‘MMR talk’ and vaccination choices: An ethnographic study in Brighton
Introduction
In the UK, the number of parents presenting their children for the combined measles, mumps and rubella (MMR) vaccination has declined significantly during the last 7 years. The MMR issue has become a high-profile example of emergent problems in public engagement with science and technology, frequently dominating media headlines and editorials.1
Amidst the controversy, this paper explores how mothers in Brighton are thinking and deciding about MMR for their infants. Certain parents came to attribute autism-like symptoms in their children to MMR vaccination in the early 1990s (Mills, 2002). Arguably, their views gained credence from clinical studies (Wakefield et al., 1998; Uhlmann et al., 2002). Subsequent studies considering the incidence of autism in relation to MMR among larger populations claim not to show an association (e.g., Taylor et al., 1999; DeWilde, Carey, Richards, Hilton, & Cook, 2001; Fombonne, 2001; see Miller, 2002, and Jefferson, Price, Demicheli, & Bianco, 2003, for reviews). The debate turns, in part, on the significance attributed to epidemiological as opposed to clinical evidence, and on the status attributed to parents’ own observations. Indeed some parents and scientists argue that while most epidemiological studies focus on autism in general, these children have a particular, distinct disease (e.g., Thrower, 2003). Support networks for parents concerned about MMR-damage (eg., Jabs, ARCH) have, through the internet, become focal points for information sharing and comparative parental experience, forging a ‘citizen science’ that has engaged with similarly interested clinical scientists in the UK and elsewhere.
As medical, popular and media debate have unfolded, parental engagement with the MMR vaccination has altered. Despite assurances of MMR safety in the scientific literature and by the British Department of Health (DH), and information campaigns aimed at parents, uptake continues to decline in many areas, and by early 2004, for children aged 24 months, stood at 79.8% for the UK and 71% for the city of Brighton and Hove (HPA, 2004). As some parents opted to have the MMR components separately, a second debate emerged concerning whether these should be provided through the NHS, privately, or not at all.
In interpreting parents’ reactions, a predominant view is that they misunderstand the science involved, and thus misperceive the supposed autism risk (e.g., Elliman & Bedford, 2001). Non-vaccination thus reflects misinformation or ignorance which needs correction by the provision of scientific information—the cornerstone of the DH strategy (Department of Health, 2001; NHS, 2004).
Other studies focus on the role of pressure groups in ‘misinforming’ the public. Thus André (2003), for example, suggests that ‘a small group of the so-called educated in developed countries’, who constitute an ‘anti-vaccination movement’ has been misclassifying health events after vaccination as vaccine reactions. Fitzpatrick (2004) makes this argument in relation to MMR. Baker emphasises the key role of pressure groups amidst divided medical opinion during the British pertussis vaccine controversy in the 1980s (Baker, 2003). The literature on anti-vaccination movements emphasises not only their long history, but also their articulation of wider social and political concerns. Durbach (2000), for example, links dissent to smallpox vaccine in the 1880s with working class movements, although Porter and Porter (1988) emphasise greater social diversity in movement concerns even at this time. While some argue that a UK anti-vaccination movement has gradually developed over the last century (Baker, 2003), others point to significant changes in social and political context and agendas (Fitzpatrick, 2004).
Associated arguments hold that mass-media coverage miscommunicates and amplifies risks to public. Amidst increasing journalistic coverage of vaccine issues and ‘scares’ in the 1990s (Cookson, 2002), it is argued that public anxiety about MMR has been fueled by—even created by—media bias and styles (e.g., Ramsay, Yarwood, Lewis, Campbell, & White, 2002; Hargreaves, Lewis, & Spears, 2002; Science Media Centre, 2002).
Studies addressing the ‘knowledge, attitudes and beliefs’ of parents have focused particularly on perceptions of the benefits and risks of immunisations, and sources of information about these. For example, the DH commissions regular attitudinal surveys in random locations across England. From these, Ramsay et al. (2002) indicate that 67% of mothers perceive the MMR as safe or to carry only slight risk; variations over preceding years were understood as linked to media coverage. They conclude that
…the fall in MMR coverage has been relatively small, mothers’ attitudes to MMR remain positive, and most continue to seek advice on immunisation from health professionals. As the vast majority of mothers are willing to have future children fully immunised, we believe that health professionals should be able to use the available scientific evidence to help to maintain MMR coverage. (Ramsay et al., 2002, p. 912).
Pareek and Pattinson (2000) surveyed attitudes and beliefs with similar findings and conclusions. Both these studies also linked attitudes with social variables such as age, education, marital status, ethnicity, and class, associating (at least early) concern over MMR with those from higher socio-economic grades.
Other studies go beyond individual beliefs and social status to consider how culture, and social and political processes, shape parents’ immunisation dilemmas and practices. Thus, Streefland, Chowdhury, and Ramos-Jimenez (1999) relate vaccination uptake to (a) how vaccination engages with local knowledge, aetiologies and perceptions of disease, and (b) specific socio-cultural contexts and experiences of interaction between people and health care providers, which together constitute ‘local vaccination cultures’ (Streefland et al., 1999, p. 1707). Studies of this genre have associated vaccination refusal with particular social groups having ‘alternative’ lifestyles and philosophical outlooks (e.g., Rogers & Pilgrim, 1995).
Some such works address political dimensions to cultural experience, including people's confidence and trust in engaging with health institutions. In medicine (Williams & Calnan, 1996; Gabe, Kelleher, & Williams, 1994), as around other scientific issues (e.g., Beck, 1992; Irwin & Wynne, 1996), it is suggested the public increasingly treat ‘official’ views with skepticism, questioning the institutional positions, funding and wider political or social control agendas of those promoting technologies. Such critique is visible in some strands of the anti-vaccination literature (Scheibner, 1993; McTaggart, 2000; Coulter, 1990). Low confidence and trust in vaccine information sources have been linked with vaccination refusal in the case of both Pertussis (Meszaros et al., 1996) and MMR (Evans et al., 2001). Some parents’ skepticism over claims of MMR safety have been linked to their perception that GPs are ‘paid to immunise’, or that supportive scientific research is biased by pharmaceutical company funding (Evans et al., 2001). Nevertheless, other evidence suggests that doctors are trusted more than any other group.2
These cultural, social and political perspectives suggest that parental reflection on MMR may fail to match the narrow, risk-based framings dominant in public health. Especially where disagreements amongst experts prevail, they may frame the issue in terms not of risk (involving calculable probabilities among known outcomes) but of uncertainty (see Hobson-West, 2003).
In Evans et al.'s (2001) focus group study, all participants found the MMR decision difficult and stressful, while immunisers and non-immunisers shared many views, questioning the strong analytical distinction that other studies have drawn between them. This study, like Petts and Niemeyer's (2003), goes further, however, to suggest that parental engagement with MMR is part of a wider social world, in which issues of respect, authority and social relations shape decisions, although their group-based methodologies constrain full exploration of these.
To set parental engagement with MMR within the wider social world of which it has become a part, our research examined parents’ personal experiences and reflections within the unfolding social processes and relationships in which they are involved. The research combined detailed narratives that enabled mothers to speak widely around the issue and reflect what they regarded as most important (see Mattingly & Garro, 2002, on narrative approaches), with participant observation and short, informal discussions. The latter considered how people talk about MMR amongst themselves, and how such talk is shaped by, and shapes, social context. Our approach also focused on the interactions between particular health professionals and parents, allowing exploration of the social and political relations underlying categories such as ‘trust’, and of how they broker more personal concerns with professional directives.
Section snippets
Study methodology
The city of Brighton and Hove, on England's south coast, was chosen for the study due to its particularly sharp decline in MMR coverage, its locality to the researchers and the interest shown by local public health professionals. This university town in the UK's relatively affluent south east has become increasingly popular as both a tourist destination and by commuters moving from London. The last census (2001) reveals a relatively youthful and mobile population (ONS, 2001; CEPT, 2004). Of the
Discussion
Our ethnographic and biographical approach has shown how parental engagement with MMR is part of an unfolding of experiences in relation to child health and institutions, and is shaped by other aspects of these experiences. In focusing on mothers’ narratives, we have neither attempted to address the gender dynamics around MMR choice nor sought to relate MMR talk and practice systematically to social categories such as class, gender and education. Both these dimensions are addressed in the
Acknowledgements
We would like to thank the parents, health professionals and local institutions in Brighton who participated in and helped facilitate this study. The study is part of a comparative project on ‘Childhood Vaccination: science and public engagement in international perspective’ funded by the Economic and Social Research Council (ESRC) Science in Society Research Programme, and we are grateful for this support. We would like to thank the members of the study's Stakeholder Advisory Panel: Graham
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