This study explored factors that influenced vaccination decision-making among parents with an anthroposophical worldview. Our findings show that parents in this study did not refuse all Dutch NIP vaccinations, but mostly refused the MMR vaccination. The participants made a deliberate decision whether or not to vaccinate. This is not in line with 81% of Dutch parents who are reported to make no comparative assessment of vaccinations [16
]. The vaccination decisions of parents in this study are related to their lifestyle, perception of health, beliefs about childhood diseases, risk perception of the diseases, perceptions about vaccine components and vaccine effectiveness, and trust in institutions.
A previous study indicated that there is limited time for consultations at CWCs and therefore limited time to discuss childhood vaccination with parents [13
]. This does not apply to parents who visit an anthroposophical CWC. All parents in this study indicated that they had positive experiences when visiting an anthroposophical CWC and mentioned that the consultations were longer and they were provided with more information. Some parents had had a negative experience at a standard CWC and indicated that standard CWCs are not flexible enough with regard to the Dutch NIP. These negative experiences may have resulted in their reluctance to accept the Dutch NIP and PHI guidance.
Parents in this study are not fully opposed to childhood vaccination. Mostly these parents refuse the MMR vaccination because they perceive measles, mumps, and rubella to be childhood diseases that are essential for the physical and mental development of their child. This is consistent with findings among anthroposophists by Duffell (2001) [10
]. The rejection of the MMR vaccination is also reflected in lower vaccination coverage for the MMR vaccine [6
] and outbreaks of measles among anthroposophists [6
]. Another factor that influences parents' choice whether or not to vaccinate is the low perceived risk of the vaccine-preventable diseases, which is also shown in other studies [17
]. In addition, this study shows that the perceived severity of a disease seems to be more important than the perceived susceptibility to that disease. Parents indicated that they were aware of the possible negative outcomes of not vaccinating their child and were willing to take responsibility for those outcomes.
Most Dutch NIP vaccinations are combination vaccines. The parents were quite negative about the combination vaccines because of the perceived overload of the immune system (an anxiety also felt by parents who accepted all childhood vaccination [20
]) and because it limits their choices in vaccinating (parents can only vaccinate their children with combination vaccines and cannot choose separate vaccines). This point of view seems in line with wishes of anthroposophical CVPs to offer a flexible schedule and no combination vaccines [13
], while CVPs at a regular CWC were positive about the combination vaccines because of their efficiency [13
]. Some studies mentioned that another important factor for refusing vaccination is the side effects [2
]. The parents in our study were specifically concerned about the negative effects of the vaccine components. Besides that, some parents in this study had doubts about the efficacy of the vaccines. The findings above suggest that determinants that are associated with vaccination decision-making among anthroposophists are comparable to determinants held by parents in general. Only the view about healthy child development and childhood diseases distinguishes the parents in this study from parents in general.
Another topic that is raised by different studies among parents who refuse vaccination is their information need [22
]. Parents in this study indicated they need information about the risks of vaccination as well as the components and effectiveness of the vaccines, and that they would like to receive more detailed scientific information. Not only the parents would like more information, anthroposophical CVPs have also indicated that they need more information to better educate parents [13
]. Parents mentioned the CVPs as the most important source of information about childhood vaccination [25
]. The focus should, therefore, not only be on providing information to parents, but also to CVPs, which would enable them to provide parents with more and better information. In addition, if parents' information needs are not fulfilled, they might start searching for information themselves, with the result that their vaccination decision-making may be influenced by widespread antivaccine messages [27
]. Parents do not always trust the PHI, but the institute is still perceived as the most important, logical, and reliable information source about the Dutch NIP. To increase the reliability of the information provided by the PHI, references should be listed about the information sources used in their education material.
It should be mentioned that this study has some limitations. First, it might be that our study did not reach full saturation [30
]. During the third focus group, no new themes emerged, compared to the former two focus groups, so we assumed that more focus groups were unnecessary but we did not test this by conducting a final focus group. The second limitation of our study is that we have no insight into the parents' demographic variables, like levels of education. A study by Hak et al. (2005) [31
] showed that highly educated parents are more critical towards childhood vaccination. Third, there is potential for moderator bias in this study [32
]. We tried to avoid this by the use of a standardized topic list, an assistant who was present at the focus groups, digital voice recorder, and verbatim transcriptions.
Further quantitative research on perceptions about the (Dutch) NIP is needed to be able to generalize results. The six themes that emerged from these results could be useful for developing quantitative research about parents, and anthroposophical parents in particular, who are critical of childhood vaccination. Quantitative research is also needed to get more insight in which determinants are most important in the decision making of parents with an anthroposophical worldview and whether these determinants are different from determinants influencing vaccine refusal in general.