Nara Women's University
Changing Ideas about Mandatory Childhood
Vaccination: Vaccine Hesitancy and New
Parental Norms in Taiwan
メタデータ

言語: Japanese
出版者: アジア・ジェンダー文化学研究センター
公開日: 2023-05-18
キーワード (Ja): ワクチン忌避, 小児期の予防接種, 台湾
キーワード (En): Childhood Vaccination, Taiwan,
Vaccine Hesitancy
作成者: Chen-I,Kuan
メールアドレス:所属:

URL

http://hdl.handle.net/10935/5928

アジア・ジェンダー文化学研究【第 7 号】2023

Changing Ideas about Mandatory Childhood Vaccination:
Vaccine Hesitancy and New Parental Norms in Taiwan*
Chen-I Kuan**Introduction
Vaccine hesitancy, which refers to the phenomenon that, despite vaccine
availability, people still delay or refuse to vaccinate (MacDonald, 2015), has existed fora long history and has expanded globally. When some vaccine-controllable diseases,
such as measles, came back to affect people’s health, WHO defined it as one of theten global health threats (World Health Organization, 2019). Meanwhile, vaccine
hesitancy is highly contextual. In the United Kingdom and the United States, many
parents suspect that childhood vaccination is associated with autism. They do notbelieve in scientific evidence, which was provided by the governments and scientists
to disapprove the causul relation between vaccines and autism. The parents think thatthe scientific evidence may be presented in favor of the pharmaceutical industry andthe political interests of governments (Baker, 2008; Bearman, 2010; Kirkland, 2012).
Very differently, parents in developing countries may view vaccination as a Westernconspiracy because of the long-term unequal power relationships between developing
and Western nations (Yahya, 2007).
In the current literature of studies on vaccine hesitancy, we hear very little
about parental experiences in this regard in East Asia. But vaccine hesitancy does
exist in this area of the world. I started ethnographic research in 2018 and tried tounderstand: Who are the parents feeling hesitant about vaccination? What are they
hesitant about? What are the contexts behind their hesitancy?
Situations in Taiwan
Vaccine hesitancy was hardly noticed in Taiwan partly because the vaccination
rates have been high. According to statistics, vaccination rates have reached above
95% since the 1980s and have been among the highest globally (Taiwan CDC, 2013).
However, the situation is changing recently.
In 2006, the mass media reported vaccine hesitancy in Taiwan. A group of
highly-educated parents publicly questioned the safety and necessity of childhood
vaccination (Chiu, 2006). This hesitancy toward childhood vaccination appears to
expand. In 2017, before the new semester started, the Bureau of Health in Taipei* Parts of this article are adopted from Kuan 2022.
** Assistant Professor in the Institute of Health Behaviors and Community Sciences, National Taiwan University.

Gender and Culture in Asia Vol.7, 20233

アジア・ジェンダー文化学研究【第 7 号】2023

City found that around eight thousand new elementary school students were undervaccinated and appealed for parents’ cooperation (Shen, 2017).
Besides, a group of parents whose children encountered adverse events
following immunization(AEFI) organized together and argued for transparent
information regarding vaccination (Chen & Chiu, 2014). This organization officiallyregistered in 2019.
Theoretical Perspectives
Regarding theoretical perspectives, previous studies focus more on how parents
define risk differently. For example, vaccine hesitancy often occurs among parents
using complementary and alternative medicine (CAM) since they have different views
on body and diseases from biomedicine (Attwell, Ward, Meyer, Rokkas, & Leask, 2018;
Sobo, 2015). Or parents who reject vaccination based on their distrust of institutions
may define malpractice in the pharmaceutical industry and the government as theprimary source of risk instead of diseases (Baker, 2008; Bearman, 2010; Kirkland, 2012).
When parents have various concerns about childhood vaccination, theirdecision-making may at the same time involve their perceived responsibility as parents.
Parents’ emphasis on the uniqueness of their children (Reich, 2016) and their obligation
to make the right decision for their children (Bobel, 2002) have been described in someliterature. Therefore, I particularly examine the complex relationships between vaccine
hesitancy and new parental norms through my qualitative data.
MethodI started my ethnographic investigation in 2018. To understand how vaccines
are described and discussed differently, my research assistant and I went to every
possible related occasion. They included lectures and activities about vaccinesorganized by NGOs, parental groups, and medical conferences. We also got to observe
vaccine adverse event-related court with a permit of the parents.
Informants recruitments were first conducted through personal networks
combined with snowballing and later through website advertisements. My research
assistant and I interviewed 16 parents, including those who delay or reject vaccinating
their children. And for the purpose of contrast, we also interviewed parents who fully
vaccinated their children.

Findings
The parents who are hesitant to childhood vaccination are mostly from CAM
or unconventional parenting communities. Unconventional parenting communities

4

Gender and Culture in Asia Vol.7, 2023

（特集）Changing Ideas about Mandatory Childhood Vaccination: Vaccine Hesitancy and New Parental Norms in Taiwan

refer to those who adopt methods that differ from mainstream ones, such as natural
childbirths, homeschooling, or sending children to Waldorf schools. This result issimilar to studies in Europe and North America. But in my research, even parents who
followed the immunization policy and fully vaccinated their children also feel anxious
about childhood vaccines. This thought-provoking phenomenon points to the influenceof new parental norms. As shown in the following, parents perceived a new role andresponsibility regarding childhood vaccination.
Emphasis on uniqueness of each child
Most CAM-using parents use Chinese medicine, and a few use homeopathy.
But more often, parents combine more than one type of CAM in daily care for theirchildren. The parents attribute their refusal of vaccination to their different views on
body and disease. First, they emphasized that letting children build up their immune
systems through interactions with viruses in natural environments is authentic and not
replaceable by vaccination. In their viewpoint, an immune system built up throughvaccination is weak. They believe this is evident from the fact that some children get
infected even after vaccination. As a mother expressed: “There are many cases thatchildren got infected, even after vaccination. Because their body is weak, the virus caneasily break in.”
By integrating CAM into daily care for children combined with good food anda healthy lifestyle, parents seek to prepare children well for diseases. The practices
reflect a concept quite different from the biomedical theory of vaccination. As said bya mother that “to vaccinate is to keep the child away from diseases. But we, who use
Chinese medicine, is to prepare the child a body which is ready to deal with sick.”
When the parents seek to prepare their children well for diseases, theyemphasis the uniqueness of each child. My research assistant and I went to interview amother in her apartment. The mother pulled out a box full of herd and explained how
she carefully observed her children every day and added herb into cooking according.
In other words, while deciding not to vaccinate their children, the parents devote timeand energy to the so-called immune DIY, boosting children’s immune systems with ahealthy diet and lifestyle. In this type of care practices, parents are those who know
their children best, instead of authoritative physicians (Attwell et al., 2018).
The emphasis on the uniqueness of each child is also found in other studies
on vaccine hesitancy. For example, Jennifer Reich’s research in the US shows, underneoliberal motherhood, vaccine hesitancy has a lot to do with the idea that each childis unique, and parents should carefully observe and tailor care according to each child’s
uniqueness. Vaccination as a universal intervention for all children starts to appear

Gender and Culture in Asia Vol.7, 20235

アジア・ジェンダー文化学研究【第 7 号】2023

somehow problematic (Reich, 2016).
“Blindly following is the biggest risk”
Another group of parents feeling hesitant about vaccination come fromunconventional parenting community, those who adopt parenting styles alternative tothe mainstream one including homeschooling, Waldorf school system, and homebirth.
Parents in this group refuse to blindly obey the rules, and emphasize self-determination.
As a mother working in NGO expressed like this: “No matter what, information should
be available and transparent. Then you get to say yes or no. This is the basic humanright. Vaccination should not be exceptional. I ask for information, and I make decision.
This is the same thing as what I am arguing for in natural childbirth movement.”
This group of parents learn to question authoritative power and making
decision for themselves through other movements they involve. For this group ofparents, blindly following is the biggest risk. They tend to have low trust of institutions.
Instead of diseases, they view malpractice in institutions as major risk. A motherinterviewed express her concern of vaccine by mentioned the new policy of mandatory
vaccination for HPV for female teenagers in Taiwan:
“[In the news] it is said that the government will make HPV vaccine mandatory.
Every junior high school girl has to be vaccinated. But I just saw another news
that there occur many adverse events associated with HPV vaccine in Japan.
Did not Taiwanese government saw the news? Why does not the government
think that we should better wait and observe the event? Why does it rush us
into this vaccination? Is it because the government gets huge money frompharmaceutical companies?”
The mother suspected that the government kept promote the vaccine despite the sideeffects because there is corruption going on.
Intensive Parenting: vaccination decisions become “parents’ homework”
Most importantly, the immune DIY mentioned above often requires intensive
parenthood in which parents spend tremendous amount of time and energy looking
after children. Many interviewees insist on giving kids homemade food, taking themoutdoors, and avoiding children using 3C. Some participants even move their families
to the countryside based on the same idea. The whole concept is also to prevent
pollution from the mainstream lifestyle that has been heavily industrialized.
During interviews, I was impressed by the extent that parents devote tochildcare. A mother whose daughters going to a Waldford school showed me the charts

6

Gender and Culture in Asia Vol.7, 2023

（特集）Changing Ideas about Mandatory Childhood Vaccination: Vaccine Hesitancy and New Parental Norms in Taiwanthat parents and teachers use to record and communicate daily life details of children,
including whether children eat out or eat at home, and what they eat and drink in every
single meal, the frequency of using restroom, and time of sleep. This type of record help
parents to trace back and identify what to adjust when something goes wrong with
their children bodily.
The new norm of intensive parenthood has a great influence on parental ideas
and practices regarding childhood vaccination. Traditionally, parents are assumed tofollow the mandatory vaccination policy that are viewed as the best way to protect
their children. However, in contrast, parents in my research often describe the decisionmaking on mandatory childhood vaccines as “parents’ homework.” When parents’hesitancy toward vaccination come from different concerns, they all point to theinsufficient information as the crucial aspect. Parents using CAM found it horrifying
to injecting something un-natural into their children and eager to know the made of,necessity, safety of the vaccines. Unconventional parenting community has low trust in
the institution and ask for information in order to make their own decisions.
It’s noteworthy to point out some emerging social conditions that may
reinforce parental need of information. First of all, informed decision is alreadyhighly emphasized in the field of health. Individuals are expected to be the informed
consumer of medical resources. The responsibility of decision-making shifts from thestate to individuals. People no longer rely merely on experts for making decisions.
Collecting information before making decisions is largely a principle in health issues. Asa mother said here, “I need to know what you inject into the body of my beloved child.
Nowadays, everything is required to mark its content materials, such as food, drinks,
even drugs and pills. But vaccine is the only exception”
Under contemporary parental norms, parents perceive new responsibility indeciding on childhood vaccination. In fact, even parents who fully vaccinate theirchildren told me they hope to know more about vaccines. A lack of information often
leads to anxiety and distrust. I once interviewed a mother who followed the mandatory
policy of childhood vaccination. At the end of the interview, I asked her, "if you could
give a policy suggestion, what would you say?" She responded almost immediately,"I wish the government could give us more information, so we would not feel soanxious when we take children to vaccinate." This newly perceived responsibilityof making vaccination decision is also indicated by a study on hesitant compilers inAustralia. Parents increasingly perceive vaccination as their decision for which theymust adequately be informed to fulfil their parental duties (Enkel, Attwell, Snelling, &Christian, 2018).

Gender and Culture in Asia Vol.7, 20237

アジア・ジェンダー文化学研究【第 7 号】2023

Societal changes and transforming parental norms
Based on the above, vaccine hesitancy is closely related to changing parental
norms in Taiwan. According to Lan Peichia, a Taiwanese sociologist who wrote thebook, because of the rapid social change and educational reform in the post-war era,a paradigm shift occurred in parenting. The young generation, especially those in the
new middle class, adopted modern parenting ideas and sought guidance, by contrast
with their parents, who tended to raise children based on tradition (Lan, 2019). Social
conventions and negligence of children's individuality are no longer the norms. In thiscontext, Taiwanese parents have gradually synchronized their views with their Westerncounterparts and pursued scientific childcare and intensive parenthood. Parents,
particularly mothers, are advised to follow expert childcare guidance. They are also
expected to critically read expert literature to inform decision-making regarding theirchildren (Apple, 2006). Besides, parenting has increasingly become 'child-centered, andparents invest a considerable amount of time and resources into caring for their children
and responding to their needs (Apple, 2006). The new parental norms have become thefoundation of attitudes toward childhood vaccination. Parents no longer simply follow
the rules but seek information to make informed decisions for their children.
As Dr. Lan highlights in her book, there exist differences among social classes.
the lifestyles and childcare methods are not feasible for most parents and thus do
not represent the majority of families in Taiwan. However, it is noteworthy to pointout that the new norms are mainstreaming. A parenting booklet published by the
Ministry of Public Health and Welfare described intensive parenting (Health Promotion
Administration, 2017) and encouraged it at the policy level. However, health authorities
have not acknowledged parents' increased demand for vaccine information causedby newly defined parental responsibilities. The failure to recognize parents' needs for
vaccine information and the lack thereof cause anxiety towards childhood vaccination
among parents. This kind of miscommunication become even more significant during
COVID-19 pandemics.
Conclusion
Based on above, I conclude that vaccine hesitancy among parents should beunderstood as the ideas and practices emerging in new socio-cultural conditions. As I
have shown that to assume these parents as ignorant and irresponsible can no longer
help us to get to the core of the problem. What might be worse is that this assumption
may hinder us to recognize parents’ need for information and in turn reinforce vaccine
hesitancy. I argue that only a substantial understanding of parents’ concerns can help
to develop an effective communication strategy. For this regard, I cite a sentence from
Elisa Sobo who was also an anthropologist studying vaccine hesitancy that “people are8

Gender and Culture in Asia Vol.7, 2023

（特集）Changing Ideas about Mandatory Childhood Vaccination: Vaccine Hesitancy and New Parental Norms in Taiwan

very ready to listen — if they’re heard” (Gordon, 2019).
References
Apple, R. D. (2006). Perfect Motherhood: Science and Childrearing in America. New
Brunswick, New Jersey; London: Rutgers University Press.
Attwell, K., Ward, P. R., Meyer, S. B., Rokkas, P. J., & Leask, J. (2018). “Do-it-yourself”:
Vaccine rejection and complementary and alternative medicine(CAM). Social
Science & Medicine, 196, 106-114. doi:10.1016/j.socscimed.2017.11.022
Baker, J. P. (2008). Mercury, vaccines, and autism: one controversy, threehistories. American journal of public health, 98(2), 244-253. doi:10.2105/
AJPH.2007.113159
Bearman, P. (2010). Just-so Stories: Vaccines, Autism, and the Single-bullet Disorder.
Social Psychology Quarterly, 73(5), 112-115.
Bobel, C. (2002). The paradox of natural mothering. Philadelphia: Temple University
Press.
Chen, Y. T., & Chiu, Y. C. (2014). Adverse Reactions Occur after BCG Vaccination,
Anxious Parents Expect Safety Surveillance Liberty Times. (In Chinese). Retrieved
from https://health.ltn.com.tw/article/paper/745443. Accessed 15 August 2019.
Chiu, S. Y. (2006). Respect the alternative practices: I Chose Not to Vaccinate My
Child. United Evening News. (In Chinese). Retrieved from http://olddoc.tmu.edu.
tw/pinging/XXX/xxx028.HTM. Accessed 26 February 2018.
Enkel, S. L., Attwell, K., Snelling, T. L., & Christian, H. E. (2018). ‘Hesitant compliers’:
Qualitative analysis of concerned fully-vaccinating parents. Vaccine, 36(44), 64596463. doi:10.1016/j.vaccine.2017.09.088
Gordon, M. (Writer). (2019). Medical Anthropologist Explores 'Vaccine Hesitancy'. In
Shots HEALTH NEWS FROM NPR. U.S.: National Public Radio. Retrieved fromhttps://www.npr.org/sections/health-shots/2019/02/13/694449743/medicalanthropologist-explores-vaccine-hesitancy. Accessed 9 January 2023.
Health Promotion Administration (MOHW). (2017). How to raise happy children withlove: positive parenting tools for 0 to 6 years. Ministry of Health and Welfare(Taiwan) (In Chinese). Retrieved from https://health99.hpa.gov.tw/material/3308
Kirkland, A. (2012). Credibility battles in the autism litigation. Social Studies of
Science, 42(2), 237-261. doi:10.1177/0306312711435832
Kuan CI. (2022). Vaccine hesitancy and emerging parental norms: A qualitative study
in Taiwan. Sociolology of Health Illness. 44(3):692-709. doi: 10.1111/14679566.13446. Epub 2022 Feb 17. PMID: 35174516.
Lan, P. C. (2019). Struggling to Raise Children: Globalization, Parental Anxiety, andUnequal Childhoods (1st ed.). Taipei: SpringHill Publishing. (In Chinese).

Gender and Culture in Asia Vol.7, 20239

アジア・ジェンダー文化学研究【第 7 号】2023

MacDonald, N. E. (2015). Vaccine hesitancy: Definition, scope and determinants.
Vaccine, 33(34), 4161-4164.
Reich, J. A. (2016). Calling the Shots: Why Parents Reject Vaccines. New York: NewYork University Press.
Shen, N. Y. (2017). Eight Thousand Schoolchildren Not fully Vaccinated, Taipei Health
Officials Urgently Remind Parents. Apple Daily (Taiwan). (In Chinese). Retrieved
from https://tw.appledaily.com/new/realtime/20170710/1157940/. Accessed 26
February 2018.
Sobo, E. J. (2015). Social Cultivation of Vaccine Refusal and Delay among Waldorf(Steiner) School Parents. Medical Anthropology Quarterly, 29(3), 381-399.
doi:10.1111/maq.12214
Taiwan Center for Disease Control, Taiwan Pediatric Association, & The Infectious
Diseases Society of Taiwan. (2013). Infection and Vaccine (1st ed.). Taipei:
Taiwan Center for Disease Control. (In Chinese).
World Health Organization (WHO). (2019). Ten Threats to Global Health in 2019 [Press
release]. Retrieved from https://www.who.int/emergencies/ten-threats-to-globalhealth-in-2019. Accessed 18 February 2019..
Yahya, M. (2007). Polio vaccines—“no thank you!” barriers to polio eradication in
Northern Nigeria. African Affairs, 106(423), 185-204. doi:10.1093/afraf/adm016

10

Gender and Culture in Asia Vol.7, 2023