How a 'Good Parent' Decides on Childhood Vaccination. Demonstrating Independence and Deliberation during Dutch Healthcare Visits

"...findings shed new light on the interactional unfolding of parental vaccination decisions."

Childhood vaccination consultations are considered an important phase in parents' decision-making process. A growing body of research shows that a vaccination decision is not only a matter of weighing benefits and risks but also a consideration of social norms and group membership. This article focuses on how parents shape their identity - what type of parent they are - in and through such interactions. Particularly in institutional settings, studies have demonstrated that parents often work to present themselves as "good parents". The study described here examines that "identity work" by recording Dutch vaccination conversations between healthcare providers (HCPs) and parents during routine health consultations for their newborns.

HCPs recruited parents of newborns for study participation and used their own mobile devices to make audio recordings of 20 vaccination consultations with one or both parents present. The data from 15 conversations were analysed using Conversation Analysis and Discursive Psychology.

The study found that the topic of vaccination was often initiated with the question, "Have you already thought about vaccination?" (HYATAV) and that this formulation was consequential for parental identity work. Exploring the interactions that follow from this way of initiating the vaccination conversation, the researchers show that: (i) interlocutors treat the question as consisting of two types of queries: (a) whether the parents have reflected on, discussed, or otherwise considered vaccinating their child (the "literal query") or (b) whether they intend or have planned to vaccinate their child (the "inferred purpose query"); (ii) conversational trajectories differ according to which of the queries is attended to, and (iii) parents work up a "good parent" identity in response to HYATAV by demonstrating that they think about their child's vaccination beforehand and make their decisions independently.

Reflecting on the findings, the researchers note that HYATAV provides the opportunity to elicit a first indication of the parent's position towards vaccination and enables the nurse to design her recommendations in a way that takes the parent's perspective into account. Furthermore, this question format invites parents to present their decision in their own terms rather than merely confirming a more direct alternative (e.g., "Are you going to vaccinate?"). Thus, HYATAV seemingly promotes freedom of choice and patient autonomy.

However, examining the different ways in which the nurse modifies her reaction to parents' responses reveals that acceptance and refusal are not treated as equal alternatives. Pro-vaccination choices are always treated as unproblematic and consistently lead to a conclusion of the conversation. Specifically, any alignment to the inferred purpose query is treated as preferred and sufficient, regardless of how or if the literal query has been addressed. Ambiguous answers are treated in ways that maintain or maximise the understanding that parents will vaccinate. As it turns out, participants orient to vaccination acceptance as the preferred consultation outcome, despite the ostensibly participatory nature of HYATAV.

The study provides further evidence that the vaccination decision is inextricably linked with the conception of what good and responsible parenting looks like. It shows that:

• In contrast to the predominant portrayal in literature, it is not only vaccine-hesitant parents who are preoccupied with building a "good parent" identity by making well-informed choices or not trusting blindly. Instead, the data suggest that parents who ostensibly approve of vaccination display a very similar orientation.
• The findings show what interactional resources and practices parents have available for creating a "good parent" identity for themselves. When addressing the literal query, parents postpone a vaccination decision in favour of a display and discussion of their information-seeking process. Thereby, they demonstrate, first, that good parents inform themselves about vaccination before deciding, which is in line with the normative orientations that vaccine-hesitant parents put forward when commenting on the reasons for their hesitancy. A second form of good parenting - i.e., independent decision-making - is displayed when parents attend to the inferred purpose query.

The practical implications of HYATAV for vaccination consultations include:

• In contrast to the presumptive approach, according to which the HCP presents vaccination as the default option ("we will give your child her shots today"), HYATAV invites parents to formulate their decision in their own words. Some parents in the recordings adopted interactional strategies that show they made their decision independently from the nurse, despite choosing the default option. Others treat HYATAV as requiring a special account for their stance on vaccination, which in turn has to be compatible with a "good parent" identity. The delivery of certain responses, such as indications of being uninformed or asking the "wrong" questions, may therefore place a burden on the respondent. In spite of its participatory format, HYATAV therefore does not seem ideally suited to foster patient participation.
• If the goal is to impose a minimum of constraints on parents to articulate questions and concerns, then initiation formats lacking a "good parent" slot, in the sense of having to demonstrate deliberation or independence in making the vaccination decision, are likely to be most effective. The presumptive approach fulfils this requirement but appears to be designed to short-circuit parents' questions and concerns at the same time.

"Ultimately, further research in this domain will enable practitioners to expand their repertoire of initiation formats and understand their affordances and constraints. As a one-size-fits-all practice is unlikely to exist, it is up to the HCPs to use their professional judgement to assess which communicative behaviour is most appropriate for the situation at hand."