ARTICLE

Qualitative Analysis of Mothers’ Decision-Making

About Vaccines for Infants: The Importance of Trust
Andrea L. Benin, MDa,b, Daryl J. Wisler-Scher, MDb,c, Eve Colson, MDb, Eugene D. Shapiro, MDb,d, Eric S. Holmboe, MDe

aRobert Wood Johnson Clinical Scholars Program, bDepartment of Pediatrics, and dDepartment of Epidemiology and Public Health and General Clinical Research Center,
Yale University School of Medicine, New Haven, Connecticut; cDepartment of Pediatrics, School of Medicine, Columbia University, New York, New York; eAmerican Board
of Internal Medicine, Philadelphia, Pennsylvania

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
BACKGROUND. The high visibility of controversies regarding vaccination makes it
increasingly important to understand how parents decide whether to vaccinate
www.pediatrics.org/cgi/doi/10.1542/
their infants. peds.2005-1728
OBJECTIVE. The purpose of this research was to investigate decision-making about doi:10.1542/peds.2005-1728
vaccinations for infants. Dr Benin is independent of any commercial
funder, had full access to all of the data in
DESIGN. We conducted qualitative, open-ended interviews. the study, and takes responsibility for the
integrity of the data and the accuracy of
PARTICIPANTS. Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 the data analysis.

months. Key Words

immunizations, vaccination, attitudes,
parents, qualitative research
RESULTS. We addressed 3 topics: attitudes to vaccination, knowledge about vaccina-
Accepted for publication Oct 17, 2005
tion, and decision-making. Mothers who intended to have their infants vaccinated
Address correspondence to Andrea L. Benin,
(“vaccinators,” n ⫽ 25) either agreed with or did not question vaccination or they MD, 789 Howard Ave, New Haven, CT 06519.
accepted vaccination but had significant concerns. Mothers who did not intend to E-mail: andrea.benin@yale.edu

vaccinate (“nonvaccinators,” n ⫽ 8) either completely rejected vaccination or they PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2006 by the
purposely delayed vaccinating/chose only some vaccines. Knowledge about which American Academy of Pediatrics
vaccines are recommended for children was poor among both vaccinators and
nonvaccinators. The theme of trust in the medical profession was the central
concept that underpinned all of the themes about decision-making. Promoters of
vaccination included trusting the pediatrician, feeling satisfied by the pediatrician’s
discussion about vaccines, not wanting to diverge from the cultural norm, and
wanting to adhere to the social contact. Inhibitors included feeling alienated by or
unable to trust the pediatrician, having a trusting relationship with an influential
homeopath/naturopath or other person who did not believe in vaccinating, worry
about permanent side effects, beliefs that vaccine-preventable diseases are not
serious, and feeling that since other children are vaccinated their child is not at
risk.

CONCLUSION. Trust or lack of trust and a relationship with a pediatrician or another

influential person were pivotal for decision-making of new mothers about vacci-

1532 BENIN et al
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nating their children. Attempts to work with mothers May 2002 to July 2003. English-speaking mothers with
who are concerned about vaccinating their infants infants healthy enough to be in a level 1 nursery and
should focus not only on providing facts about vaccines who delivered at the Yale-New Haven Hospital (New
but also on developing trusting and positive relation- Haven, CT) or who delivered at home in the care of 1 of
ships. 2 participating midwifery practices in Connecticut were
eligible for the study. If hospitalized, mothers were ap-
proached for inclusion during their hospitalization at a
G IVEN THE HIGH visibility in the media of controver-
sies about vaccination of infants, it is important to
understand how parents decide whether to vaccinate
time when they were not receiving narcotic pain medi-
cations or needing more than routine medical care.
Mothers who were recruited through midwifery prac-
their children to be able to communicate appropriately
tices were identified before their delivery; after they
with parents about vaccinations.1–10 Previous studies
delivered, the interviewer went to their homes to per-
have identified important promoters and inhibiters of
form the interviews. We chose to interview mothers of
parents’ acceptance of vaccines.11–18 Promoters have in-
newborns, because parents face a decision about vacci-
cluded the desire to prevent disease,11 a belief in the
nation against hepatitis B shortly after the birth of their
social contract (the desire to help the community by
child, and we wanted them to be actively involved in the
participating in herd immunity, also called “altruism”),12
decision-making process at the time of the interview. We
and the desire to do what is the cultural norm/what
also wanted to be able to explore the degree to which
most other people do (also called “bandwagoning”).12
mothers may make decisions about vaccination while
Inhibitors have included a fear of harming their child,18
they are pregnant.
adhering to a reversed social contract (feeling that their
As is frequently done in qualitative research,20,22,25,26
unvaccinated child is not at risk for disease, because
we used purposeful sampling with a random compo-
most other children are vaccinated, also called “free-
nent. To ensure saturation of themes related to non-
riding”),12,15 a preference for making acts of omission
vaccination and trust, once we had interviewed 2 pilot
over acts of commission (preferring not to have acted
mothers and 15 mothers selected randomly, we
when there is any risk to the action),15,16,19 a perceived
switched to a purposeful sampling of black mothers and
ability to control their child’s susceptibility to and out-
of mothers who did not want to vaccinate their infants.
come of the disease,15 a low perceived susceptibility to
Black mothers were sampled randomly from mothers
disease,18 a belief that it is better to develop immunity
who delivered in the hospital and who indicated on their
from disease than from vaccination,18 doubts about the
admission sheet that they were black. Mothers who did
reliability of information about vaccines,15,18 and a fear
not want to vaccinate their infants were referred by
that too many immunizations may be dangerous.11,18
midwives or by pediatricians; all who were referred were
Existing studies11–18 have been largely quantitative or
included. Only 2 mothers whom we approached refused
based on hypothetical decision-making about vaccina-
to participate; they refused because of inconvenient tim-
tion and, thus, may not have adequately elicited the
ing. This type of purposeful sampling is appropriate for
comprehensive range of mothers’ attitudes in the way
qualitative work, because the goal is to select informa-
that a qualitative study can. Qualitative research pro-
tion-rich cases who will “illuminate the questions under
vides a framework for describing social phenomena,
study” (not to select a probability-based sample).26
such as comprehension and behaviors, that are based on
Mothers were enrolled until no new concepts were
complex beliefs that may be difficult to measure in a
identified by the additional interviews, that is, until the
standardized quantitative manner.20–23 A qualitative ap-
point of “theoretical saturation,”22: (1) no new or rele-
proach is based in inductive reasoning whereby hypoth-
vant data seem to emerge regarding a category, (2) the
eses are drawn from observations (in contrast to deduc-
category is well developed in terms of its properties and
tive or hypothesis-testing methods).24 This approach
dimensions demonstrating variation, and (3) the rela-
allows for the generation of hypotheses that can subse-
tionships among categories are well established and val-
quently be tested in a quantitative manner.24 We sought
idated.22 The study was approved by the Institutional
to use qualitative methodology to describe the full range
Review Board at Yale University School of Medicine.
of mothers’ attitudes about vaccinating their children
Informed consent was obtained from all of the mothers
and the promoters and inhibitors of mothers’ acceptance
before the interviews.
of vaccinations during the time when mothers are ac-
tively deciding whether to vaccinate their infants.
Data Collection
METHODS
First Interview
Study Design and Sample For the first phase of the study, 1 author (A.L.B., a
The study was a qualitative study based on a 2-phase white, female pediatrician), conducted in-depth, open-
open-ended interview of 33 postpartum mothers from ended interviews23,27,28 in person with postpartum moth-

PEDIATRICS Volume 117, Number 5, May 2006 1533

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ers during their immediate postpartum period. The in-
terviewer was not involved in the medical care of the
participants. Open-ended questions assessed mothers’
attitudes about vaccination, their concerns about vacci-
nation, and the sources they used to obtain information
about vaccination. Questions included general questions
about how parents felt about vaccinating their infant, for
example, “How do you feel about vaccinating your in-
fant?” “What do you see as the benefits of vaccinating
your new infant?” and “What do you see as the risks of
vaccinating your new infant?” We also included several
questions designed to elicit how mothers obtained infor-
mation about vaccines and how they wanted to obtain
information: “Where do you get information about vac-
cines?” and “What information do you want about vac-
cines?” Closed-ended questions elicited information
about demographics, number of children, plans for vac-
cination, general health practices, and knowledge about
vaccination.
Follow-up Interview
For the second phase of the study, the same interviewer
performed open-ended interviews by telephone when
the child was between 3 and 6 months old. The fol-
low-up interview reassessed knowledge and attitudes
about vaccination, as well as sources of information
used. By the time of follow-up, children should have
received ⱖ1 set of vaccinations if they were going to get
them. Questions focused on parents’ experiences related
to vaccinating their infants and their interactions with
the medical system related to vaccination. The main
questions included, “Tell me about your experience
when you took your infant to the doctor to get shots/
went for a checkup (for those refusing vaccinations)?”
“How did you feel about it?” “Did you have any con-
cerns? What were they?” and “Tell me how you felt
about the process of deciding whether to vaccinate.”
For both the first and the follow-up interviews, we
used standardized interview guides with probes and fol-
low-up questions to elicit detail and clarification. We
audio taped all of the interviews, including those by
telephone, and the tapes were transcribed in their en-
tirety by an independent transcriptionist.
Evaluation of Knowledge
Questions regarding knowledge about vaccines were
asked after both the first and the follow-up interviews.
With the first interview, 10 multiple-choice questions
inquired about common adverse effects of vaccines,
about common controversies about vaccines, and about
which vaccines parents had heard about and thought
their child might either get or have gotten. The focus of
the questions was intended to explore mothers’ recog-
nition of the names of vaccines and the diseases pre-
vented. With the follow-up interview, a subset of 6 of
the 10 questions was repeated. Before asking these ques-
1534 BENIN et al
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tions, without prompting, we asked mothers to list the
names of the vaccines their child had received. In addi-
tion, as one measure of how many mothers in this group
held misconceptions about vaccines, we counted how
many mothers spontaneously offered erroneous infor-
mation during the open-ended interviews.
Data Analysis
We analyzed transcribed data by using common coding
techniques for qualitative data and the methods of
grounded theory.20,22,23,26,27 In this process, we read the
transcripts of the interviews and identified themes
within the mothers’ answers. Using these themes that
we identified, we generated a structured classification of
codes. We coded the data in a series of iterative steps,
and we revised and refined the code structure multiple
times as we developed new insights and elicited new
relationships between the themes present in the moth-
ers’ comments. To develop the code structure, 2 mem-
bers of the research team (A.L.B. and D.J.S.) indepen-
dently read each of the transcripts line-by-line,
abstracted key themes and ideas, and coded each of the
transcripts. They then met and assigned final codes
through a negotiated process. During its development,
the code structure was reviewed and refined multiple
times by the full research team. Once coded, we entered
data into a software package (NUD*IST, QSR N6, Don-
caster, Victoria, Australia) designed to manage unstruc-
tured, qualitative data. This software aids in the cata-
loguing of and reporting of supporting quotations.
Interviews lasted between ⬃30 minutes and 2 hours.
After the analysis was completed in that the coding
structure and classification schema was fully developed
and all of the transcripts had been analyzed, 2 members
of the research team (A.L.B. and D.J.S.) independently
reread all of the transcripts, recoded them using the
main subset of the coding structure (56 codes), and
classified mothers into categories. The researchers then
met and assigned final codes and classification together,
resolving differences through negotiation. By this stage,
independently, the researchers had virtually complete
agreement on coding and classification. This recoding
process provided a check of validity as a form of “mul-
tiple coding,” a technique by which independent re-
searchers code an interview so that coding strategies can
be cross-checked.29 To ensure that our analyses were
systematic and verifiable,20,23 we used interview guides,
audio taping of the interviews, and transcription by an
independent transcriptionist, as well as detailed docu-
mentation of analytic decisions and changes in the cod-
ing structure.
As a way to characterize knowledge about vaccina-
tion by mothers in the study, we tallied correct responses
and used the Wilcoxon rank-sum test with a 2-tailed P
value to compare the median number of correct re-
sponses between each group of mothers and the group
of mothers who were vaccine acceptors.
RESULTS
We interviewed 33 mothers 19 to 43 years old (median:
32 years; interquartile range: 26 –35 years) from both
suburban and inner-city areas of Connecticut; 10 (33%)
were primigravida. The majority, 22 (67%), were white,
8 (30%) were black, and 3 (9%) were Hispanic. Nine
(30%) received assistance from the Women, Infants, and
Children program. We were able to reach 19 (58%) for
follow-up interviews.
Attitudes About Vaccination
Based on a combination of mothers’ actions and the
attitudes that they expressed during the interviews, we
categorized mothers into 2 main groups: “vaccinators” (n
⫽ 25) or “nonvaccinators” (n ⫽ 8; Fig 1). These catego-
ries of vaccinators and nonvaccinators were further sub-
divided into 4 categories. Vaccinators were subdivided
into: (1) “accepters,” mothers who agreed with or did
not question vaccination (n ⫽ 20); or (2) “vaccine-hes-
itant mothers,” mothers who accepted vaccination but
had significant concerns about vaccinating their infants
(n ⫽ 5). Nonvaccinators were subclassified as (3) “late
vaccinators,” mothers who either purposely delayed vac-
cinating or chose only some vaccines (n ⫽ 3); or (4)
“rejecters,” mothers who completely rejected vaccina-
tion (n ⫽ 5). These categories are depicted in Fig 1 as
occurring along a continuum, because mothers ex-
pressed ranges of attitudes that did not fit simply into
discrete categories but rather occurred along a spectrum.
Mothers who were categorized as vaccine-hesitant
and those who were categorized as late vaccinators com-
prised the middle of the continuum (Fig 1). These 2
groups of mothers were very similar to each other with
respect to their desire for knowledge and their approach
to obtaining information. We chose the themes impor-
tant to these mothers in the middle of the continuum
to be the focus of the data that we are reporting here
because they sought information from their pediatric
providers and because they expressed a clear interest in
obtaining information about vaccines. We hypothesize
that they are the most amenable to improved contact
with traditional pediatric and public health providers. In
contrast, mothers who were nonvaccinators on the far
right end of the spectrum seemed less amenable to, or
FIGURE 1
Attitudes about vaccination: a continuum.
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interested in, such contact; they cited, for example, that
they did not vaccinate because it says not to in the Bible
or “to keep their bloodline pure.”
Knowledge About Vaccination
Sixteen mothers spontaneously offered erroneous infor-
mation during the open-ended interviews (8 vaccinators
and 8 nonvaccinators). Examples of erroneous informa-
tion included but were not limited to: a belief that their
3- to 6-month-old infant had received vaccines against
chicken pox, smallpox, or measles, mumps, and rubella;
a belief that they themselves had received a vaccination
against chicken pox as a child and subsequently devel-
oped disease with chickenpox regardless of that vacci-
nation; a belief that their infant could become infected
with the human immunodeficiency virus from vaccines;
a belief that vitamin K is a vaccine; and a belief that
infants develop influenza from the influenza vaccine.
Mothers had poor knowledge about which vaccines
children receive. At the time of the first interview, only
2 mothers could identify even 1 of the vaccines that are
recommended at 2 months of age from a list of possible
vaccines that was included as part of the multiple-choice
questions that followed the interview (Tables 1 and 2).
During the follow-up interview, in response to the open-
ended question (ie, mothers received no prompting),
“what vaccines has your child received?” only 2 of the
mothers who had reported that they had vaccinated
their infants could correctly name ⱖ1 of the 5 vaccines
their child would have received. Mothers frequently
named chicken pox and measles, mumps, and rubella
vaccines, vaccines that their child would not have re-
ceived because all of the interviews were done by 6
months of age, and those vaccines are administered
later.
In response to the closed-ended multiple-choice
questions that followed the first interview, mothers in
this study who were late vaccinators answered most of
the 10 multiple-choice questions correctly (median: 9;
range: 6 –9; P ⫽ .014 versus vaccine acceptors), mothers
in this study who were vaccine-hesitant answered a
median of 6 correctly (range: 4 –7; P ⫽ .048 versus
vaccine acceptors), mothers in this study who were re-
jecters answered a median 5.5 correctly (range: 1–9; P ⫽
.93 versus vaccine acceptors), and mothers in this study
who were vaccine accepters answered the fewest ques-
tions correctly (median: 4; range: 2–9; reference group).
Domains Associated With Decision-Making About Vaccination
We identified 3 main domains related to decision-mak-
ing about vaccination: (1) mothers’ key sources of infor-
mation, (2) promoters of accepting vaccination, and (3)
inhibitors of accepting vaccination. We focused on how
mothers’ attitudes about vaccination aligned with these
domains with particular emphasis on the issues that
PEDIATRICS Volume 117, Number 5, May 2006 1535
 TABLE 1 Questions About Knowledge: First Interview (N ⴝ 29)
Question (Correct Answer in Parentheses) No. With Each Answer
Correct Incorrect Not Sure
True/false
Any vaccination/shot can cause a bruise. (true) 18 4 7
Multiple choice (4 choices)
Which of these vaccines prevents meningitis? (Hib) 9 4 16
Which of these vaccines prevents whooping cough? (pertussis/DTaP) 11 5 9
Which of these is a proven adverse effect of the MMR vaccine? (fever) 17 3c 9
Which of these vaccines prevents liver damage and liver cancer? (HepB) 22 1 6
Which of these vaccines prevents a type of paralysis? (polio) 26 1 2
Which statement describes the rotavirus vaccine?a 5 1 22
Which statement describes thimerosal? 8 0 21
Multiple choice (choose all that apply from a list of 14 real vaccines and
1 false vaccine)
Choose vaccines typically given at 2 months of age (choosing any 2 8d 19
1 correctly without choosing an incorrect also)
Choose all vaccines heard of (choosing ⱖ5 real vaccines from list) 28b 0 0
Hib indicates Haemophilus influenzae serotype b vaccine; DTaP, diphtheria, tetanus, pertussis vaccine; HepB, hepatitis B vaccine; MMR, measles,
mumps, rubella vaccine.
a n ⫽ 28.

b One mother selected “none” and 2 selected the false vaccine in addition to correct vaccines.

c All 3 chose autism (2 were nonvaccinators).

d MMR (6), chickenpox (3), smallpox (3).

TABLE 2 Questions About Knowledge: Follow-up Interview (N ⴝ 19)

Question (Correct Answer in Parentheses)
Correct Incorrect Not Sure
True/false
Any vaccine can cause a bruise? (True)
Multiple choice (4 choices)
Which of these vaccines prevents meningitis?
(Hib)
Which of these vaccines prevents whooping
cough? (pertussis/DTaP)
Which of these is a proven side effect of the
MMR vaccine? (fever)
Which of these vaccines prevents liver
damage and liver cancer? (HepB)
Which of these vaccines prevents a type of
paralysis? (polio)
Hib indicates Haemophilus influenzae serotype b vaccine; DTaP, diphtheria, tetanus, pertussis
vaccine; HepB, hepatitis B vaccine; MMR, measles, mumps, rubella vaccine.
a One chose autism.
were relevant to the mothers in the middle of the con-
tinuum (Fig 1) because of their desire for more informa-
tion and their expressed willingness to consider addi-
tional discussion regarding vaccinations. We found that
the themes elicited from our conversations with mothers
all revolved around the central concept of trust and
whom mothers had decided to trust regarding vaccina-
tion.
Key Sources of Information
Fig 2 shows the key characteristics of mothers with
regard to sources of information about vaccination. For
mothers who were vaccinators and the subset of non-
vaccinating mothers who were late vaccinators, the pre-
No. With Each Answer
14 4 1
9 0 10
10 0 9
11 1a 7
16 0 3 FIGURE 2
Key sources of information about vaccination according to attitude about vaccination
(information most relevant for mothers who were vaccine-hesitant and late vaccinators).
17 0 2
ferred, trusted source of information was the pediatri-
cian. For nonvaccinators, the preferred, trusted sources
of information were the homeopath or naturopath, the
Internet, books, and Mothering magazine. Mothering: The
Magazine of Natural Family Living is a bimonthly maga-
zine that “celebrates the experience of parenthood as
worthy of one’s best efforts and fosters awareness of the
immense importance and value of parenthood and fam-
ily life in the development of the full human potential of
parents and children.”30 It regularly includes articles
both in favor of and opposed to vaccination and is
known to have a readership that includes a high propor-
tion of nonvaccinators.15
As depicted in Fig 2, the preferred sources of infor-
mation among nonvaccinating mothers who were late
vaccinators overlapped with that of the vaccinators.
These late vaccinators often expressed conflicting feel-
ings about how to get their questions answered and

1536 BENIN et al
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whom to trust. For example, 1 mother who was a late
vaccinator described the many sources of information
she had tried and expressed her lack of satisfaction with
the resulting information:
“I’ve gotten some information from the baby care
books…. From peers, too, friends…. Getting information
about why the vaccination schedule is the way it is, no
one can seem to really answer for me, even my doctor.
I’ve asked my doctors that question…. I really haven’t
gotten a really good answer…. I feel like I can’t get really
solid information.”
In direct contrast to how these mothers felt, those moth-
ers who were vaccinators had decided to trust the doc-
tor. For example, one mother said, “You know I
really … feel that I’ve made a decision to trust our pe-
diatrician … So that, you know, I’m kind of ceding the
responsibility of getting more information over to them,
trusting her.” These mothers did not want too much
information, because they trusted the doctor.
Because of the implications for planning the best tim-
ing for approaching mothers with information about
vaccinations, we questioned mothers about when they
sought information and when they made their decisions
regarding vaccination. Except for some mothers who
were vaccine acceptors, mothers sought information
while they were pregnant and had decided about
whether to vaccinate during their pregnancy. The fol-
lowing is a quote from a woman discussing her desire to
have information prenatally.
“I think it should be prior [to delivery] because you
never know what’s going to happen…. So I think if you
have information beforehand…. It’s like, ‘OK, got the
information on this. I know it. If they come to me and
ask me if there’s something I want to do, I can make a
decision.’ ”
Promoters of Accepting Vaccination
Overwhelmingly, we found that for vaccinators, the
main promoter of accepting vaccination was trusting the
doctor (Table 3). As one mother phrased it, “I don’t
know enough about how [vaccines] are put together
and tested to have a confidence level about that. But
that’s where the doctors come and you have to trust
them.”
Another important promoter was feeling satisfied by
the pediatrician’s discussion about vaccination, which
led to trusting that pediatrician. In particular, vaccina-
tors who were vaccine-hesitant recounted positive, often
lengthy discussions with the pediatrician.
“[The pediatrician] respected the fact that … we wanted
to sit and talk for an hour and a half about vaccina-
tions…. And he stayed very late one night … it wasn’t
something that they could charge us for…. And it’s a
very busy practice. It wasn’t as if he needed to solicit our
business.”
Part of being able to trust their pediatrician was find-
ing that their pediatrician was able to answer their ques-
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TABLE 3 Promoters and Inhibitors of Accepting Vaccination
Promoters of accepting vaccination
Vaccinators
Trusting the doctor
Feeling satisfied by the pediatrician’s discussion
Feeling that vaccinating is the cultural norm
Believing in the social contract
Having positive past experiences with vaccines
Wanting to prevent disease
Inhibitors of accepting vaccination
Vaccinators
Fearing mistakes being made
Both vaccinators and nonvaccinators
Believing children get the disease anyway (especially chicken pox and
influenza)
Believing that vaccine-preventable diseases are not so bad (eg, chicken
pox)
Nonvaccinators
Feeling alienated by and distrusting the pediatrician
Having a previous negative experience with the medical establishment
resulting in distrust
Having a trusting relationship with an influential naturopath/homeopath
or other person who supported not vaccinating
Distrusting the doctor’s information: doctor does not know and does not
have the time
Distrusting motives: vaccination is just a money-maker for pediatricians
and vaccine industry
Believing that diseases are not around, are not serious, or are easily
treatable
Worrying about permanent adverse effects (eg, autism)
Feeling that since other children are vaccinated their child is not at risk
(“reverse social contract”)
tions satisfactorily and completely. Mothers needed to
feel as though their pediatrician was knowledgeable and
had all of the relevant information.
Other promoters included a perception that vaccinat-
ing was a “cultural norm” and not wanting to depart
from that norm (also called “bandwagoning”12), believ-
ing in the social contract, mothers’ past experiences with
diseases and vaccines for themselves or for older chil-
dren, and wanting to prevent disease in their child (Ta-
ble 3).
Inhibitors of Accepting Vaccination
Vaccinators and nonvaccinators expressed a fear of mis-
takes being made, and several mothers described in-
stances when their child had received the wrong vaccine
and how this event made them question their trust in
the pediatrician. For both vaccinators and nonvaccina-
tors, inhibitors included the belief that their child would
get the diseases anyway, especially chicken pox and
influenza. Mothers also believed that vaccine-prevent-
able diseases are “not so bad”; a sizeable number of
mothers (12) cited chicken pox in this regard.
For nonvaccinators, the list of inhibitors to vaccina-
tion was lengthy. Inhibitors that were important to late
vaccinators are shown in Table 1. There were a number
of other inhibitors mentioned by only a few mothers or
PEDIATRICS Volume 117, Number 5, May 2006 1537
by those on the far end of the continuum that we have
not included here.
Most nonvaccinators expressed a sense of feeling
alienated by the pediatrician and/or the medical estab-
lishment, for example, “You just feel really painted into
a corner and there’s really no support in the medical
community. I went through … a dozen doctors who
were just being like, ‘I will not treat you if you’re not
going to vaccinate your child.’ ” Alienation was tightly
tied to their loss of trust in the pediatrician and the
medical establishment. They were not able to enter a
trusting relationship, yet they clearly were seeking such
relationships with traditional pediatrics. Six of the 8
nonvaccinators expressed a clear desire to have a trust-
ing relationship with a traditional pediatrician and had
sought such relationships but had been turned away.
The following are quotes from 2 different mothers.
“Because we wanted to find a pediatrician … I called 4
different pediatric groups that were listed in my medical
insurance book and all 4 of them said they would not see
my child…. I had nurses on the phone who would nor-
mally book appointments. My question was, ‘Do you
have a pediatrician who would be willing to discuss with
us, to vaccinate or not to vaccinate?’ She was like, ‘How
could you do that to your child?’ ”
“I’m very comfortable that they [the medical establish-
ment] have a wonderful place in what they’ve done and
in what’s possible and certainly would want to be an
American citizen with access to medical hospitals
here … when it comes down to it … I would love to
have access to the health care that we have here.”
Several nonvaccinating mothers distrusted traditional
medical care because of negative previous experiences
with the medical establishment in general, such as mis-
diagnoses or poor communication about a diagnosis.
Instead, nonvaccinating mothers ended up having a
trusting relationship with an influential naturopath or
homeopath or another person who supported not vac-
cinating.
“I really trust my homeopath. She’s amazing … she is
like one of my number one sources on this topic.
She … keeps herself really updated in this since it’s her
passion…. Her clarity and the volume of information
that she has on antivaccination is so compelling that you
want to be like, ‘OK, I’ll never vaccinate. I’ll never, ever
vaccinate.’ ”
In direct contrast to this manner in which mothers who
were nonvaccinators felt that their homeopath ex-
plained immunizations with passion and expertise, these
mothers found that the doctors left them feeling as
though they could not trust the doctor’s information, the
doctors did not have adequate knowledge about vac-
cines, and the doctors did not have time to talk about
vaccines. “But [the doctors] don’t have the answers for
me to these specific questions [about vaccines]…. I like
them a lot, but I don’t think they have the time or the
motivation to find me the answers.”
1538 BENIN et al
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Many of these mothers distrusted the motives of pe-
diatricians and the medical establishment and explained
that vaccination was exclusively for making money for
pediatricians and the vaccine industry, as one mother
described:
“What I would like to see is that pediatricians are edu-
cated more on the potential detrimental side to the vac-
cine program and not financially rewarded for giving
[vaccines]…. I mean, in Connecticut, there’s a financial
reward given to pediatricians who have a full vaccine
record.”
Inhibitors for nonvaccinators also included fears about
permanent adverse effects, such as autism, sudden in-
fant death syndrome, AIDS, and other immune diseases.
Moreover, nonvaccinators expressed a belief that vac-
cine-preventable diseases are nonexistent, are not seri-
ous, and are easily treatable.
“I’m not overly concerned with the incidence of these
diseases…. My infant is not at risk for tetanus right
now…. My doctor said that, if we lived on a farm, he
would recommend that she get tetanus right away. But
we don’t live on a farm…. And as far as the diphtheria,
there’s no diphtheria…. To give her diphtheria, it’s like
the same argument with the polio.”
What we have called the “reverse social contract” also
acted as an inhibitor: mothers felt that because most
other children are vaccinated, their child was not at risk
for vaccine-preventable diseases (also called “free-
riding”12).
Qualities of Trustworthy Relationships
Both mothers who were vaccinators and those who
were nonvaccinators described qualities of a trustworthy
health care provider. These qualities included spending a
long period of time with them, discussing the subject of
vaccines in a passionate manner, having a large amount
of scientific information, using a “whole-person” ap-
proach, behaving in a manner that was not patronizing,
and treating mothers/infants as individuals with individ-
ual needs.
DISCUSSION
We developed a schema classifying mothers’ attitudes to
vaccination and described their attitudes as existing
along a continuum: mothers were vaccine accepters,
vaccine-hesitant, late vaccinators, or vaccine rejecters,
similar to a conceptualization developed independently
by Gust et al31 and published after we completed our
analysis. This characterization of the continuum of atti-
tudes to vaccination can be used to help pediatricians
formulate how to approach individual patients and to
help public health programs tailor messages for the
mothers in the middle of the continuum (mothers who
are vaccine-hesitant and late vaccinators). These moth-
ers in the middle of the continuum have significant
concerns about vaccination, are interested in obtaining
information, and play an active role in deciding whether
to immunize their infants.
Trust or lack of trust and relationships were main
determinants of mothers’ decisions about vaccination;
this reliance on trust was especially impressive, because
mothers perceived that “diseases are not around” or are
“not so bad,” and they had little experience with vac-
cine-preventable diseases. Medical knowledge was not
the main driver of vaccination: mothers in this study
who were most knowledgeable about vaccination were
those in the middle of the continuum (possibly because
they had the most concerns and, accordingly, had sought
out information).
Discussions about vaccination can be one of the first
opportunities to form a trusting relationship between
parents and pediatricians. Communication about risks
and benefits of vaccines has been the typical approach to
this interaction32,33 and is legally mandated.34,35 However,
this communication does not always meet parents’
needs, and the dialogue between parents and pediatri-
cians on this subject is not always trusting and open, as
evidenced by studies showing that approximately one
quarter of pediatricians do not allow patients in their
practice whose parents refused vaccinations.36,37
Our findings indicate that relying only on dissemina-
tion of medical knowledge to parents in itself is not a
satisfactory approach to communication regarding vac-
cines. Instead, discussions with the mothers who were in
the middle of the continuum of attitudes to vaccination
suggest that pediatric health care providers may need to
focus both on developing trusting, open relationships
and also on providing factual, scientific information
about vaccines and vaccine controversies. As found in
other studies,11,17 mothers, including many nonvaccina-
tors, looked to their pediatric providers for information
about vaccines. Yet, when we spoke with mothers who
actively sought information from the traditional medical
establishment, there were clear differences in the quality
of the experiences with the pediatric-care provider be-
tween those mothers who chose to vaccinate (mothers
who were vaccine-hesitant) and those who did not
(mothers who were late vaccinators). Mothers who vac-
cinated had found a pediatric provider who could an-
swer their questions in detail and spend time with them.
In contrast, those who did not vaccinate had a pediatric
provider who did not know the answers to their ques-
tions about vaccine controversies, who could not spend
time with them, or who treated them condescendingly.
Many of these mothers had found a passionate, trust-
worthy homeopath or naturopath who could offer them
detailed, scientifically based information against vacci-
nating.
Mothers identified as more trustworthy those rela-
tionships in which their providers expressed a passion
about vaccination, seemed knowledgeable, were able to
offer satisfactory answers to questions that were asked,
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did not act condescending or rushed, and treated them
like an individual. These factors fall into the domain of
trust in physicians that is referred to as “trust in compe-
tence.”38–41 Perception of competence is a primary com-
ponent of patients’ trust in physicians; yet, because most
patients cannot directly assess their physician’s compe-
tence, interpersonal skills and communication style
largely determine how patients perceive their physician
in this domain.39,41 Unfortunately there are little data on
how to successfully intervene to improve patients’ trust
of physicians.40
Having a vaccine program that relies to such a large
extent on trust leaves it vulnerable. Trust can be fragile
in the face of scandals, conflicts of interest in the profes-
sion, and proliferation of negative information, even
false negative information.33 In lieu of trust alone, com-
munication with parents and the public about risks and
benefits of vaccines has been proposed as a means to
strengthen immunization activities.17,32,33,42,43 However,
our data suggest that a more complex picture of com-
munication needs to be developed. Although parents
want to receive information on vaccination from their
pediatrician,11 pediatricians have very little time to spend
discussing vaccination.44,45 Moreover, it is hard to com-
municate about risk with patients,42,46 and, specifically, it
is hard to educate parents about vaccines.44,47,48 This
study provides a broader context through which to ap-
proach communication about vaccination. These moth-
ers suggest that developing trusting relationships regard-
ing vaccination may include not establishing policies of
excluding nonvaccinators from pediatric practices; hav-
ing a detailed understanding of vaccine controversies
and scandals so that when faced with concerned moth-
ers who are in the middle of the continuum, providers
can address their needs for information; being able to
explain risks and benefits in clear and simple terms,
because most mothers have limited recognition of the
names and diseases that vaccines prevent; and beginning
the process of education about vaccination during preg-
nancy, because concerned mothers decide about vacci-
nation during their pregnancy. Many of these sugges-
tions have also been proposed by other authors,
including the recent statement from the American Acad-
emy of Pediatrics Committee on Bioethics.10,37,49–52 The
question remains unanswered as to how busy pediatric
providers can have time to follow these suggestions. It is
possible that new Current Procedural Terminology codes
for counseling about vaccination are a small step toward
facilitating these efforts.53 In addition, given the reliance
of mothers on providers of alternative medicine, pedia-
tricians and the public health community may consider
forging alliances with these groups, as well as with
groups offering prenatal classes.
Our findings should be considered in light of limita-
tions to the study’s generalizability and validity. We
relied on information from a fairly modest sample of
PEDIATRICS Volume 117, Number 5, May 2006 1539
English-speaking mothers in 1 geographical area; thus,
we cannot ensure that these results would apply nation-
wide. Also, we cannot comment on the relative frequen-
cies of attitudes held by mothers, because, as is appro-
priate for qualitative research, we did not base the study
on a random sample of participants.23 We cannot ex-
clude that there may be alternate valid explanations of
the data we collected;26,54,55 however, we used method-
ologic techniques that were intended to enrich validity:
purposeful sampling, grounded theory, coding by 2 re-
searchers, and a form of multiple coding.26,29,54–58 More-
over, our findings are both credible, as well as consistent
with those of published studies using varied method-
ologic approaches.26,29,31,54–58
We have not addressed the extent to which inher-
ently distrustful attitudes held by nonvaccinators before
they entered into a relationship with a pediatrician af-
fected the development of a trusting relationship. This
issue is particularly relevant because parents who are
less confident about vaccine safety may also be less apt to
follow the advice of their pediatrician in general.17 In-
deed, we propose that some mothers who were vaccine
rejecters on the extreme right of the continuum do hold
inherent beliefs that lead them to reject vaccination
regardless of any interaction with a health care provider.
For example, these mothers told us that they did not
vaccinate “to keep their bloodline pure.” They had low
scores on the questions regarding knowledge about vac-
cinations suggesting that they had not sought informa-
tion about vaccines. Because we found that these moth-
ers did not seem amenable to discussing vaccination, we
did not concentrate this report on them. Instead we
focused on mothers, both vaccinators and nonvaccina-
tors, in the middle of the continuum, mothers who told
us that they had sought information from pediatric pro-
viders, desired information from pediatric providers, or
desired to be included in the mainstream medical sys-
tem. Although some of these mothers may be inherently
distrustful of the medical system, we hypothesize that
they are interested in, and would benefit from, being
included in open discussions about vaccination.
In this study, we synthesized the factors found in
previous studies11–17,31,49,50 with newly found/emphasized
factors and placed them into a broad conceptual frame-
work. These data suggest that attempts to work with
mothers who are concerned about vaccinating their in-
fants should focus on developing positive relationships
in addition to providing facts about vaccines.
ACKNOWLEDGMENTS
This work was supported in part by a grant from the
National Institutes of Health (K24-AI01703), by the Yale
General Clinical Research Centers Program of the Na-
tional Center for Research Resources, National Institutes
of Health (M01-RR06022), and by the Robert Wood
Johnson Clinical Scholars Program.
1540 BENIN et al
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We thank the mothers who spent their precious post-
partum hours discussing vaccination with us, the mid-
wives who generously referred their patients to us, and
Drs Marjorie Rosenthal and Elizabeth Bradley for their
thoughtful comments.
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PEDIATRICS Volume 117, Number 5, May 2006 1541
Qualitative Analysis of Mothers' Decision-Making About Vaccines for Infants:
The Importance of Trust
Andrea L. Benin, Daryl J. Wisler-Scher, Eve Colson, Eugene D. Shapiro and Eric S.
Holmboe
Pediatrics 2006;117;1532
DOI: 10.1542/peds.2005-1728

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Qualitative Analysis of Mothers' Decision-Making About Vaccines for Infants:
The Importance of Trust
Andrea L. Benin, Daryl J. Wisler-Scher, Eve Colson, Eugene D. Shapiro and Eric S.
Holmboe
Pediatrics 2006;117;1532
DOI: 10.1542/peds.2005-1728

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