Elisa J. Sobo Department of Anthropology San Diego State University ([email protected])
Social Cultivation of Vaccine Refusal and Delay among Waldorf (Steiner) School Parents U.S. media reports suggest that vastly disproportionate numbers of un- and undervaccinated children attend Waldorf (private alternative) schools. After confirming this statistically, I analyzed qualitative and quantitative vaccination-related data provided by parents from a well-established U.S. Waldorf school. In Europe, Waldorf-related non-vaccination is associated with anthroposophy (a worldview foundational to Waldorf education)—but that was not the case here. Nor was simple ignorance to blame: Parents were highly educated and dedicated to self-education regarding child health. They saw vaccination as variously unnecessary, toxic, developmentally inappropriate, and profit driven. Some vaccine caution likely predated matriculation, but notable post-enrollment refusal increases provided evidence of the socially cultivated nature of vaccine refusal in the Waldorf school setting. Vaccine caution was nourished and intensified by an institutionalized emphasis on alternative information and by school community norms lauding vaccine refusal and masking uptake. Implications for intervention are explored. [immunization, vaccination, anthroposophy, child health, cultural cognition]
Introduction The case for pediatric vaccination seems self-evident. In the United States alone, “among children born during 1994–2013, vaccination will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 deaths . . . at a net savings of $295 billion in direct costs and $1.38 trillion in total societal costs” (Whitney et al. 2011:352). Experts say no other public health effort except sanitized water has had such a major and beneficial impact (Pollard 2007). However, kindergarten vaccination rates—the standard measure of uptake—indicate that not everyone agrees. Although certain vaccinations are required for kindergarten entrance, the number of parents filing personal belief exemptions (PBEs; waivers to enable enrollment for un- and under-vaccinated children without religious or medical contraindications) has increased in recent years, particularly in states with lenient PBE regulations (Omer et al. 2009, 2012). This is not an access issue: Exemptions are highest in MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 29, Issue 3, pp. 381–399, ISSN 0745C 2015 by the American Anthropological Association. All rights 5194, online ISSN 1548-1387. reserved. DOI: 10.1111/maq.12214
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private schools, whose average PBE rate is 6.10% compared to 2.79% in public schools (Shaw et al. 2014). Averages, however, conceal variation. Although one in 10 U.S. children are educated in private schools, a close look at PBE rate variation among private schools has not been taken (see Shaw et al. 2014). My research begins to correct for this by focusing on vaccine refusal and delay in a Waldorf school setting. Waldorf schools offer an increasingly popular form of alternative education and they are thought to account for a notably disproportionate share of PBEs. At the California Waldorf school that hosted my research, the PBE rate was 51%—10 times higher than the state’s private school average (5.2%; Lee and Abanilla N.d.). To help explain this PBE rate and inform interventions to change it, after demonstrating empirically and for the first time that U.S. Waldorf school students in general are significantly disproportionately likely to have PBEs, I describe results from a qualitative content analysis of narrative data from one Waldorf school’s parents. Following Leach and Fairhead (2007), I highlight extant local knowledge and expectations, asking what parents strive for through vaccine refusal and delay. I also ask why the school seems to attract vaccine-cautious parents and I consider, quantitatively as well as qualitatively, whether and how some of its social mechanisms foster increased vaccine refusal after families join. The findings have important practical implications.
Background Western culture today emphasizes active, informed health care consumerism, in which patients—and parents—are responsible for educating themselves so that they may make wise health care choices (e.g., Henderson and Petersen 2001:2–3; Lee et al. 2010). This “burden of responsible consumption” (Kaufman 2010:23) infuses Western parents’ experience with pediatric vaccination (see Leach and Fairhead 2007; Silverman 2010). That said, why are some parents more concerned about vaccines than vaccine-preventable diseases? What can be done to counter misplaced worries that spur dangerous choices? Some have suggested that scientific illiteracy is the problem. Public understanding of science is imperfect at best. In a 2012 survey administered by the National Science Board, only 33% of a representative U.S. sample correctly answered “scientific process” questions, such as those in regard to experimental design and probability (National Science Board 2014:7–24). Rockhill (2001) finds that people also misunderstand risk factor epidemiology, for instance in conflating “risk factor” with “causal factor.” Moreover, many people use population-level risk factor statistics to predict individual risks, although doing so is unsound. But the assumption that “correct understanding” correlates with “correct action” is specious. First, many who vaccinate do so due to its routinization or from social pressure (Leach and Fairhead 2007:49, 70, 77; see also Nichter and Nichter 1996). Moreover, rather than assuring conformity to scientifically agreed-on positions, high scientific literacy may, in fact, correlate with the contrary—as it does in regard to climate change, particularly for individuals with vested interests (Kahan et al. 2012). High scientific literacy also may intensify vaccine rejectionism (Kahan 2013).
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To understand such counterintuitive findings it is helpful to consider actual vaccine decision-making. Poltorak and colleagues’ research indicates that vaccine decisions depend “not on a singular deliberative calculus and the information and education that informs it, but on contingent and unfolding personal and social circumstances in an evolving engagement” (2005:718). In their multi-methods project, interviewed mothers’ decisions were affected “by personal histories, by birth experiences and related feelings of control, by family health histories, by their readings of their child’s health and particular strengths and vulnerabilities, by particular engagements with health services . . . and by friendships and conversations with others” (p. 709)—vaccine decision-making was a highly social process. Indeed, a recent social network analysis found that parents’ “people networks” greatly affected vaccination decisions (Brunson 2013). The proportion of people in subjects’ people networks who promoted vaccine refusal and delay or nonconformity was the most significant predictor of subjects’ own vaccine nonconformity— even when compared to individual exposure via “source networks” to materials supporting nonconformity and even when compared to subjects’ own perceptions of vaccination. These findings suggest to me that a simple “confirmation bias” (whereby information confirming one’s prior knowledge is selectively, individualistically attended to) is not at work. Rather, this seems an instance of “cultural cognition,” defined as when people match their ideas to those of valued in-group members (members of their people networks) to avoid cognitive dissonance and demonstrate solidarity (Kahan et al. 2012). Cultural cognition intensifies in the presence of “cues of group conflict” and when the ideas in question “distinguish their group from competing ones” (Kahan 2013). When it comes to vaccination, solidarity with one’s people networks may be so important that outsider challenges only strengthen beliefs: In a randomized controlled trial, Nyhan and colleagues (2014) found that information supporting vaccination reduced intent to vaccinate among parents most against vaccination to begin with. This occurred even when parents came to understand correctly that, for example, autism and vaccination are unrelated. Nyhan and colleagues suggest that vaccination rejectors mobilize other objections defensively to maintain their antivaccination stance (2014:e840). Kahan’s (2013) contention that anti-vaccination beliefs index core group values and are important to group-related self-identity, thereby triggering cultural cognition (and so remaining firm) when competing ideas are presented, seems to support Nyhan and colleagues’ suggestion. It remains speculative, however, pending research with a group that explicitly values vaccination refusal—such as may be found in a Waldorf school setting. Vaccination in Waldorf School Communities It has been suggested anecdotally that Waldorf schools host large numbers of students with PBEs. Using publically available records for California, I found that the average Waldorf school PBE rate is 57.2% (median = 54.5%; range: 38%–87%; the state’s private school average is 5.2%). Even more significantly, although Waldorf schools make up 0.01% of the state’s 1969 private schools with PBE rates on file,
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they account for half of the 10 private schools with the highest rates. Also significantly, all 20 Waldorf schools listed are in the top fifth percentile (raw data source: California Department of Health, via Hubert-Allen and Aliferis 2013).1 Why? What makes Waldorf schools different? Waldorf education is rich in the arts, heavy on experiential learning, and light on summative testing (see Petrash 2002; regarding Waldorf early childhood education in particular, see Sobo 2014). Introduced in Germany in 1919 as part of an effort to decouple government interests from education, Waldorf education has grown exponentially since, with public support in some countries and as a private alternative in the United States. With the rise of the charter school movement, and amid the current backlash against standardized testing and the related push for whole-child education, the number of Waldorf-inspired public schools has also burgeoned (Sagarin 2011). Nonetheless, with few exceptions (e.g., Parker-Rees 2011), peer-reviewed research on Waldorf education remains scant. Waldorf pedagogy takes an ostensibly non-interventionist approach to learning, contending that academic skills emerge as a child is ready. The teacher’s job, accordingly, is to scaffold and optimize this process rather than to impart “knowledge.” To this end, Waldorf school environments are as “natural” as possible, with wood furnishings, organic comestibles, and no electronics. Waldorf pedagogy has its roots in anthroposophy, a holistic philosophy promoted by Waldorf education’s founder, Rudolf Steiner (1861–1925). Anthroposophy, often glossed as “the wisdom of humankind,” offers a path to self-development resting on the assumption that a nonmaterial or spiritual universe interpenetrates and informs the material one. Anthroposophy is not taught in Waldorf schools, although it is a basis for them. The role U.S. Waldorf schools have played in vaccine-preventable disease outbreaks has not been scientifically assessed. However, European Waldorf schools have been identified as epidemiological epicenters for measles and other outbreaks (Ernst 2011; Hanratty et al. 2000). The European situation has been explained as stemming from anthroposophy’s teaching that childhood diseases strengthen children physically and mentally and prevent some future illnesses (Ernst 2011). Although Steiner himself did not rule out immunization (see Dietz 2004–2009), anthroposophical physicians do say that fevers and inflammations (i.e., common childhood diseases) help the body break down and extrude old or expired matter and contribute to cell renewal and growth as well as to overall immune system strength (e.g., Dietz 2004–2009; Incao 2004– 2009; compare Duffell 2001). The understanding that vaccinations harm the immune system also has been reported among anthroposophists in the Netherlands (Streefland et al. 1999); some scientific research supports this claim (e.g., Alfven et al. 2005; Alm et al. 1999, 2002; Enriquez et al. 2005; Rosenlund et al. 2009). Open Questions The anthroposophy–vaccine avoidance equation is accepted in Europe. However, whether the same simplistic “cultural beliefs” explanation accounts for high PBE rates in U.S. Waldorf schools remains untested. So does the applicability of a more socially oriented perspective. For instance, we know nothing about the impact of
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Waldorf school community membership on vaccine acceptance over time (i.e., for one’s younger children or in regard to adolescent vaccinations). Likewise, we do not know whether and how Waldorf schools attract vaccine-nonconforming parents to begin with. My work seeks to help fill these gaps and enrich our understanding of the PBE problem by extending prior social anthropological perspectives on vaccine decisionmaking (e.g., Brunson 2013; Leach and Fairhead 2007) to a setting where vaccine refusal and delay actually is common. After asking about anthroposophy’s influence, I attempt to characterize in detail any social mechanisms that may fuel high PBE rates, and to gauge whether cultural cognition is a factor also. If so, this has important implications for intervention.
Methods Site and Sample The school hosting the study was about 30 years old and served 280 pre-K through 12th-grade students, whose ethnic mix was 4% Asian, 3% black or African American, 9% Hispanic or Latino, 60% white, and 24% two or more races. The latter compared to 2.1% countywide. The school does not collect income data, but records show it received 166 tuition assistance applications for 2009–10. Average tuition paid that year was $6,802 (personal communication). The IRB-approved project that findings are drawn from aimed to develop a health survey for Waldorf parents using methods common to such a task: focus groups and interviews. The school served 195 households. To help avoid amassing a biased sample, households were randomly numbered and then resorted numerically.2 Starting with family number one, research assistants (RAs) Sean Tangco and Erik Hendrickson recruited primary caretakers (parents, guardians) using an outreach letter and follow-up phone calls and emails. The RAs assembled two focus groups and conducted six formative and 18 cognitive interviews, stopping when saturation was reached. Focus group members (12) and interviewees (24) were unique, independent subjects. Vaccination was not queried initially. But parents presented vaccination as a central concern, thereby obligating me to attend to it. This article therefore analyzes data that, however rich, emerged as a survey-building by-product.
Data Collection and Analysis Focus groups were convened to jump-start the survey development process. Only two were planned due to the small relative size of the population, from which individual interviewees also would need to be recruited. There were a total of 12 focus group members. After collecting household data forms (self-reports of age, household income, and so on), the RAs asked each group about preventive health practices, dietary and eating habits, allergies, fever treatments, and related health issues.3 Each meeting lasted two hours, with 1.5 hours devoted to narrative data collection.
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Then, six individual formative interviews were conducted to gather narrative data regarding the same topics privately. The quota of six was set in relation to the small population size and the related need to reserve enough participants for subsequent cognitive or “think aloud” interviews. In the latter, participants explained their responses to items proposed by prior participants for the survey. For instance, the draft survey listed all recommended vaccinations (with lay translations of which diseases these were for) and asked whether each child was, given his or her age, completely, partially, or not vaccinated. The draft survey also contained items relating to household dietary practices (e.g., food eaten or avoided), child health indicators (e.g., allergies, weight, screen time), and health promotion practices (e.g., therapies used). Forty cognitive interviews were planned. Data saturation made that unnecessary: We stopped at 18. The mean durations of the formative and cognitive interviews were 71 and 99 minutes, respectively. Narrative data from the focus groups and the formative and cognitive interviews were audio-recorded and transcribed. I reviewed the three data sets as they came in, using standard ethnographically informed content analysis techniques (open and relational coding based on iterative review, theoretical model building, etc.; see Glaser and Strauss 1967; Quinn 2005; Ryan and Bernard 2003; Sobo 2009; Strauss and Corbin 1998). In this way, major themes and subthemes as well as their relationships were identified. The content analysis was enhanced by my first-hand experience as a Waldorf parent. This enabled me to grasp efficiently certain aspects of parent discourse that would have taken an outsider much longer to parse and to produce a culturally sensitive analysis that takes into account internal variation. The analysis also was informed by the quantitative data. I generated descriptive statistics from the household demographic form to describe the sample. I also extracted vaccination answers from the draft surveys when possible, bearing in mind the limitations of self-reports made on a draft instrument.
Findings Each participant represented one Waldorf school household as primary caregiver. Table 1 summarizes participant characteristics. Seventeen participants provided vaccination data on the draft survey (see Table 2). In families with more than one child (e.g., CI-04; CI = cognitive interview), the older child is shown first (to protect privacy, actual ages are undisclosed). The median age on enrollment for older children was four years; younger children often began a little earlier. In Waldorf schools, pre-school extends through age five; six is the standard age for kindergarten. The host school’s kindergarten PBE rate was, as previously noted, 51%. Yet, in Table 2, only two children were totally unvaccinated, and the average child was about two-thirds up to date on his or her vaccines (see Table 2). Moreover, of the nine families with multiple children, five vaccinated their younger children less frequently, suggesting that birth order may predict vaccination status. For instance, Justine (respondent CI-10; all names are pseudonyms) had a 10-year-old child. He was first enrolled at preschool age and was fully
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Table 1.
387
Participant characteristics (N = 36)
Average participant age (years) Gender Female Male Education1 High school or vocational degree Bachelor’s degree Master’s or doctoral degree Average household income1, 2 Average number of children
45 30 6 11 17 8 $119,839 (median = $100,000) 2
1
U.S. Census data show that, nationwide, about three in 10 adults have a bachelor’s degree and about one in 10 have advanced degrees; about one in 10 have not finished even high school (Anonymous 2013). 2 Median household income in California (2007–2011) was $61,632 (U.S. Census Bureau 2013).
vaccinated. Justine’s second child, born after she had become so committed to Waldorf education that she underwent teacher training, is wholly unvaccinated. More typically, when a drop-off in vaccination occurred it was gradual, as, for instance, in Felicia’s family (the last in Table 2). Felicia explained that this occurred in tandem with social learning, through peer networks. She apologized about her oldest child’s immunizations: “I didn’t know any better” (CI-74). As a focus group participant explained, “A lot of people that come [here] have vaccinated their children . . . and then they chose to discontinue” (FG-2; FG = focus group). Another told of vaccinating her older child “in my pre-Waldorf awareness years”; she stopped after “learning more” when she “entered this community” (FG-1). Publically available data confirm the uptick in vaccine refusal subsequent to enrollment. California recently mandated a pertussis (whooping cough) booster (Tdap) for 7th grade. Of the study school’s 70 2011–2013 7th-grade students, 71.43% had PBEs on file.4 The difference between this and the kindergarten rate (51%) has significance: The state’s overall 7th-grade private school Tdap PBE rate did not differ notably from the state’s overall private school kindergarten PBE rate. Thus, the observed increase did not reflect a statewide tendency for parents to slacken when it comes to adolescent vaccinations. Nor did it reflect an exodus of vaccinators prior to 7th grade: While four of the 42 students reported on the household demographic forms were leaving in the fall, these were all high-school transfers.5 Orientation to Child Health Vaccination choices cannot be understood without some knowledge of participants’ overall orientation to child health, which highlighted prevention through “healthy living” and accepting sickness as part of life. As Bertana said of childhood illness: “We look at it as part of the process of growing up and building a strong immune system” (FI-11; FI = Formative Interview).
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Table 2. Required Vaccinations by Family (N = 17) and Child (oldest child first); 2 = fully vaccinated for age, 1 = partially vaccinated, 0 = not vaccinated; total = 10 indicates all vaccinations are up to date
Parent ID
Measles, Diphtheria, Chicken mumps, tetanus, pox Hepatitis rubella pertussis (varicella) B (MMR) Polio (DTaP)
Total score
Younger children, fewer vaccines?
CI-04
0 0
0 0
2 1
0 0
2 1
4 2
Fewer
CI-10
. 0
. 0
. 0
. 0
. 0
101 0
Fewer
CI-12
0 0
0 0
0 0
0 1
0 1
0 2
No change
CI-13
2
.
2
2
2
8
–
CI-14
2
2
2
2
2
10
–
CI-18
1
2
1
1
2
7
–
CI-27
0 0 0
2 2 1
2 2 2
2 2 2
2 2 2
8 8 7
Fewer
CI-28
2
0
2
2
2
8
–
CI-29
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
10 10 10
CI-31
1
2
2
2
2
9
–
CI-45
2
0
2
2
2
8
–
CI-48
0
0
0
2
1
3
–
532
0
0
0
1
2
3
–
CI-63
2 2
2 2
2 2
2 2
2 2
10 10
No change
CI-62
2 1
2 1
2 1
2 1
2 1
10 5
Fewer
CI-72
1 1
1 1
1 1
1 1
1 1
5 5
No change
CI-74
1 0 0
0 0 0
2 1 0
1 1 0
2 2 2
6 4 2
Fewer
0.93
0.96
1.36
1.36
1.64
Averages 1 2
Source: parent narrative. Submitted survey but did not provide cognitive interview.
No change
6.21 N.A. (median = 7)
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Bertana’s use of “we” signifies a sense of collective identity that was clearly articulated by many: “That’s what we are, is community” (FG-1). Participants often explained child health preferences in regard to this community. One father, a self-described “newbie to the Waldorf world,” said he now uses “wood and steel utensils, no more plastic because of Waldorf.” “No television,” he added, “No social media” (CI-28); outside influences were thus curtailed. Participants said: “It’s a lifestyle”—one meant to “keep their children healthier, so they don’t get to the point where they need to go to the doctor” (FG-1). Many parents were cautious about allopathic medicine (which they labeled as such, or as “Western” or “mainstream”). They saw it as shortsighted in “just treating the symptoms” (FI-59). Eduardo warned: “You don’t take something to necessarily to get rid of a headache; you look at what is underlying in the fact that someone is getting headaches” (FI-46). This holistic approach was generally individualistic and favored support versus intervention. Homeopathy was highly endorsed. “Medicine,” in one parent’s words, “should be there to augment the body’s natural process towards health rather than replace the body’s ability to heal itself” (FI-11) or, worse, damage it with “toxins” (FI-68)—to which smaller bodies are more “sensitive” (CI-74). How did parents know these things? “The teachers are really good about educating” (CI-48)—and, more importantly, parents self-educated. As one said, “[I] throw all kinds of pencils and homework upon myself” (FG-1). Advice was shared: Helen, to provide an example, told of a “big information sharing session” regarding food storage containers (CI-12). Information often came from alternative sources thought “not biased by the government or a laboratory” (CI-72). Most parents were “somewhat skeptical of the government and somewhat skeptical of sort of big brother and organized medicine, big medicine, big pharma, that kind of thing” (CI-48). But parents also made assertions like: “I’ll tend to go with something that’s from NIH, and then I’ll even like go and look at some of the things on PubMed” (CI-31). Indeed, “research” often was invoked to authenticate a given health care choice (e.g., “If you look at brain research” [FI-11]; “It is pretty well empirically documented” [FG-2]; “I made that educated choice based on my research” [FG-1]). Several parents referred to schooling or training in explaining their ability to evaluate and digest information. Noted Darlene: “Doctors only go to another four years of education, it’s not much. . . . Are they much more knowledgeable than you? . . . You have to take self-responsibility and I think in a Waldorf community parents take self-responsibility” (FI-59). Parents took pride in their “diligent” and “conscientious” or “conscious parenting” (CI-28, CI-31, FI-17) approach to pediatric care: “Really, I think we delve about as deep as you can” (FG-1). As Helen said, “Waldorf parents . . . really take the time to think about things, like they just don’t go through just taking whatever society or lobbyists gives them, or advertising” (CI-12). Alternative choices were taken to symbolize one’s capacity for independent thinking. In speaking about health, very few participants mentioned anthroposophy spontaneously. In response to its proposed use as a survey item anyhow, many cognitive interviewees said things like: “I do not know enough about it to answer” (CI-31) and “I don’t know the word” (CI-14); indeed, a number struggled with anthroposophy’s
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pronunciation. And when prompted with an open-ended free-list type survey question regarding typical household health practices, only one of the survey-piloting parents entered it (in contrast, most mentioned homeopathy). Nobody mentioned anthroposophy in relation to vaccination. Likewise, nobody cited institutional tolerance for non-vaccination in explaining why they chose the school. In fact, one mother complained in a focus group that the school did not proactively inform parents about the waiver option. The research did not ask why parents chose the school, but many spontaneously mentioned the match between the school’s ethos and their own holistic, “conscious” approach to raising children. Leticia noted that committing to Waldorf education “takes courage” (FI-61) because it is so unconventional; others made similar observations. Vaccination nonconformity was analogous: “It shows that the parents are individual thinkers . . . it takes a lot of work to go against the grain of society” (FI-11). Vaccination-specific Understandings Many parents expressed distaste for vaccines (reflected in Table 2). Ten key reasons for their disuse emerged: the profit motives of those who make, sell, and administer them; foregone benefits of getting a disease naturally; the low general risk for exposure to various vaccine-preventable diseases; individualized exposure risks, the potential severity of a given disease; the physical immaturity of young children; vaccine toxicity; side effects; vaccine failure rates; and, conversely, the idea that because vaccines do work that others will be protected and so one’s own status should not matter. To start, parents often cited suspicions regarding the profit motives of corporations (one said that even the American Academy of Pediatrics was “beholden to companies” and that this was reflected in their endorsements [CI-28]). Parents also often pointed to the otherwise foregone benefits of some diseases for immune system health. As Bertana noted, “[It] would strengthen our children’s immune system to get that disease so why immunize against it?” (FI-11). Another common theme was a perceived low risk for exposure. Here is Bertana again: “If my family lived in Kenya, we would vaccinate our children” (FI-11). Nonetheless, most children had at least some vaccinations. When not attributed to one’s “pre-Waldorfian” ignorance, these were often justified in terms of individualized exposure risks. For instance, Catarina explained: “The reason [my child] has the tetanus is because we have [a farm] and that’s a place where tetanus thrives” (CI-18). Referencing both chances of exposure and an “as needed” orientation toward intervention, Catarina also noted that “city kids don’t need to get it ‘cause it’s not an issue. And you get a tetanus shot if you’re injured anyways. If you get a puncture wound and you go to the hospital.” Some parents considered also the potential severity of a given disease in making a vaccination decision. “You going to risk rabies? Rabies is incurable,” said one parent (FG-1). But when parents wanted vaccines for single diseases, they were often refused (“Apparently [single vaccines are] not stocked very often” [CI-18]). Chicken pox was a favorite foil in arguments against vaccinating for diseases with low perceived severity. Parents often invoked their own childhood experience
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in justifying this. A typical statement was, “Yeah, we all had chicken pox . . . what the heck was the problem?” (FG-1). After joining the school, this parent “stopped [her son’s varicella shots] midway.” Some parents viewed younger, smaller children as ineligible for vaccination because of their general physical immaturity; one participant said Waldorf “parents seem to be more aware of any type of effects to the small bodies, the children’s bodies” (FG-1); another referred to “very heavy-duty things that are not good for a young body” (FG-2). Kat said, “I should wait ‘til they are older to have to manage so much chemical” (FI-39). But even for older children, many parents felt that “vaccines are really toxic” (FI-39). As one parent said regarding toxicity: “If you look at the ingredients of it you would not willingly put that into your child if you knew what was in it” (FG-2). Known side effects also were a concern. As one parent put it, beginning (as was common) with scientistic authorizing rhetoric, “There is a lot of research out there that actually shows that a lot of the vaccines can cause autoimmune disease and allergies, especially food allergies [and . . . ] a lot of learning disabilities” (FG-2). Another parent in the group then clarified (again with reference to experts) that the now-debunked autism link was, in fact, indirect: “If the immune system is not one hundred percent and you get any of these vaccines, it can cause damaging effects.” Likewise, Lou recounted having learned after the fact that “infant immunizations . . . go straight to the brain and so a brain that is already been compromised— [that leads to] seizures” (CI-58). New explanations regarding antecedent conditions were being rallied to replace disproven causal claims (e.g., the MMR–autism link)— without parents having to change sides in the debate. Another point often made was that vaccines fail anyway. For example, validating his information by tracing its genealogy, Ivan said, “I know for a fact that the flu vaccine—I just heard on NPR that it’s just a random guess” (CI-28). In regard to a recent whooping cough outbreak, another parent declared authoritatively: “Probably ninety percent of the people [who contracted pertussis] had been vaccinated . . . and they had it much worse” (FG-2). Simultaneously, vaccine refusal was justified because vaccines do work. As one parent asked, rhetorically: “If you feel like the vaccines are effective and in fact your child got vaccinated, then why are you scared of children that aren’t vaccinated [laughter]? Wouldn’t they be protected under this then? I don’t know [laughter]. I never quite understood that” (FG-2). Rather than looking at the population level, which is where epidemiological risk and vaccine effectiveness really live, this parent used the individual as the unit of analysis. That was, in fact, the norm: Although Waldorf education has a social mission, participants overlooked the plight of disease-vulnerable people.
Social Mechanisms that Sustain Cultural Norms Consensus held that “typical” Waldorf parents “don’t vaccinate” (CI-48). Against this standard, some parents reported a tendency to remain silent regarding mainstream practices such as vaccinating: “There’s prejudice against mainstream medicine” and “there’s pressure to conform” (FG-1). “There’s a vibe,” said Malia,
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describing another parent being warned against allopathic medicine in a way she saw as “presumptuous” (CI-14). The “vibe” is reinforced institutionally, in keeping with the school’s overarching “alternative bent” (FG-1): Recall that even the curriculum was not “what the government says that it should be.” Although the study school does not officially endorse health practices beyond early bedtimes, wholesome foods, lots of outdoor play, and media avoidance, “the culture of the school” (FG-1) looks away from biomedicine. Darlene reported: “The school philosophy actually embraces illness because they believe that when your body has a strong illness, particularly a fever, it precedes a developmental leap in the child” (FI-59). Health-related guest speakers, flyers, and copies of articles passed around always reflected an alternative perspective. Families received “encouragement, kind of like a collective community concern [at the school] like we should be skeptical of what’s out there and we should double check what we are putting into our bodies, and our children’s bodies” (FG-1). Most cast such encouragement as supportive, but Natasha labeled hard-liners “selfabsorbed” and prone to “cramming it down our throat” (CI-13). Given this climate, interviewers were told: “A lot of people . . . don’t speak up about [vaccinating], because they don’t want to be that person who doesn’t follow the Waldorf mentality” (FG-2). Some said they kept silent about allopathic activities to avoid social isolation or evade confrontation (e.g., “I wouldn’t have wanted people to ask me to take [child] off of medication” [CI14]). Paradoxically, keeping mainstream behaviors secret supported belief in their rarity. After a strongly anti-vaccine dialogue in a focus group, one participant did proclaim “I immunize my kids. . . . Many parents that I know immunize their kids here.” But she followed this with an affiliative proclamation regarding how she handles fevers: “I don’t run for the antibiotic or Tylenol—I wait, let the fever go up.” “I have a lot of fights with my parents,” she added, again asserting common cause with school community members versus outsiders: “I’m considered to be very extremist.” Others used similar rhetoric to confirm good “Waldorfian” citizenship; some also invoked freedom of choice to justify vaccination—but freedom to reject mainstream medicine went without saying given the Waldorf school context. As an alternative, vaccinating parents diverted discussion to the quality of education offered. They distanced themselves from “extremist” health views, saying things like “I came to Waldorf despite this issue, kids not being immunized, not because of it” (FG-2). Attraction to the school’s “philosophy of educational values” trumped disagreement with health ideas that were, for these parents, “too far swung” (CI-14).
Discussion The study school had a discordantly high kindergarten PBE rate. Moreover, nonvaccination rates went up post-enrollment. Contra European findings linking vaccine refusal and delay to anthroposophy (e.g., Ernst 2011), this school’s parents generally were unfamiliar with anthroposophy as well as with anthroposophical medicine. Simple lack of information also was not to blame: Study parents were highly educated and took seriously their perceived responsibility for child health; they were actively engaged in health-related self-education. Indeed, this was
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expected of, and encouraged by, school community members. They were far from uninformed. To support an increase in community demand for vaccination, then, we must consider what parents do know and what they desire (see Leach and Fairhead 2007). Moreover, given the inherently social nature of vaccine decision-making (see Brunson 2013; Kahan 2013; Poltorak et al. 2005), we must consider the social mechanisms that reinforce vaccine refusal and delay. Findings indicated that institutionally supported skepticism regarding governmental and corporate interests and parents’ community-promoted self-identity as independent thinkers funneled attention toward alternative information sources. Such sources—which supported talk of vaccine toxicity, ineffectiveness, needlessness (except to those with a profit motive), and developmental inappropriateness for small bodies—were more likely to be publicized within the school community via social networks than were mainstream scientific materials. This was because of community rules favoring alternative perspectives and stigmatizing conventional ones. Parents who vaccinated therefore remained silent about having done so, and information that was circulated never included pro-vaccine messages. Parents who perceived themselves as part of a special community with particular lifestyle expectations were reinforced socially for accepting and further disseminating what they learned from alternative sources. Given that many parents found the school’s “alternative bent” (FG-1) attractive, it is likely that a somewhat larger proportion than normal of preschool students were missing at least some vaccinations upon first enrolling. But enrolling one’s family—joining the school’s community— often intensified vaccine avoidance and even propagated it among previously vaccinating parents. The social fabric of the school served as an incubator, fostering the extraordinarily high PBE rates seen in mandated reportage (51% upon kindergarten entry; 71.5% in 7th grade) and encouraging the noted drop in vaccinations for a family’s younger children. According to these findings, the anti-vaccination stereotype becomes increasingly accurate as the duration of a family’s enrollment increases and the number of one’s enrolled children grows—and as the number of people in one’s people network who disfavor vaccination expands (see Brunson 2013). This increased frequency of vaccine refusal, and the equation between non-vaccination, the independence of mind that it is taken to signify, and Waldorfian identity make it harder and harder to contravene the norm without threatening one’s sense of group membership, or creating cognitive dissonance. Put another way, cultural cognition leads Waldorf parents to make vaccine choices that support locally normative understandings and thereby reinforce favored social ties (see Kahan 2013; Kahan et al. 2012). Implications for Practice Successful intervention may seem impossible in light of findings indicating that, to maintain healthy within-community social relations, Waldorf parents will practice cultural cognition, favoring ideas confirming in-group norms, even when provided so-called correct information. For instance, the Centers for Disease Control and Prevention (CDC) webpage “Why Immunize?” (CDC/NCIRD 2014) contains a Vaccine Safety and Adverse Events link, which reveals that autism and sudden
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infant death syndrome have been concerns and includes sub-links regarding how to report side effects and a safety resources list. These may be taken to support prior doubts. So may the existence of a resource whose title begins “If You Choose Not to Vaccinate Your Child” (CDC 2012), suggesting that opting out is a viable choice. This document, which uses patently neutral language, outlines steps to minimize risks. It states that when there is a vaccine-preventable outbreak, “it may not be too late to get protection by getting vaccinated,” which can be taken as support for a “just in time” approach to vaccination. Given the importance of social relations and cultural cognition’s resultant power, what can be done? Lewandowsky and colleagues (2012) show that cultural cognition can be mitigated if belief-challenging information is presented to people after an experience that affirms their self-worth or core values. But this is tricky. For instance, the CDC’s aforementioned “Why Immunize” page begins by stating it is “reasonable to ask whether it’s really worthwhile to keep vaccinating.” This certainly affirms Waldorf parents’ “think for yourself” ethos. But it also can be taken to suggest that non-vaccination is reasonable. Affirming informed health care consumer engagement more broadly could have forestalled that. For Waldorf parents specifically, core values to be affirmed include the priority placed on children’s schooling and dedication to their health, both of which demonstrate a commitment to good parenting. Lewandowsky and colleagues (2012) also recommend framing specific messages and corrective information in worldview-consonant terms. Anthropologists have long espoused the need for culturally appropriate messaging; Nichter and Nichter’s (1996) work on increasing community demand for vaccination and other public health goods in developing nations by leveraging local perceptions provides a fine example. Nichter and Nichter advocate tailored interventions attending to the finegrained details of what people already do to protect child health and using culturally appropriate analogies in education efforts to better contextualize the information being shared. We must be willing to learn from those targeted; we must shift the parameters of engagement “beyond compliance [toward] partnership” (Nichter and Nichter 1996:xvii). To increase community demand among Waldorf parents, vaccine promotions should leverage parents’ favored ideas and address community concerns. One obvious response to the present findings would be for smaller manufacturers to develop more “natural” and non-industrial vaccination formulations, along with marketing and distribution plans authentically opposed to those of big pharma. More immediately, vaccination intervention efforts should drop the neutral language that implies false equality between vaccination choices and begin deploying culturally consonant imagery. Pro-vaccine messages aimed at Waldorf parents should emphasize how vaccination, booster shots included, help children’s immune systems self-strengthen naturally (vs. working synthetically, or in lieu of the child’s own biology). Analogies also could be drawn from homeopathic medicine here. Moreover, possible “side effects,” such as fever, could be recast as indications of self-strengthening and bodily renewal and as demonstration that the benefits of childhood illness are not being foregone (regarding such in West Africa, see Leach and Fairhead 2007:116). The fact that even fully vaccinated children experience (ostensibly potentially beneficial) febrile illness during childhood anyhow also should
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be highlighted. Messages regarding vaccination series for young teens (e.g., human papillomavirus [HPV], meningococcal conjugate vaccine [MCV4]) as well as catchup shots and boosters (e.g., Tdap) could confirm the maturity of teen bodies and thus the developmental appropriateness of these vaccinations. In light of parents’ cognizance of risk for exposure, messages might target diseases that are statistically more dangerous instead of globally recommending all immunizations when parents are simply not interested in full coverage (yet). The very fact of an outbreak may be used as evidence that now is the time to vaccinate for that particular disease—particularly if high vaccine effectiveness is proven (media coverage of vaccine ineffectiveness will undermine a just in time campaign strategy). Statistics regarding injury and death due to the outbreak can be used to offset any accusations of fear-mongering. Also, because of parent’s distaste for profit motives, factually backed references to the vested interests of people and companies promoting vaccine refusal and delay or alternative substitutes may be helpful. It is also important to know the statistics regarding vaccine-related injuries, including those attributed to purported toxins and to put them into comparative context to demonstrate how favored childhood activities (e.g., climbing trees) or every-day undertakings (e.g., eating carrots) can be, relatively speaking, far more dangerous. Clinicians should have individual vaccines available for parents disinterested in the cocktail approach so that, rather than leaving with nothing, a child might at least get the single vaccination. Reminders that vulnerable individuals need protecting may have value too, given Waldorf education’s high-level orientation toward the public good. “Community immunity” can be referenced, but glib use of the phrase “herd immunity” is ill advised: It can be taken to imply “going along with the herd”—which is not in keeping with the Waldorf ethos. All messages should leave intact parents’ self-conception as “individual thinkers” as well as “conscious” parents (see Lewandowsky et al. 2010). And they should carefully avoid acknowledging that vaccination is a polarizing issue, as this in itself can trigger group-identity confirming cultural cognition (Kahan 2013). Reminding parents that school community belonging has more to do with education than vaccination and is itself proof of one’s independence of mind is key to breaking the grip of cultural cognition on vaccine uptake at Waldorf schools. Publicizing that about half of Waldorf students are fully vaccinated and that total non-vaccination is in fact rare will also be helpful, as should recruiting socially esteemed parents (or teachers and staff) who are pro-vaccination, supporting them in publicly championing vaccination within the school community, and demonstrating that vaccinating one’s children is not inimical to being free thinking or to school community membership. Indeed, because such actions have the potential to dislodge vaccination’s social stigma, these could be the most important practical steps of all.
Conclusion This research advances recent scholarship suggesting that social relations themselves are paramount drivers of vaccine refusal and delay (e.g., Brunson 2013). It does so by providing details regarding the social mechanisms that sustain cultural norms (including through the process of cultural cognition; see Kahan 2013), and by
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demonstrating how social settings can serve as incubators or crucibles, intensifying essentialized or defining group tendencies or values regarding vaccination. U.S. Waldorf schools make a major contribution to un- and under-vaccination (and not because of anthroposophy, contra European findings). Increasing community demand for vaccination in Waldorf school communities requires use of culturally appropriate analogies and strategies that affirm rather than deride Waldorf parents’ core values, which, after all, prioritize child health.
Notes Acknowledgments. Data this article draws on were collected by Research Associates Sean Tangco and Erik Hendrickson as part of a larger project funded in part by a Critical Thinking Grant from San Diego State University. Sam Katzman transcribed group and individual interview recordings, and Samuel Spevack entered the quantitative data collected. I am grateful for this assistance. Highest thanks are due to teachers and staff at the host school for facilitating the research and to parents for their enthusiastic participation. 1. Fisher’s Exact (chi square) Test confirms the statistical significance of these observations, with 2-tailed p-values of 0.032507 and 0.000008 respectively. 2. Not included were households in which the primary caregiver was also a class teacher at the lower school (pre-K through 8th grade), because these teachers were being recruited for another, related study. Also, parents with children in high school only were excluded from the focus group and formative interview subsamples to ensure that the survey was not overly focused on adolescent health. Parents employed at the school also were excluded from the focus groups, to protect against undue self-presentation bias. 3. The questions were: (1) Please tell me what are some health-enhancing or preventive health practices common among Waldorf Families that you think a survey should ask about? (2) What are some things we should ask parents to tell us about their children that will give us a good idea about how healthy the children are? (3) How do Waldorf families’ dietary and eating habits differ from the mainstream American family’s? Why? (4) What kinds of allergies are you seeing among children these days, and why? (5) How do you treat childhood illnesses involving fever? Are there any “shoulds” or “should nots”? (6) Do your children have routine daily or otherwise regular practices of any kind that you hate for them to skip because skipping them is bad for their health? Do they have any therapeutic regimens they follow? (7) What other kinds of health-related practices are there in the Waldorf community, if not your home, that we should think about including in the survey? 4. See http://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationLevels.aspx for data used to calculate this rate (relevant reports are from 2011, 2012, and 2013). 5. Outside of the sample, families have left before high school due to financial pressure or job relocations, to abate a child’s learning difficulties, or to homeschool.
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Rockhill, B. 2001 The Privatization of Risk. American Journal of Public Health 91:365–368. Rosenlund, H., H. Rosenlund, A. Bergstrom, J. S. Alm, J. Swartz, A. Scheynius, M. van ¨ Hage, K. Johansen, B. Brunekreef, E. von Mutius, M. J. Ege, J. Riedler, C. BraunFahrlander, M. Waser, G. Pershagen, and the PARSIFAL Study Group ¨ 2009 Allergic Disease and Atopic Sensitization in Children in Relation to Measles Vaccination and Measles Infection. Pediatrics 123:771–778. Ryan, G. W., and H. R. Bernard 2003 Techniques to Identify Themes. Field Methods 15:85–109. Sagarin, S. K. 2011 The Story of Waldorf Education in the United States: Past, Present, and Future. Great Barrington, MA: Steinerbooks. Shaw, J., B. Tserenpuntsag, L.-A. McNutt, and N. Halsey 2014 United States Private Schools Have Higher Rates of Exemptions to School Immunization Requirements than Public Schools. Pediatrics 165:129–133. Silverman, G. 2010 H1N1 Vaccination and the Moral Identities of Parents. Presented at the 109th Annual Meeting of the American Anthropological Association. New Orleans, November 15–20. Sobo, E. J. 2009 Culture and Meaning in Health Services Research: A Practical Field Guide. Walnut Creek, CA: Left Coast Press, Inc. 2014. Play’s Relation to Health and Well Being in Preschool and Kindergarten: A Waldorf (Steiner) Education Perspective. International Journal of Play 3:9–23. Strauss, A., and J. Corbin 1998 Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage. Streefland, P., A. M. R. Chowdhury, and P. Ramos-Jimenez 1999 Patterns of Vaccination Acceptance. Social Science & Medicine 49:1705–1716. U.S. Census Bureau 2013 State & County QuickFacts: California. http://quickfacts.census.gov/qfd/states/ 06000.html (accessed June 26, 2014). Whitney, C., F. Zhou, J. Singleton, and A. Schuchat 2011 Benefits from Immunization during the Vaccines for Children Program Era— United States, 1994–2013. Morbidity and Mortality Weekly Report 63:352–355.
Social Cultivation of Vaccine Refusal and Delay among Waldorf (Steiner) School Parents U.S. media reports suggest that vastly disproportionate numbers of un- and undervaccinated children attend Waldorf (private alternative) schools. After confirming this statistically, I analyzed qualitative and quantitative vaccination-related data provided by parents from a well-established U.S. Waldorf school. In Europe, Waldorf-related non-vaccination is associated with anthroposophy (a worldview foundational to Waldorf education)—but that was not the case here. Nor was simple ignorance to blame: Parents were highly educated and dedicated to self-education regarding child health. They saw vaccination as variously unnecessary, toxic, developmentally inappropriate, and profit driven. Some vaccine caution likely predated matriculation, but notable post-enrollment refusal increases provided evidence of the socially cultivated nature of vaccine refusal in the Waldorf school setting. Vaccine caution was nourished and intensified by an institutionalized emphasis on alternative information and by school community norms lauding vaccine refusal and masking uptake. Implications for intervention are explored. [immunization, vaccination, anthroposophy, child health, cultural cognition]
Introduction The case for pediatric vaccination seems self-evident. In the United States alone, “among children born during 1994–2013, vaccination will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 deaths . . . at a net savings of $295 billion in direct costs and $1.38 trillion in total societal costs” (Whitney et al. 2011:352). Experts say no other public health effort except sanitized water has had such a major and beneficial impact (Pollard 2007). However, kindergarten vaccination rates—the standard measure of uptake—indicate that not everyone agrees. Although certain vaccinations are required for kindergarten entrance, the number of parents filing personal belief exemptions (PBEs; waivers to enable enrollment for un- and under-vaccinated children without religious or medical contraindications) has increased in recent years, particularly in states with lenient PBE regulations (Omer et al. 2009, 2012). This is not an access issue: Exemptions are highest in MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 29, Issue 3, pp. 381–399, ISSN 0745C 2015 by the American Anthropological Association. All rights 5194, online ISSN 1548-1387. reserved. DOI: 10.1111/maq.12214
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private schools, whose average PBE rate is 6.10% compared to 2.79% in public schools (Shaw et al. 2014). Averages, however, conceal variation. Although one in 10 U.S. children are educated in private schools, a close look at PBE rate variation among private schools has not been taken (see Shaw et al. 2014). My research begins to correct for this by focusing on vaccine refusal and delay in a Waldorf school setting. Waldorf schools offer an increasingly popular form of alternative education and they are thought to account for a notably disproportionate share of PBEs. At the California Waldorf school that hosted my research, the PBE rate was 51%—10 times higher than the state’s private school average (5.2%; Lee and Abanilla N.d.). To help explain this PBE rate and inform interventions to change it, after demonstrating empirically and for the first time that U.S. Waldorf school students in general are significantly disproportionately likely to have PBEs, I describe results from a qualitative content analysis of narrative data from one Waldorf school’s parents. Following Leach and Fairhead (2007), I highlight extant local knowledge and expectations, asking what parents strive for through vaccine refusal and delay. I also ask why the school seems to attract vaccine-cautious parents and I consider, quantitatively as well as qualitatively, whether and how some of its social mechanisms foster increased vaccine refusal after families join. The findings have important practical implications.
Background Western culture today emphasizes active, informed health care consumerism, in which patients—and parents—are responsible for educating themselves so that they may make wise health care choices (e.g., Henderson and Petersen 2001:2–3; Lee et al. 2010). This “burden of responsible consumption” (Kaufman 2010:23) infuses Western parents’ experience with pediatric vaccination (see Leach and Fairhead 2007; Silverman 2010). That said, why are some parents more concerned about vaccines than vaccine-preventable diseases? What can be done to counter misplaced worries that spur dangerous choices? Some have suggested that scientific illiteracy is the problem. Public understanding of science is imperfect at best. In a 2012 survey administered by the National Science Board, only 33% of a representative U.S. sample correctly answered “scientific process” questions, such as those in regard to experimental design and probability (National Science Board 2014:7–24). Rockhill (2001) finds that people also misunderstand risk factor epidemiology, for instance in conflating “risk factor” with “causal factor.” Moreover, many people use population-level risk factor statistics to predict individual risks, although doing so is unsound. But the assumption that “correct understanding” correlates with “correct action” is specious. First, many who vaccinate do so due to its routinization or from social pressure (Leach and Fairhead 2007:49, 70, 77; see also Nichter and Nichter 1996). Moreover, rather than assuring conformity to scientifically agreed-on positions, high scientific literacy may, in fact, correlate with the contrary—as it does in regard to climate change, particularly for individuals with vested interests (Kahan et al. 2012). High scientific literacy also may intensify vaccine rejectionism (Kahan 2013).
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To understand such counterintuitive findings it is helpful to consider actual vaccine decision-making. Poltorak and colleagues’ research indicates that vaccine decisions depend “not on a singular deliberative calculus and the information and education that informs it, but on contingent and unfolding personal and social circumstances in an evolving engagement” (2005:718). In their multi-methods project, interviewed mothers’ decisions were affected “by personal histories, by birth experiences and related feelings of control, by family health histories, by their readings of their child’s health and particular strengths and vulnerabilities, by particular engagements with health services . . . and by friendships and conversations with others” (p. 709)—vaccine decision-making was a highly social process. Indeed, a recent social network analysis found that parents’ “people networks” greatly affected vaccination decisions (Brunson 2013). The proportion of people in subjects’ people networks who promoted vaccine refusal and delay or nonconformity was the most significant predictor of subjects’ own vaccine nonconformity— even when compared to individual exposure via “source networks” to materials supporting nonconformity and even when compared to subjects’ own perceptions of vaccination. These findings suggest to me that a simple “confirmation bias” (whereby information confirming one’s prior knowledge is selectively, individualistically attended to) is not at work. Rather, this seems an instance of “cultural cognition,” defined as when people match their ideas to those of valued in-group members (members of their people networks) to avoid cognitive dissonance and demonstrate solidarity (Kahan et al. 2012). Cultural cognition intensifies in the presence of “cues of group conflict” and when the ideas in question “distinguish their group from competing ones” (Kahan 2013). When it comes to vaccination, solidarity with one’s people networks may be so important that outsider challenges only strengthen beliefs: In a randomized controlled trial, Nyhan and colleagues (2014) found that information supporting vaccination reduced intent to vaccinate among parents most against vaccination to begin with. This occurred even when parents came to understand correctly that, for example, autism and vaccination are unrelated. Nyhan and colleagues suggest that vaccination rejectors mobilize other objections defensively to maintain their antivaccination stance (2014:e840). Kahan’s (2013) contention that anti-vaccination beliefs index core group values and are important to group-related self-identity, thereby triggering cultural cognition (and so remaining firm) when competing ideas are presented, seems to support Nyhan and colleagues’ suggestion. It remains speculative, however, pending research with a group that explicitly values vaccination refusal—such as may be found in a Waldorf school setting. Vaccination in Waldorf School Communities It has been suggested anecdotally that Waldorf schools host large numbers of students with PBEs. Using publically available records for California, I found that the average Waldorf school PBE rate is 57.2% (median = 54.5%; range: 38%–87%; the state’s private school average is 5.2%). Even more significantly, although Waldorf schools make up 0.01% of the state’s 1969 private schools with PBE rates on file,
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they account for half of the 10 private schools with the highest rates. Also significantly, all 20 Waldorf schools listed are in the top fifth percentile (raw data source: California Department of Health, via Hubert-Allen and Aliferis 2013).1 Why? What makes Waldorf schools different? Waldorf education is rich in the arts, heavy on experiential learning, and light on summative testing (see Petrash 2002; regarding Waldorf early childhood education in particular, see Sobo 2014). Introduced in Germany in 1919 as part of an effort to decouple government interests from education, Waldorf education has grown exponentially since, with public support in some countries and as a private alternative in the United States. With the rise of the charter school movement, and amid the current backlash against standardized testing and the related push for whole-child education, the number of Waldorf-inspired public schools has also burgeoned (Sagarin 2011). Nonetheless, with few exceptions (e.g., Parker-Rees 2011), peer-reviewed research on Waldorf education remains scant. Waldorf pedagogy takes an ostensibly non-interventionist approach to learning, contending that academic skills emerge as a child is ready. The teacher’s job, accordingly, is to scaffold and optimize this process rather than to impart “knowledge.” To this end, Waldorf school environments are as “natural” as possible, with wood furnishings, organic comestibles, and no electronics. Waldorf pedagogy has its roots in anthroposophy, a holistic philosophy promoted by Waldorf education’s founder, Rudolf Steiner (1861–1925). Anthroposophy, often glossed as “the wisdom of humankind,” offers a path to self-development resting on the assumption that a nonmaterial or spiritual universe interpenetrates and informs the material one. Anthroposophy is not taught in Waldorf schools, although it is a basis for them. The role U.S. Waldorf schools have played in vaccine-preventable disease outbreaks has not been scientifically assessed. However, European Waldorf schools have been identified as epidemiological epicenters for measles and other outbreaks (Ernst 2011; Hanratty et al. 2000). The European situation has been explained as stemming from anthroposophy’s teaching that childhood diseases strengthen children physically and mentally and prevent some future illnesses (Ernst 2011). Although Steiner himself did not rule out immunization (see Dietz 2004–2009), anthroposophical physicians do say that fevers and inflammations (i.e., common childhood diseases) help the body break down and extrude old or expired matter and contribute to cell renewal and growth as well as to overall immune system strength (e.g., Dietz 2004–2009; Incao 2004– 2009; compare Duffell 2001). The understanding that vaccinations harm the immune system also has been reported among anthroposophists in the Netherlands (Streefland et al. 1999); some scientific research supports this claim (e.g., Alfven et al. 2005; Alm et al. 1999, 2002; Enriquez et al. 2005; Rosenlund et al. 2009). Open Questions The anthroposophy–vaccine avoidance equation is accepted in Europe. However, whether the same simplistic “cultural beliefs” explanation accounts for high PBE rates in U.S. Waldorf schools remains untested. So does the applicability of a more socially oriented perspective. For instance, we know nothing about the impact of
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Waldorf school community membership on vaccine acceptance over time (i.e., for one’s younger children or in regard to adolescent vaccinations). Likewise, we do not know whether and how Waldorf schools attract vaccine-nonconforming parents to begin with. My work seeks to help fill these gaps and enrich our understanding of the PBE problem by extending prior social anthropological perspectives on vaccine decisionmaking (e.g., Brunson 2013; Leach and Fairhead 2007) to a setting where vaccine refusal and delay actually is common. After asking about anthroposophy’s influence, I attempt to characterize in detail any social mechanisms that may fuel high PBE rates, and to gauge whether cultural cognition is a factor also. If so, this has important implications for intervention.
Methods Site and Sample The school hosting the study was about 30 years old and served 280 pre-K through 12th-grade students, whose ethnic mix was 4% Asian, 3% black or African American, 9% Hispanic or Latino, 60% white, and 24% two or more races. The latter compared to 2.1% countywide. The school does not collect income data, but records show it received 166 tuition assistance applications for 2009–10. Average tuition paid that year was $6,802 (personal communication). The IRB-approved project that findings are drawn from aimed to develop a health survey for Waldorf parents using methods common to such a task: focus groups and interviews. The school served 195 households. To help avoid amassing a biased sample, households were randomly numbered and then resorted numerically.2 Starting with family number one, research assistants (RAs) Sean Tangco and Erik Hendrickson recruited primary caretakers (parents, guardians) using an outreach letter and follow-up phone calls and emails. The RAs assembled two focus groups and conducted six formative and 18 cognitive interviews, stopping when saturation was reached. Focus group members (12) and interviewees (24) were unique, independent subjects. Vaccination was not queried initially. But parents presented vaccination as a central concern, thereby obligating me to attend to it. This article therefore analyzes data that, however rich, emerged as a survey-building by-product.
Data Collection and Analysis Focus groups were convened to jump-start the survey development process. Only two were planned due to the small relative size of the population, from which individual interviewees also would need to be recruited. There were a total of 12 focus group members. After collecting household data forms (self-reports of age, household income, and so on), the RAs asked each group about preventive health practices, dietary and eating habits, allergies, fever treatments, and related health issues.3 Each meeting lasted two hours, with 1.5 hours devoted to narrative data collection.
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Then, six individual formative interviews were conducted to gather narrative data regarding the same topics privately. The quota of six was set in relation to the small population size and the related need to reserve enough participants for subsequent cognitive or “think aloud” interviews. In the latter, participants explained their responses to items proposed by prior participants for the survey. For instance, the draft survey listed all recommended vaccinations (with lay translations of which diseases these were for) and asked whether each child was, given his or her age, completely, partially, or not vaccinated. The draft survey also contained items relating to household dietary practices (e.g., food eaten or avoided), child health indicators (e.g., allergies, weight, screen time), and health promotion practices (e.g., therapies used). Forty cognitive interviews were planned. Data saturation made that unnecessary: We stopped at 18. The mean durations of the formative and cognitive interviews were 71 and 99 minutes, respectively. Narrative data from the focus groups and the formative and cognitive interviews were audio-recorded and transcribed. I reviewed the three data sets as they came in, using standard ethnographically informed content analysis techniques (open and relational coding based on iterative review, theoretical model building, etc.; see Glaser and Strauss 1967; Quinn 2005; Ryan and Bernard 2003; Sobo 2009; Strauss and Corbin 1998). In this way, major themes and subthemes as well as their relationships were identified. The content analysis was enhanced by my first-hand experience as a Waldorf parent. This enabled me to grasp efficiently certain aspects of parent discourse that would have taken an outsider much longer to parse and to produce a culturally sensitive analysis that takes into account internal variation. The analysis also was informed by the quantitative data. I generated descriptive statistics from the household demographic form to describe the sample. I also extracted vaccination answers from the draft surveys when possible, bearing in mind the limitations of self-reports made on a draft instrument.
Findings Each participant represented one Waldorf school household as primary caregiver. Table 1 summarizes participant characteristics. Seventeen participants provided vaccination data on the draft survey (see Table 2). In families with more than one child (e.g., CI-04; CI = cognitive interview), the older child is shown first (to protect privacy, actual ages are undisclosed). The median age on enrollment for older children was four years; younger children often began a little earlier. In Waldorf schools, pre-school extends through age five; six is the standard age for kindergarten. The host school’s kindergarten PBE rate was, as previously noted, 51%. Yet, in Table 2, only two children were totally unvaccinated, and the average child was about two-thirds up to date on his or her vaccines (see Table 2). Moreover, of the nine families with multiple children, five vaccinated their younger children less frequently, suggesting that birth order may predict vaccination status. For instance, Justine (respondent CI-10; all names are pseudonyms) had a 10-year-old child. He was first enrolled at preschool age and was fully
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Table 1.
387
Participant characteristics (N = 36)
Average participant age (years) Gender Female Male Education1 High school or vocational degree Bachelor’s degree Master’s or doctoral degree Average household income1, 2 Average number of children
45 30 6 11 17 8 $119,839 (median = $100,000) 2
1
U.S. Census data show that, nationwide, about three in 10 adults have a bachelor’s degree and about one in 10 have advanced degrees; about one in 10 have not finished even high school (Anonymous 2013). 2 Median household income in California (2007–2011) was $61,632 (U.S. Census Bureau 2013).
vaccinated. Justine’s second child, born after she had become so committed to Waldorf education that she underwent teacher training, is wholly unvaccinated. More typically, when a drop-off in vaccination occurred it was gradual, as, for instance, in Felicia’s family (the last in Table 2). Felicia explained that this occurred in tandem with social learning, through peer networks. She apologized about her oldest child’s immunizations: “I didn’t know any better” (CI-74). As a focus group participant explained, “A lot of people that come [here] have vaccinated their children . . . and then they chose to discontinue” (FG-2; FG = focus group). Another told of vaccinating her older child “in my pre-Waldorf awareness years”; she stopped after “learning more” when she “entered this community” (FG-1). Publically available data confirm the uptick in vaccine refusal subsequent to enrollment. California recently mandated a pertussis (whooping cough) booster (Tdap) for 7th grade. Of the study school’s 70 2011–2013 7th-grade students, 71.43% had PBEs on file.4 The difference between this and the kindergarten rate (51%) has significance: The state’s overall 7th-grade private school Tdap PBE rate did not differ notably from the state’s overall private school kindergarten PBE rate. Thus, the observed increase did not reflect a statewide tendency for parents to slacken when it comes to adolescent vaccinations. Nor did it reflect an exodus of vaccinators prior to 7th grade: While four of the 42 students reported on the household demographic forms were leaving in the fall, these were all high-school transfers.5 Orientation to Child Health Vaccination choices cannot be understood without some knowledge of participants’ overall orientation to child health, which highlighted prevention through “healthy living” and accepting sickness as part of life. As Bertana said of childhood illness: “We look at it as part of the process of growing up and building a strong immune system” (FI-11; FI = Formative Interview).
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Table 2. Required Vaccinations by Family (N = 17) and Child (oldest child first); 2 = fully vaccinated for age, 1 = partially vaccinated, 0 = not vaccinated; total = 10 indicates all vaccinations are up to date
Parent ID
Measles, Diphtheria, Chicken mumps, tetanus, pox Hepatitis rubella pertussis (varicella) B (MMR) Polio (DTaP)
Total score
Younger children, fewer vaccines?
CI-04
0 0
0 0
2 1
0 0
2 1
4 2
Fewer
CI-10
. 0
. 0
. 0
. 0
. 0
101 0
Fewer
CI-12
0 0
0 0
0 0
0 1
0 1
0 2
No change
CI-13
2
.
2
2
2
8
–
CI-14
2
2
2
2
2
10
–
CI-18
1
2
1
1
2
7
–
CI-27
0 0 0
2 2 1
2 2 2
2 2 2
2 2 2
8 8 7
Fewer
CI-28
2
0
2
2
2
8
–
CI-29
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
10 10 10
CI-31
1
2
2
2
2
9
–
CI-45
2
0
2
2
2
8
–
CI-48
0
0
0
2
1
3
–
532
0
0
0
1
2
3
–
CI-63
2 2
2 2
2 2
2 2
2 2
10 10
No change
CI-62
2 1
2 1
2 1
2 1
2 1
10 5
Fewer
CI-72
1 1
1 1
1 1
1 1
1 1
5 5
No change
CI-74
1 0 0
0 0 0
2 1 0
1 1 0
2 2 2
6 4 2
Fewer
0.93
0.96
1.36
1.36
1.64
Averages 1 2
Source: parent narrative. Submitted survey but did not provide cognitive interview.
No change
6.21 N.A. (median = 7)
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Bertana’s use of “we” signifies a sense of collective identity that was clearly articulated by many: “That’s what we are, is community” (FG-1). Participants often explained child health preferences in regard to this community. One father, a self-described “newbie to the Waldorf world,” said he now uses “wood and steel utensils, no more plastic because of Waldorf.” “No television,” he added, “No social media” (CI-28); outside influences were thus curtailed. Participants said: “It’s a lifestyle”—one meant to “keep their children healthier, so they don’t get to the point where they need to go to the doctor” (FG-1). Many parents were cautious about allopathic medicine (which they labeled as such, or as “Western” or “mainstream”). They saw it as shortsighted in “just treating the symptoms” (FI-59). Eduardo warned: “You don’t take something to necessarily to get rid of a headache; you look at what is underlying in the fact that someone is getting headaches” (FI-46). This holistic approach was generally individualistic and favored support versus intervention. Homeopathy was highly endorsed. “Medicine,” in one parent’s words, “should be there to augment the body’s natural process towards health rather than replace the body’s ability to heal itself” (FI-11) or, worse, damage it with “toxins” (FI-68)—to which smaller bodies are more “sensitive” (CI-74). How did parents know these things? “The teachers are really good about educating” (CI-48)—and, more importantly, parents self-educated. As one said, “[I] throw all kinds of pencils and homework upon myself” (FG-1). Advice was shared: Helen, to provide an example, told of a “big information sharing session” regarding food storage containers (CI-12). Information often came from alternative sources thought “not biased by the government or a laboratory” (CI-72). Most parents were “somewhat skeptical of the government and somewhat skeptical of sort of big brother and organized medicine, big medicine, big pharma, that kind of thing” (CI-48). But parents also made assertions like: “I’ll tend to go with something that’s from NIH, and then I’ll even like go and look at some of the things on PubMed” (CI-31). Indeed, “research” often was invoked to authenticate a given health care choice (e.g., “If you look at brain research” [FI-11]; “It is pretty well empirically documented” [FG-2]; “I made that educated choice based on my research” [FG-1]). Several parents referred to schooling or training in explaining their ability to evaluate and digest information. Noted Darlene: “Doctors only go to another four years of education, it’s not much. . . . Are they much more knowledgeable than you? . . . You have to take self-responsibility and I think in a Waldorf community parents take self-responsibility” (FI-59). Parents took pride in their “diligent” and “conscientious” or “conscious parenting” (CI-28, CI-31, FI-17) approach to pediatric care: “Really, I think we delve about as deep as you can” (FG-1). As Helen said, “Waldorf parents . . . really take the time to think about things, like they just don’t go through just taking whatever society or lobbyists gives them, or advertising” (CI-12). Alternative choices were taken to symbolize one’s capacity for independent thinking. In speaking about health, very few participants mentioned anthroposophy spontaneously. In response to its proposed use as a survey item anyhow, many cognitive interviewees said things like: “I do not know enough about it to answer” (CI-31) and “I don’t know the word” (CI-14); indeed, a number struggled with anthroposophy’s
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pronunciation. And when prompted with an open-ended free-list type survey question regarding typical household health practices, only one of the survey-piloting parents entered it (in contrast, most mentioned homeopathy). Nobody mentioned anthroposophy in relation to vaccination. Likewise, nobody cited institutional tolerance for non-vaccination in explaining why they chose the school. In fact, one mother complained in a focus group that the school did not proactively inform parents about the waiver option. The research did not ask why parents chose the school, but many spontaneously mentioned the match between the school’s ethos and their own holistic, “conscious” approach to raising children. Leticia noted that committing to Waldorf education “takes courage” (FI-61) because it is so unconventional; others made similar observations. Vaccination nonconformity was analogous: “It shows that the parents are individual thinkers . . . it takes a lot of work to go against the grain of society” (FI-11). Vaccination-specific Understandings Many parents expressed distaste for vaccines (reflected in Table 2). Ten key reasons for their disuse emerged: the profit motives of those who make, sell, and administer them; foregone benefits of getting a disease naturally; the low general risk for exposure to various vaccine-preventable diseases; individualized exposure risks, the potential severity of a given disease; the physical immaturity of young children; vaccine toxicity; side effects; vaccine failure rates; and, conversely, the idea that because vaccines do work that others will be protected and so one’s own status should not matter. To start, parents often cited suspicions regarding the profit motives of corporations (one said that even the American Academy of Pediatrics was “beholden to companies” and that this was reflected in their endorsements [CI-28]). Parents also often pointed to the otherwise foregone benefits of some diseases for immune system health. As Bertana noted, “[It] would strengthen our children’s immune system to get that disease so why immunize against it?” (FI-11). Another common theme was a perceived low risk for exposure. Here is Bertana again: “If my family lived in Kenya, we would vaccinate our children” (FI-11). Nonetheless, most children had at least some vaccinations. When not attributed to one’s “pre-Waldorfian” ignorance, these were often justified in terms of individualized exposure risks. For instance, Catarina explained: “The reason [my child] has the tetanus is because we have [a farm] and that’s a place where tetanus thrives” (CI-18). Referencing both chances of exposure and an “as needed” orientation toward intervention, Catarina also noted that “city kids don’t need to get it ‘cause it’s not an issue. And you get a tetanus shot if you’re injured anyways. If you get a puncture wound and you go to the hospital.” Some parents considered also the potential severity of a given disease in making a vaccination decision. “You going to risk rabies? Rabies is incurable,” said one parent (FG-1). But when parents wanted vaccines for single diseases, they were often refused (“Apparently [single vaccines are] not stocked very often” [CI-18]). Chicken pox was a favorite foil in arguments against vaccinating for diseases with low perceived severity. Parents often invoked their own childhood experience
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in justifying this. A typical statement was, “Yeah, we all had chicken pox . . . what the heck was the problem?” (FG-1). After joining the school, this parent “stopped [her son’s varicella shots] midway.” Some parents viewed younger, smaller children as ineligible for vaccination because of their general physical immaturity; one participant said Waldorf “parents seem to be more aware of any type of effects to the small bodies, the children’s bodies” (FG-1); another referred to “very heavy-duty things that are not good for a young body” (FG-2). Kat said, “I should wait ‘til they are older to have to manage so much chemical” (FI-39). But even for older children, many parents felt that “vaccines are really toxic” (FI-39). As one parent said regarding toxicity: “If you look at the ingredients of it you would not willingly put that into your child if you knew what was in it” (FG-2). Known side effects also were a concern. As one parent put it, beginning (as was common) with scientistic authorizing rhetoric, “There is a lot of research out there that actually shows that a lot of the vaccines can cause autoimmune disease and allergies, especially food allergies [and . . . ] a lot of learning disabilities” (FG-2). Another parent in the group then clarified (again with reference to experts) that the now-debunked autism link was, in fact, indirect: “If the immune system is not one hundred percent and you get any of these vaccines, it can cause damaging effects.” Likewise, Lou recounted having learned after the fact that “infant immunizations . . . go straight to the brain and so a brain that is already been compromised— [that leads to] seizures” (CI-58). New explanations regarding antecedent conditions were being rallied to replace disproven causal claims (e.g., the MMR–autism link)— without parents having to change sides in the debate. Another point often made was that vaccines fail anyway. For example, validating his information by tracing its genealogy, Ivan said, “I know for a fact that the flu vaccine—I just heard on NPR that it’s just a random guess” (CI-28). In regard to a recent whooping cough outbreak, another parent declared authoritatively: “Probably ninety percent of the people [who contracted pertussis] had been vaccinated . . . and they had it much worse” (FG-2). Simultaneously, vaccine refusal was justified because vaccines do work. As one parent asked, rhetorically: “If you feel like the vaccines are effective and in fact your child got vaccinated, then why are you scared of children that aren’t vaccinated [laughter]? Wouldn’t they be protected under this then? I don’t know [laughter]. I never quite understood that” (FG-2). Rather than looking at the population level, which is where epidemiological risk and vaccine effectiveness really live, this parent used the individual as the unit of analysis. That was, in fact, the norm: Although Waldorf education has a social mission, participants overlooked the plight of disease-vulnerable people.
Social Mechanisms that Sustain Cultural Norms Consensus held that “typical” Waldorf parents “don’t vaccinate” (CI-48). Against this standard, some parents reported a tendency to remain silent regarding mainstream practices such as vaccinating: “There’s prejudice against mainstream medicine” and “there’s pressure to conform” (FG-1). “There’s a vibe,” said Malia,
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describing another parent being warned against allopathic medicine in a way she saw as “presumptuous” (CI-14). The “vibe” is reinforced institutionally, in keeping with the school’s overarching “alternative bent” (FG-1): Recall that even the curriculum was not “what the government says that it should be.” Although the study school does not officially endorse health practices beyond early bedtimes, wholesome foods, lots of outdoor play, and media avoidance, “the culture of the school” (FG-1) looks away from biomedicine. Darlene reported: “The school philosophy actually embraces illness because they believe that when your body has a strong illness, particularly a fever, it precedes a developmental leap in the child” (FI-59). Health-related guest speakers, flyers, and copies of articles passed around always reflected an alternative perspective. Families received “encouragement, kind of like a collective community concern [at the school] like we should be skeptical of what’s out there and we should double check what we are putting into our bodies, and our children’s bodies” (FG-1). Most cast such encouragement as supportive, but Natasha labeled hard-liners “selfabsorbed” and prone to “cramming it down our throat” (CI-13). Given this climate, interviewers were told: “A lot of people . . . don’t speak up about [vaccinating], because they don’t want to be that person who doesn’t follow the Waldorf mentality” (FG-2). Some said they kept silent about allopathic activities to avoid social isolation or evade confrontation (e.g., “I wouldn’t have wanted people to ask me to take [child] off of medication” [CI14]). Paradoxically, keeping mainstream behaviors secret supported belief in their rarity. After a strongly anti-vaccine dialogue in a focus group, one participant did proclaim “I immunize my kids. . . . Many parents that I know immunize their kids here.” But she followed this with an affiliative proclamation regarding how she handles fevers: “I don’t run for the antibiotic or Tylenol—I wait, let the fever go up.” “I have a lot of fights with my parents,” she added, again asserting common cause with school community members versus outsiders: “I’m considered to be very extremist.” Others used similar rhetoric to confirm good “Waldorfian” citizenship; some also invoked freedom of choice to justify vaccination—but freedom to reject mainstream medicine went without saying given the Waldorf school context. As an alternative, vaccinating parents diverted discussion to the quality of education offered. They distanced themselves from “extremist” health views, saying things like “I came to Waldorf despite this issue, kids not being immunized, not because of it” (FG-2). Attraction to the school’s “philosophy of educational values” trumped disagreement with health ideas that were, for these parents, “too far swung” (CI-14).
Discussion The study school had a discordantly high kindergarten PBE rate. Moreover, nonvaccination rates went up post-enrollment. Contra European findings linking vaccine refusal and delay to anthroposophy (e.g., Ernst 2011), this school’s parents generally were unfamiliar with anthroposophy as well as with anthroposophical medicine. Simple lack of information also was not to blame: Study parents were highly educated and took seriously their perceived responsibility for child health; they were actively engaged in health-related self-education. Indeed, this was
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expected of, and encouraged by, school community members. They were far from uninformed. To support an increase in community demand for vaccination, then, we must consider what parents do know and what they desire (see Leach and Fairhead 2007). Moreover, given the inherently social nature of vaccine decision-making (see Brunson 2013; Kahan 2013; Poltorak et al. 2005), we must consider the social mechanisms that reinforce vaccine refusal and delay. Findings indicated that institutionally supported skepticism regarding governmental and corporate interests and parents’ community-promoted self-identity as independent thinkers funneled attention toward alternative information sources. Such sources—which supported talk of vaccine toxicity, ineffectiveness, needlessness (except to those with a profit motive), and developmental inappropriateness for small bodies—were more likely to be publicized within the school community via social networks than were mainstream scientific materials. This was because of community rules favoring alternative perspectives and stigmatizing conventional ones. Parents who vaccinated therefore remained silent about having done so, and information that was circulated never included pro-vaccine messages. Parents who perceived themselves as part of a special community with particular lifestyle expectations were reinforced socially for accepting and further disseminating what they learned from alternative sources. Given that many parents found the school’s “alternative bent” (FG-1) attractive, it is likely that a somewhat larger proportion than normal of preschool students were missing at least some vaccinations upon first enrolling. But enrolling one’s family—joining the school’s community— often intensified vaccine avoidance and even propagated it among previously vaccinating parents. The social fabric of the school served as an incubator, fostering the extraordinarily high PBE rates seen in mandated reportage (51% upon kindergarten entry; 71.5% in 7th grade) and encouraging the noted drop in vaccinations for a family’s younger children. According to these findings, the anti-vaccination stereotype becomes increasingly accurate as the duration of a family’s enrollment increases and the number of one’s enrolled children grows—and as the number of people in one’s people network who disfavor vaccination expands (see Brunson 2013). This increased frequency of vaccine refusal, and the equation between non-vaccination, the independence of mind that it is taken to signify, and Waldorfian identity make it harder and harder to contravene the norm without threatening one’s sense of group membership, or creating cognitive dissonance. Put another way, cultural cognition leads Waldorf parents to make vaccine choices that support locally normative understandings and thereby reinforce favored social ties (see Kahan 2013; Kahan et al. 2012). Implications for Practice Successful intervention may seem impossible in light of findings indicating that, to maintain healthy within-community social relations, Waldorf parents will practice cultural cognition, favoring ideas confirming in-group norms, even when provided so-called correct information. For instance, the Centers for Disease Control and Prevention (CDC) webpage “Why Immunize?” (CDC/NCIRD 2014) contains a Vaccine Safety and Adverse Events link, which reveals that autism and sudden
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infant death syndrome have been concerns and includes sub-links regarding how to report side effects and a safety resources list. These may be taken to support prior doubts. So may the existence of a resource whose title begins “If You Choose Not to Vaccinate Your Child” (CDC 2012), suggesting that opting out is a viable choice. This document, which uses patently neutral language, outlines steps to minimize risks. It states that when there is a vaccine-preventable outbreak, “it may not be too late to get protection by getting vaccinated,” which can be taken as support for a “just in time” approach to vaccination. Given the importance of social relations and cultural cognition’s resultant power, what can be done? Lewandowsky and colleagues (2012) show that cultural cognition can be mitigated if belief-challenging information is presented to people after an experience that affirms their self-worth or core values. But this is tricky. For instance, the CDC’s aforementioned “Why Immunize” page begins by stating it is “reasonable to ask whether it’s really worthwhile to keep vaccinating.” This certainly affirms Waldorf parents’ “think for yourself” ethos. But it also can be taken to suggest that non-vaccination is reasonable. Affirming informed health care consumer engagement more broadly could have forestalled that. For Waldorf parents specifically, core values to be affirmed include the priority placed on children’s schooling and dedication to their health, both of which demonstrate a commitment to good parenting. Lewandowsky and colleagues (2012) also recommend framing specific messages and corrective information in worldview-consonant terms. Anthropologists have long espoused the need for culturally appropriate messaging; Nichter and Nichter’s (1996) work on increasing community demand for vaccination and other public health goods in developing nations by leveraging local perceptions provides a fine example. Nichter and Nichter advocate tailored interventions attending to the finegrained details of what people already do to protect child health and using culturally appropriate analogies in education efforts to better contextualize the information being shared. We must be willing to learn from those targeted; we must shift the parameters of engagement “beyond compliance [toward] partnership” (Nichter and Nichter 1996:xvii). To increase community demand among Waldorf parents, vaccine promotions should leverage parents’ favored ideas and address community concerns. One obvious response to the present findings would be for smaller manufacturers to develop more “natural” and non-industrial vaccination formulations, along with marketing and distribution plans authentically opposed to those of big pharma. More immediately, vaccination intervention efforts should drop the neutral language that implies false equality between vaccination choices and begin deploying culturally consonant imagery. Pro-vaccine messages aimed at Waldorf parents should emphasize how vaccination, booster shots included, help children’s immune systems self-strengthen naturally (vs. working synthetically, or in lieu of the child’s own biology). Analogies also could be drawn from homeopathic medicine here. Moreover, possible “side effects,” such as fever, could be recast as indications of self-strengthening and bodily renewal and as demonstration that the benefits of childhood illness are not being foregone (regarding such in West Africa, see Leach and Fairhead 2007:116). The fact that even fully vaccinated children experience (ostensibly potentially beneficial) febrile illness during childhood anyhow also should
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be highlighted. Messages regarding vaccination series for young teens (e.g., human papillomavirus [HPV], meningococcal conjugate vaccine [MCV4]) as well as catchup shots and boosters (e.g., Tdap) could confirm the maturity of teen bodies and thus the developmental appropriateness of these vaccinations. In light of parents’ cognizance of risk for exposure, messages might target diseases that are statistically more dangerous instead of globally recommending all immunizations when parents are simply not interested in full coverage (yet). The very fact of an outbreak may be used as evidence that now is the time to vaccinate for that particular disease—particularly if high vaccine effectiveness is proven (media coverage of vaccine ineffectiveness will undermine a just in time campaign strategy). Statistics regarding injury and death due to the outbreak can be used to offset any accusations of fear-mongering. Also, because of parent’s distaste for profit motives, factually backed references to the vested interests of people and companies promoting vaccine refusal and delay or alternative substitutes may be helpful. It is also important to know the statistics regarding vaccine-related injuries, including those attributed to purported toxins and to put them into comparative context to demonstrate how favored childhood activities (e.g., climbing trees) or every-day undertakings (e.g., eating carrots) can be, relatively speaking, far more dangerous. Clinicians should have individual vaccines available for parents disinterested in the cocktail approach so that, rather than leaving with nothing, a child might at least get the single vaccination. Reminders that vulnerable individuals need protecting may have value too, given Waldorf education’s high-level orientation toward the public good. “Community immunity” can be referenced, but glib use of the phrase “herd immunity” is ill advised: It can be taken to imply “going along with the herd”—which is not in keeping with the Waldorf ethos. All messages should leave intact parents’ self-conception as “individual thinkers” as well as “conscious” parents (see Lewandowsky et al. 2010). And they should carefully avoid acknowledging that vaccination is a polarizing issue, as this in itself can trigger group-identity confirming cultural cognition (Kahan 2013). Reminding parents that school community belonging has more to do with education than vaccination and is itself proof of one’s independence of mind is key to breaking the grip of cultural cognition on vaccine uptake at Waldorf schools. Publicizing that about half of Waldorf students are fully vaccinated and that total non-vaccination is in fact rare will also be helpful, as should recruiting socially esteemed parents (or teachers and staff) who are pro-vaccination, supporting them in publicly championing vaccination within the school community, and demonstrating that vaccinating one’s children is not inimical to being free thinking or to school community membership. Indeed, because such actions have the potential to dislodge vaccination’s social stigma, these could be the most important practical steps of all.
Conclusion This research advances recent scholarship suggesting that social relations themselves are paramount drivers of vaccine refusal and delay (e.g., Brunson 2013). It does so by providing details regarding the social mechanisms that sustain cultural norms (including through the process of cultural cognition; see Kahan 2013), and by
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demonstrating how social settings can serve as incubators or crucibles, intensifying essentialized or defining group tendencies or values regarding vaccination. U.S. Waldorf schools make a major contribution to un- and under-vaccination (and not because of anthroposophy, contra European findings). Increasing community demand for vaccination in Waldorf school communities requires use of culturally appropriate analogies and strategies that affirm rather than deride Waldorf parents’ core values, which, after all, prioritize child health.
Notes Acknowledgments. Data this article draws on were collected by Research Associates Sean Tangco and Erik Hendrickson as part of a larger project funded in part by a Critical Thinking Grant from San Diego State University. Sam Katzman transcribed group and individual interview recordings, and Samuel Spevack entered the quantitative data collected. I am grateful for this assistance. Highest thanks are due to teachers and staff at the host school for facilitating the research and to parents for their enthusiastic participation. 1. Fisher’s Exact (chi square) Test confirms the statistical significance of these observations, with 2-tailed p-values of 0.032507 and 0.000008 respectively. 2. Not included were households in which the primary caregiver was also a class teacher at the lower school (pre-K through 8th grade), because these teachers were being recruited for another, related study. Also, parents with children in high school only were excluded from the focus group and formative interview subsamples to ensure that the survey was not overly focused on adolescent health. Parents employed at the school also were excluded from the focus groups, to protect against undue self-presentation bias. 3. The questions were: (1) Please tell me what are some health-enhancing or preventive health practices common among Waldorf Families that you think a survey should ask about? (2) What are some things we should ask parents to tell us about their children that will give us a good idea about how healthy the children are? (3) How do Waldorf families’ dietary and eating habits differ from the mainstream American family’s? Why? (4) What kinds of allergies are you seeing among children these days, and why? (5) How do you treat childhood illnesses involving fever? Are there any “shoulds” or “should nots”? (6) Do your children have routine daily or otherwise regular practices of any kind that you hate for them to skip because skipping them is bad for their health? Do they have any therapeutic regimens they follow? (7) What other kinds of health-related practices are there in the Waldorf community, if not your home, that we should think about including in the survey? 4. See http://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationLevels.aspx for data used to calculate this rate (relevant reports are from 2011, 2012, and 2013). 5. Outside of the sample, families have left before high school due to financial pressure or job relocations, to abate a child’s learning difficulties, or to homeschool.
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