary. You break with something you grew up with.”(Respondent 21)"
"“And I was really shocked by that… I didn’t dare to talk with anyone about it simply because I, myself, thought that I had done it. I found the guilt on my part to be so heavy…, that I really didn’t talk to anyone about it…(Respondent 4)"
"Now, yeah, I wanted to know for sure for myself whether I could continue or not. I didn’t know for myself but also didn’t dare to anymore[…] and then I prayed specifically: “Lord, if you want us to no longer vaccinate, then let the oldest who has had all the vaccinations get the mumps. Now, a couple of weeks later, he came down with the mumps. I was certain about things then. (Respondent 4)"
Referring to the generally very high vaccination coverage in The Netherlands, some non-vaccinating parents reported discussions with colleagues or neighbors who did not understand their objections to vaccination. On the other hand, some of the deliberately vaccinating parents — particularly those living in a largely non-vaccinating community — mentioned feeling uncomfortable in light of social control. They did not dare to speak of their decision to vaccinate with members of the congregation or even family members.
"“Because if there’s the mumps or the measles, that’s the talk of the day at school and they ask out of interest if we have already had them. I don’t tell them that we’ve been vaccinated then but simply say nothing. I just walk a bit further up if I notice that they’re talking about it.” (Respondent 22, deliberately vaccinating family)"
Only the traditionally vaccinating parents did not report any psychosocial consequences of their decision to vaccinate.