Abstract:

This study aimed to learn how middle-class parents in the city of São Paulo, Brazil, interpreted the country's prevailing vaccination requirements, based on their experiences with vaccinating, selectively vaccinating, or not vaccinating their children. A qualitative approach was used with in-depth interviews. The analytical process was guided by content analysis and the theoretical framework of the anthropology of the law and morality. For parents that vaccinated, Brazil's culture of immunization outweighed the feeling of compliance with the law; for selective parents, selection of vaccines was not perceived as deviating from the law. In both, the act of vaccinating their children was a matter of moral status. Meanwhile, the non-vaccinators, counter to the legal perspective, attributed their choice to care for the child on grounds that mandatory vaccination was contrary to their way of life; they experienced a feeling of social coercion and fear of legal impositions. Vaccination is an important practice in public health, but it can reveal tensions and conflicts from normative systems, whether moral, cultural, or legal.

Keywords:
Obligatory Vaccination; Parental Notification; Child Health

Introduction

Vaccines are a preventive intervention known for their impact in reducing morbidity and mortality from vaccine-preventable diseases ¹1. Plotkin SA, Orenstein W, Offit P. Vaccines. 5th Ed. Philadelphia: Saunders Elsevier; 2008.. Mass vaccination is based on the vaccines' herd immunity effect, by which immunized individuals indirectly protect the unvaccinated and can eliminate circulation of the infectious agent and thus protect both the community and vulnerable individuals ¹1. Plotkin SA, Orenstein W, Offit P. Vaccines. 5th Ed. Philadelphia: Saunders Elsevier; 2008.^{), (2}2. Rose G. Estratégias da medicina preventiva. Porto Alegre: Editora Artmed; 2010.. Scientific and technological legitimation provided the basis for vaccination requirements in various countries of the world, notably in the latter half of the 20th century ¹1. Plotkin SA, Orenstein W, Offit P. Vaccines. 5th Ed. Philadelphia: Saunders Elsevier; 2008..

In Brazil, the institutionalization of public vaccination policies began with the creation of the National Immunizations Program (PNI) under Law 6,259 of October 30, 1975. The law regulated activities in epidemiological surveillance, vaccination, and compulsory notification of diseases nationwide ³3. Brasil. Lei nº 6.259, de 30 de outubro de 1975. Dispõe sobre a organização das ações de vigilância epidemiológica, sobre o programa nacional de imunizações, estabelece normas relativas à notificação compulsória de doenças, e dá outras providências. Diário Oficial da União 1975; 31 out., providing government with a highly relevant legal framework for mandatory vaccinations in the country. Formulated before the 1988 Brazilian Federal Constitution, and thus before the Brazilian Unified National Health System (SUS), Article 3 of Law 6,259/1975 states that it is the responsibility of the Brazilian Ministry of Health to elaborate the PNI, which determines the vaccinations, including mandatory ones, and provides that "mandatory vaccinations will be provided systematically and free of cost by public agencies and entities, as well as by private entities, funded by the federal, state, and municipal governments, throughout the national territory".

Law 6,259/1975 was regulated by Decree 78,231 of August 12, 1976, adding details on the implementation of mandatory vaccination in Brazil. According to Article 27 of the regulation, "nationwide mandatory vaccinations will be determined by the Ministry of Health, against vaccine-preventable diseases considered relevant in the country's disease profile" ⁴4. Brasil. Decreto nº 78.231, de 12 de agosto de 1976. Regulamenta a Lei nº 6.259, de 30 de outubro de 1975, que dispõe sobre a organização das ações de vigilância epidemiológica, sobre o programa nacional de imunizações, estabelece normas relativas à notificação compulsória de doenças, e dá outras providências. Diário Oficial da União 1976; 13 ago.. Article 29 of the decree further states that it is the duty of all citizens to submit to mandatory vaccination, together with all minors under their custody or responsibility. Exemption from mandatory vaccination is only allowed when the individual presents a medical report explicitly contraindicating the vaccine ⁴4. Brasil. Decreto nº 78.231, de 12 de agosto de 1976. Regulamenta a Lei nº 6.259, de 30 de outubro de 1975, que dispõe sobre a organização das ações de vigilância epidemiológica, sobre o programa nacional de imunizações, estabelece normas relativas à notificação compulsória de doenças, e dá outras providências. Diário Oficial da União 1976; 13 ago..

Mandatory vaccination of minors was later reinforced by the Statute for Children and Adolescents (ECA), Law 8,069/1990, regulating Article 227 of the 1988 Constitution, aimed at establishing minors' rights and comprehensive protection. In Article 14, sole paragraph, the Statute provides that "vaccination of children is mandatory in cases recommended by the health authorities" ⁵5. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o estatuto da criança e do adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul..

In addition to the above-mentioned legal provisions, the manuals, protocols, and technical guidelines orienting physicians and other health professionals define "not vaccinating" children (in cases that do not meet the formal technical contraindications) as an act of parental neglect or "omission of care". Non-vaccination is thus legally and technically defined as refusing of an intervention with proven benefits for the child. For example, in a document of the Brazilian Federal Board of Medicine, when a physician confronts parents' refusal to vaccinate their children, "the child's best interest should prevail, and the responsibility of the physician and the hospital exists independently of the parents. Thus, regardless of parental responsibility, it is necessary to notify and decide in favor of protecting the child, who is suffering a situation of neglect" ⁶6. Waksman RD, Hirschheimer MR, coordenadores. Manual de atendimento às crianças e adolescentes vítimas de violência. Brasília: Conselho Federal de Medicina/Sociedade de Pediatria de São Paulo; 2011. (p. 46).

Despite these legal and professional-ethical requirements, epidemiological evidence has revealed tensions in the acceptance of vaccination by some social segments ⁷7. Waldman EA. Mesa-Redonda: desigualdades sociais e cobertura vacinal: uso de inquéritos domiciliares. Rev Bras Epidemiol 2008; 11 Suppl 1:129-32.. Despite steadily increasing overall vaccination rates in the Brazilian population since creation of the PNI ⁸8. Domingues CMAS, Teixeira AMS. Coberturas vacinais e doenças imunopreveníveis no Brasil no período 1982-2012: avanços e desafios do Programa Nacional de Imunizações. Epidemiol Serv Saúde 2013; 22:9-27.^{), (9}9. Barata RB, Ribeiro MCSA, Moraes JC, Flannery B; on behalf of the Vaccine Coverage Survey 2007 Group. Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008. J Epidemiol Community Health 2012; 66:934-41., according to a household survey, beginning in the 2000s the vaccination rates have declined in the social stratum in the city of São Paulo with the highest income and most education, with significantly lower coverage in stratum A when compared to stratum E ¹⁰10. Moraes JC, Ribeiro MCSA, Simões O, Castro PC, Barata RB. Qual a cobertura vacinal real? Epidemiol Serv Saúde 2003; 12:147-53.. The same was shown in 10 Brazilian state capitals (including São Paulo) in a national study in 2007-2008 ⁹9. Barata RB, Ribeiro MCSA, Moraes JC, Flannery B; on behalf of the Vaccine Coverage Survey 2007 Group. Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008. J Epidemiol Community Health 2012; 66:934-41.. In addition, the recent reemergence of measles in Brazil, especially since 2011, in which most cases had been in direct or indirect contact with cases acquired abroad, triggered some foci of susceptible individuals in the population ¹¹11. Centro de Vigilância Epidemiológica "Prof. Alexandre Vranjac". Alerta sarampo 2015. http://www.cve.saude.sp.gov.br/htm/resp/pdf/Alerta_Sarampo_2015_jan_rev.pdf (acessado em 03/Mar/2015).
http://www.cve.saude.sp.gov.br/htm/resp/... .

Given the issue's relevance, the current challenges for public health, and the Brazilian context's specificities, the current study aimed to elucidate how middle-class fathers and mothers in the city of São Paulo interpret the country's vaccination requirements, based on their experiences with vaccinating, selectively vaccinating, or not vaccinating their children.

Methods and analytical framework

This article is part of a larger research project on parental care in families with high income and high education in the city of São Paulo. Data were collected with a qualitative approach, using in-depth interviews. This technique has the potential to reveal values and meanings that individuals assign to their personal experiences, thereby capturing the dimension of subjectivity ¹²12. Becker H. Métodos de pesquisa em ciências sociais. São Paulo: Editora Hucitec; 1994.^{), (13}13. Fontana A, Frey JH. The interview: from structured questions to negotiated text. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 2nd Ed. Thousand Oaks: Sage Publications; 2005. p. 645-72.^{), (14}14. Poupart J. A entrevista de tipo qualitativo: considerações epistemológicas, teóricas e metodológicas. In: Poupart J, Deslauriers JP, Groulx LH, Laperrière A, Mayer R, Pires AP, organizadores. A pesquisa qualitativa: enfoques epistemológicos e metodológicos. Petrópolis: Editora Vozes; 2008. p. 215-53. that we find important for achieving the study's objective. The interviews used an open and flexible script aimed at obtaining narratives that explored the experiences in the process of choosing whether to vaccinate, selectively vaccinate, or not vaccinate their children, the influences permeating such decisions, and the feelings associated with these experiences.

Definition of the study participants prioritized working with the couple, including both the father and mother as narrators of childcare and vaccination of the children. Couples in the study included: (1) married men and women that lived together; (2) with at least one child up to five years of age; (3) both with at least a university degree and belonging to the upper and upper-middle classes - A1, A2, B1, B2 ¹⁵15. Associação Brasileira de Empresas de Pesquisa. Critério de Classificação Econômica Brasil, 2011. http://www.abep.org/novo/Content.aspx?ContentID=301 (acessado em 03/Nov/2011).
http://www.abep.org/novo/Content.aspx?Co... ; and (4) living in the city of São Paulo. The selection was intended to grasp the different experiences with vaccinating versus not vaccinating the children within the setting of conjugality, seeking to avoid complicating the analysis by including other family arrangements. The children's age bracket of 0 to 5 years of age was intended to address the interviewees during the period with the highest concentration of vaccines in Brazil's prevailing basic immunization calendar (PNI) ⁸8. Domingues CMAS, Teixeira AMS. Coberturas vacinais e doenças imunopreveníveis no Brasil no período 1982-2012: avanços e desafios do Programa Nacional de Imunizações. Epidemiol Serv Saúde 2013; 22:9-27.. The socioeconomic criterion, schooling, and place of residence were intended to approach the socio-demographic profile in which previous epidemiological studies had shown a downward trend in childhood vaccination rates ⁹9. Barata RB, Ribeiro MCSA, Moraes JC, Flannery B; on behalf of the Vaccine Coverage Survey 2007 Group. Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008. J Epidemiol Community Health 2012; 66:934-41.^{), (10}10. Moraes JC, Ribeiro MCSA, Simões O, Castro PC, Barata RB. Qual a cobertura vacinal real? Epidemiol Serv Saúde 2003; 12:147-53..

The interviews were held separately with the father and mother in 13 couples and jointly (with both the father and mother) in two couples. This diversity was intended to enrich the empirical data, since the separate interviews aimed to obtain a more in-depth narrative from each individual without the spouse's interference or value judgment, while the joint interviews aimed to capture gender dimensions and childcare details in the family's dynamics at the moment of the interview.

Participants were accessed using the "snowball" technique ¹⁶16. Kendall C, Kerr LR, Gondim RC, Werneck GL, Macena RH, Pontes MK, et al. An empirical comparison of respondent-driven sampling, time location sampling, and snowball sampling for behavioral surveillance in men who have sex with men, Fortaleza, Brazil. AIDS Behav 2008; 12(4 Suppl):S97-104., oriented according to the child's vaccination status. The couples were thus divided into three groups: (1) "those that vaccinated" (immunized their children according to the PNI calendar); (2) "those that vaccinated selectively" (chose some vaccines and/or postponed the dates; and (3) "those that did not vaccinate" (intentionally opted not to vaccinate their children). This typology was based on international studies that also focused on parents' views on vaccination of their children ¹⁷17. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust. Pediatrics 2006; 117:1532-41.^{), (18}18. Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr 2012; 12:154., but with adaptations (the term "accepting" for couples "that vaccinated" and "rejecting" for those "that did not vaccinate"), intending not to label or judge the study participants, and assuming that the choice to vaccinate or not vaccinate was not fixed or rigid, but amenable to changes. Importantly, the couple's agreement concerning non-vaccination of the child was not an initial criterion in recruiting the couples, but rather the child's vaccination status (that is, complete, partial, or absent vaccination). However, the couple's agreement or disagreement was included in the analysis of the interviews.

The final number of interviews was determined during the fieldwork, using the criterion of theoretical saturation, which considered the meanings attributed to the experience of non-vaccination of children ¹⁹19. Fontanella BJ, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saúde Pública 2008; 24:17-27.. The final sample consisted of 30 individuals, totaling 15 couples, or 5 couples in each group.

The interviews were held from January to July 2011. The audio was digital-recorded, totaling an audio database of 971 minutes. The full interviews were then transcribed, and accuracy of the transcripts was verified. Analysis and interpretation of the material used thematic content analysis ¹³13. Fontana A, Frey JH. The interview: from structured questions to negotiated text. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 2nd Ed. Thousand Oaks: Sage Publications; 2005. p. 645-72.. An exhaustive reading of the material allowed identifying both predefined and emerging themes, following by categorization of the analysis in the following themes: decision-making concerning non-vaccination of children; parental, conjugal, and generational relations in the option for non-vaccination; childcare in the context of non-vaccination; and individual versus collective relations in vaccination of the children. The current article focuses on the interface between the latter two themes. Data were grouped by category using the NVivo package, version 8 (QRS International Pty, Doncaster, Australia).

As the theoretical framework, the analysis drew on the Anthropology of Law and Morality, concentrating on the characteristic empirical research of anthropological foundations, seeking to contribute to the understanding of the symbolic dimension of norms, rights, and laws ²⁰20. Oliveira LRC. A dimensão simbólica dos direitos e a análise de conflitos. Rev Antropol (São Paulo) 2010; 53:451-73., assuming that legal and moral standards can generate conflicts ²¹21. Simmel G. A natureza sociológica do conflito. In: Moraes Filho E, organizador. Simmel. São Paulo: Editora Ática; 1983. p. 122-34., beyond the (inter)subjective understanding of "conflict".

In the interface between Anthropology and Law, the conceptual distinction between law and morality is necessary to enhance the discussions and reflections on human and social actions, reactions, and interactions vis-à-vis standardizations. Morality is a set of norms and values established and accepted by society or social segments, contextualized in time and space, orienting and standardizing human conduct ²²22. Segato RL. Antropologia e direitos humanos: alteridade e ética no movimento de expansão dos direitos universais. Mana 2006; 12:207-36.. The distinction between custom or tradition and morality is based primarily on the fact that morality has an operational component or rational guide ²³23. Oliveira LRC. Antropologia e moralidade, 1993. http://www.anpocs.org.br/portal/publicacoes/rbcs_00_24/rbcs24_07.htm (acessado em 08/Mai/2015).
http://www.anpocs.org.br/portal/publicac... . Law is a regulation of human life established by the state and government, mediating life in community through the nation's social contract ²²22. Segato RL. Antropologia e direitos humanos: alteridade e ética no movimento de expansão dos direitos universais. Mana 2006; 12:207-36.. Referring to the two societal dimensions, "one can thus say that the morality of a given time or a given people and the law are systems that interact and exchange influences - the former, rooted in tradition and customs; the latter based on the deliberate and rational act of the contract and enactment by the group that controls the mechanisms for ratification of law" ²²22. Segato RL. Antropologia e direitos humanos: alteridade e ética no movimento de expansão dos direitos universais. Mana 2006; 12:207-36. (p. 220).

In the current study, the legal norms and professional ethics pertaining to vaccination of children in Brazil and the (non)acceptance of vaccination by some couples revealed tensions and conflicts that are relevant to public health. These conflicts, the object of the current study, were analyzed in the attempt to grasp the symbolic dimension or the meanings concerning vaccination requirements in Brazil from the parents' perspective. Thus, the idea is not to anthropologically analyze the law, legal penalties, the sense of justice, or even the right to vaccination versus non-vaccination, but to capture "the way the issues are experienced by the actors, or how they acquire meaning in their practices and motivate given patterns in their propensity to act" ²⁰20. Oliveira LRC. A dimensão simbólica dos direitos e a análise de conflitos. Rev Antropol (São Paulo) 2010; 53:451-73. (p. 464). In other words, we seek to situate the subjects' stances and the way they assess their decisions concerning vaccination versus non-vaccination of their children, in addition to the meanings assigned to such practices in the cultural context that informs laws and norms.

The study received prior approval from the Institutional Review Board of the School of Medicine, University of São Paulo (review 167/12). The interviews were only held after the participants signed a free and informed consent form. The names have been changed to guarantee the subjects' anonymity and data confidentiality. The study involves no conflicts of interest.

Meanings ascribed to vaccination requirements in Brazil

Participants' age ranged from 24 to 41 years, and most (both men and women) were in their thirties. That is, all the participants were born in the 1970s and 1980s, when the National Immunizations Program was created and expanded. All participants reported having been vaccinated in childhood. Of the 15 families, seven had two children and eight had one child at the time of the interview. The majority lived in neighborhoods in the upscale Central-West Side, but some came from other areas in the city of São Paulo. In addition to undergraduate degrees, some participants had Master's or PhDs. They were mainly employed in private companies or government agencies or worked as liberal professionals. Only Francisco was unemployed at the time of the interview. Table 1 lists the participants and their socio-demographic characteristics.

We chose to work with the analytical dimensions by comparing the three groups, but some decisions had to be made in the midst of tensions concerning the positions and values of the couples' members, especially among those who vaccinated selectively or did not vaccinate their children.

Participants expressed different meanings concerning Brazil's vaccination requirements. Couples that vaccinated their children said that vaccinating was an act of duty and parental responsibility. The decision was almost automatic for them, influenced by reproduction of a family tradition and by the credibility of the pediatric management, consequently ratifying children's vaccination as a valued and legitimate social practice. In these terms, no tensions appeared in this group as to the decision to vaccinate the children.

"I feel responsible. I mean like, 'Oh, poor little girl, it's going to hurt your leg', but the owie will soon go away, so you have to have the shot" (Camilo).

"You have to vaccinate. It's the parents' duty, and to give all the vaccines! In a public or private clinic, you can choose, but it's the parents' duty, because it's easier to prevent than to treat" (Bruno).

In these couples' narratives, the meaning assigned to the act of vaccinating the child, beyond the symbolic value of parental responsibility, included the idea of a perennial value cultivated by family tradition, passed down from when these parents themselves were vaccinated in childhood.

"I think it's because families see this as very important, I think that vaccinating and the care that you have with the doctor have a big influence on the family. So it's always been automatic" (Helena).

Without underestimating the parents' role and generational influence on the process of vaccinating children, the quotes by these couples refer to the idea that sustaining and emphasizing the act of vaccinating the children has more to do with the cultural value of vaccination (both in the private family setting and in the country's wider social environment) and less with the fact that it is legally mandatory. In other words, the acceptability appears to be anchored less in legality and more in the hegemonic cultural dimension attributed to this preventive measure. This perception corroborates what Hochman ²⁴24. Hochman G. Vacinação, varíola e uma cultura da imunização no Brasil. Ciênc Saúde Coletiva 2011; 16:375-86. calls a "culture of immunization" in contemporary Brazil. The author contends that nationwide mass vaccination, especially the campaigns to eradicate smallpox from 1967 to 1980 (driven by the World Health Organization), like the progressive introduction of available vaccines for the population, vaccination on a nationwide scale, marketing strategies with vaccination of famous individuals, and events in public squares during a period of political repression were determinant in the emergence of the "culture of immunization" in the country. A predominant feature in the discourse of these couples is a system of social reciprocity in which persons vaccinate themselves and their children according to culturally consolidated norms. The fact that these parents take vaccinating their children for granted is consistent with the legal requirement, but in their discourse it appears not to hinge on the law's presence or absence.

Among the couples that vaccinated selectively, vaccination as a value continued to appear in their discourse, despite the tensions in some couples concerning the selection criteria and the decisions on when to administer the vaccines or to suspend the vaccination calendar in case of adverse events. What changed in comparison to couples that vaccinated their children according to the full calendar was the symbolic value assigned to the parents' duty and responsibility. In this case, given an extensive and generalized calendar for the entire Brazilian population, parental responsibility what based precisely on the specification of the child's best interests.

"Society generalizes all of this. But I can make the decisions, even though they may not always be right, but at least I can stop and think, and personalize. (...) So, it's about assuming the responsibility myself, which is really up to me. It's not the government's responsibility or anybody else's. It's ours, as parents, as a family" (Andreia).

"Living in São Paulo today, I think there could be some flexibility with this calendar, and there could be more debate about it" (Sílvia).

Individualization of the child's vaccination in relation to the Ministry of Health's recommended vaccination calendar ³3. Brasil. Lei nº 6.259, de 30 de outubro de 1975. Dispõe sobre a organização das ações de vigilância epidemiológica, sobre o programa nacional de imunizações, estabelece normas relativas à notificação compulsória de doenças, e dá outras providências. Diário Oficial da União 1975; 31 out.^{), (4}4. Brasil. Decreto nº 78.231, de 12 de agosto de 1976. Regulamenta a Lei nº 6.259, de 30 de outubro de 1975, que dispõe sobre a organização das ações de vigilância epidemiológica, sobre o programa nacional de imunizações, estabelece normas relativas à notificação compulsória de doenças, e dá outras providências. Diário Oficial da União 1976; 13 ago. was not seen as deviation or possible legal infringement, but as variation of behavior within the cultural norm of vaccination. As a moral backdrop, these selective couples claimed the prerogative of autonomy in caring for their children, even in the face of generalized norms.

The couples that did not vaccinate viewed the act of not vaccinating as care for their child, as opposed to the legal perspective, which defines such practice as child neglect (except for medical contraindications), since immunization is scientifically proven to be beneficial to children's health ⁵5. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o estatuto da criança e do adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul.. On moral grounds that the parents' responsibility and duty is to choose what is best for the child regardless of prevailing legal requirements, the parents who did not vaccinate differed from the other two groups (those that vaccinated and those that vaccinated selectively) by not assigning a positive value to vaccination. On the contrary, they questioned and rejected it as good for their child's health.

"We still have laws in Brazil that give you total decision-making power to proceed as you wish with your own children. The laws should prevent atrocities like parents beating their children, these terrible things that keep happening. I think [the country] is on a promising path, but still not in relation to vaccination, because I think greater mobilization is needed" (Virginia).

"Respect in my home is my own decision. I'm the mother. Let them do a psychological test to prove I'm not insane, that I'm making a conscious choice" (Paula).

What prevailed in this group was the mother's role in initiating a critical discussion of vaccination, permeated by different shades of tensions and discussions in the couple on non-vaccination of the children, ranging from more harmonious understanding - based on the man's trust in the woman's questioning and decisions - to reports of clashes in the couple during the process of non-vaccination.

"We ended up deciding it was better not to vaccinate. I really trust her, and we had read a lot of research results on the internet, and another scientific study on the subject. I was really comfortable about it, too. I thought it was better not to vaccinate, at least not then" (Fernando).

"To decide to vaccinate or not, what's the best vaccine to give, what's the final solution, is very difficult. We negotiate a lot, we discuss a lot, understand?" (Vinícius).

Thus, the vaccination calendar recommended by the PNI and vaccines in general are seen as illegitimate by these individuals. This becomes more obvious when they say they feel fine about the decision concerning their child's health, that they feel their children are more protected when they don't vaccinate.

"I'm completely secure about the decision. I don't have the slightest fear that they'll catch a disease and die. If by any chance that happens, I'll understand that it could have happened even if they'd been vaccinated" (Virginia).

The discourses of couples that did not vaccinate their children featured a position based on symbolic values and practices that emphasized and sought natural childbirth, healthier lifestyles, fewer medical and hospital interventions in health processes (as opposed to disease) - such as childbirth seen as physiological rather than pathological, childcare centered on the healthy child, etc. - and parental decision-making autonomy vis-à-vis government, biomedical, or public health norms in childcare. The justifications reported by these couples, who based their critical analysis of vaccination and their decision for non-vaccination, published in a previous study that focused on the interface between parental care and vaccination of children ²⁵25. Couto MT, Barbieri CLA. Cuidar e (não) vacinar no contexto de famílias de alta renda e escolaridade em São Paulo, SP, Brasil. Ciênc Saúde Coletiva 2015; 20:105-14., were: the argument that the disease has been eliminated or is mild, fear of adverse events, criticism of the vaccines' composition and/or efficacy, Brazil's vaccination calendar, the pharmaceutical industry's financial interest and profit, and choice of other forms of health protection (like more a natural lifestyle). Vaccines were not all problematized identically, and the criticisms for the oral polio vaccine and measles-mumps-rubella stood out due to the alleged risk of adverse events and the perception that these diseases are under control in Brazil, as well as the vaccines for rotavirus and influenza, which they considered mild diseases.

Non-vaccinating couples thus expressed values related to more natural lifestyles, such as fewer medical interventions, contending that their children are healthy. The narratives of these couples emphasized that universal legal standardization of vaccination makes little sense to their lifestyles; they take a stance in the private family sphere that goes against the dominant cultural value associated with vaccination in the country as a whole.

Mass vaccination of children: between culture and the law

Among couples that vaccinated or selectively vaccinated, adherence (total or partial) to vaccination added to broader tradition and family and social custom. They viewed vaccinating the child as an act of moral status. For them, the legitimacy of vaccination in Brazil achieved the status of a cultural assimilation, to the point that this act had been incorporated into their imaginary, independently of the law's existence. Quotes by some of the parents showed that they were even unaware that vaccination is legally mandatory in Brazil.

"It's the first time I've thought about it. Maybe some vaccines should be legally mandatory, like it's not the parent's choice, you have to vaccinate, period. I tend to be against this business of being voluntary, but if it doesn't affect my family or friends, I go out and publically demonstrate for vaccines. I'm not raising any rallying cry" (Guilherme).

Meanwhile, couples that did not vaccinate their children were more aware of the legal requirements and their consequences, as expressed mainly by their fear of being reported for "deviant" conduct, fear of loss of authority over care of their children by public agencies such as the Guardianship Council, and fear of unfair judgment.

"So I'm afraid someone will report me to the Guardianship Council and force me to vaccinate. Because then my daughter will have to have a dozen vaccines all at once. That's all I'm afraid of. I'm not worried about her health. I know she's fine, well cared-for" (Amanda).

"So we chose not to vaccinate. Nowadays, honestly, my main concern is not the disease at all. It's more of a legal concern, because there's the legal obligation to vaccinate, but even there you could challenge it in court if necessary" (Fernando).

"My fear is that people will actually question our power over the children. They may want to submit to the Guardianship Council whether the children will remain in our custody, understand? We have to make the best possible decisions on these matters. But it's a heavy burden, understand? Because we're alone, and we know other won't back us on these decisions" (Vinícius).

These couples said they felt morally comfortable about the decision made on a matter of the child's health, and the feelings that stood out in the "deviant" practice resulted from the possible legal consequences. These were experienced more as coercion from their closest social milieu than as a direct personal experience (or that of peers) like a penalty for disobeying the law or an actual report of legal punishment.

"We follow some debates on the internet, about people reporting others anonymously. You know, in school, they send e-mails saying 'so-and-so's kid isn't vaccinated'. And they ask to see the child's vaccination card, because sometimes I think it bothers people" (Diogo).

"From friends, too, because everybody vaccinated, we because didn't vaccinate, they say, 'You're crazy! Irresponsible, you were supposed to vaccinate'" (Fernando).

"Not to mention the threat that people will decide to interfere in the matter. Our nightmare is, 'Now you're going to give these vaccines, I'm going to take these kids here to give these vaccines.' You can be labeled a negligent parent. So we live under this threat of somebody deciding to use authority against us" (Vinícius).

In the legal sphere, Article 5-II of the Brazilian Federal Constitution provides that "no one will be forced to do or refrain from doing something except by virtue of the law". Thus, whenever there is a law requiring a certain act, the act is theoretically mandatory nationwide. In addition to the explicit provision on mandatory vaccination as defined in Article 3 of Law 6,259/1975, various other legal provisions in Brazil spell out this obligation in detail. Whenever the law specifies a duty, in order for the duty to be followed by people, the legislation provides a set of possible penalties for non-compliance. In the case of vaccination, government enforces the law by requiring a copy of children's vaccination card when they enroll in a public daycare center or by requesting proof of vaccination to obtain the Bolsa Família benefit, to take public admissions exams, or for public employment. An unprecedented class action suit reviewed on September 23, 2013, coming from the São Paulo State Court of Justice, Jacareí Circuit Court, based on article 273 of the Civil Code, and article 213/1 of the ECA, ruled that a couple who had not vaccinated their children had 5 days to do so. In case of non-compliance with the court order, a daily fine was set at one minimum wage ²⁶26. Tribunal de Justiça do Estado de São Paulo. Comarca de Jacareí. Processo número 0012994-09.2013.8.26.0292. http://www.mpsp.mp.br/portal/pls/portal/docs/1/2423200.PDF (acessado em 25/Fev/2014).
http://www.mpsp.mp.br/portal/pls/portal/... .

The fact that couples who vaccinated or selectively vaccinated their children were unaware of (or failed to mention) Law 6,259/1975, the fact that such penalties hardly affected the social stratum studied here (high-income couples with at least university diplomas), and the fact that an unprecedented case of legal enforcement only occurred in 2013 shed doubt on the law's efficacy. As identified in the participants' interviews, incorporation of the act of vaccinating by many families appears to be associated with the cultural and moral norm established in the country. Meanwhile, non-vaccinating couples, in relation to non-compliance, experienced obstacles that were more coercive than actual legal penalties. Such coercion and hostility, backed by the social norm, is reflected in the isolation of these couples, who experience antagonism between personal satisfaction vis-à-vis non-vaccination and social normative requirements.

"We never discuss the vaccination issue with anyone in our daily lives, because of the prejudice. Somebody might report us. People's heads are really complicated, they might get scared" (Diogo).

"So I treat this [non-vaccination] as a secret" (Vinícius).

"We don't tell anyone, we don't talk about it. We only comment with people that we really trust. That's the reason for all the quiet, the caution and all" (Ana).

Final remarks

Vaccines as a technique and mass vaccination as a public health practice comprise a fertile and complex field, considering their benefits and properties for the community and the possible conflicts stemming from normative systems, whether of a moral/cultural or legal order. This study problematized how parents that make different decisions about vaccinating their children signify the country's vaccination requirements through their own experiences.

The initial process of cultural assimilation of the vaccine as a value in childcare and the virtuous view of public immunization policies in Brazil - culminating in the steady popularization of immunization and increasingly higher vaccine coverage rates ⁸8. Domingues CMAS, Teixeira AMS. Coberturas vacinais e doenças imunopreveníveis no Brasil no período 1982-2012: avanços e desafios do Programa Nacional de Imunizações. Epidemiol Serv Saúde 2013; 22:9-27. - preceded the law making vaccination mandatory in 1975, vaccination as a right guaranteed by the 1988 Federal Constitution, the Health Act of 1990, and the ECA of 1990 ²⁴24. Hochman G. Vacinação, varíola e uma cultura da imunização no Brasil. Ciênc Saúde Coletiva 2011; 16:375-86..

This national scenario and its specificities encompass a diversity of positions on the vaccination of children, as observed in this study. Notwithstanding decisions that align with or diverge to varying degrees from the legal requirements, they all share the value of parental responsibility in the context of the decision not to vaccinate, from an individualizing perspective in the private family sphere. The interviewees belong to a middle-class cultural world in the city of São Paulo that draws on these norms to conduct particular readings (whether through full acceptance of the laws and requirements or different degrees of problematizing or questioning, or even refusal to adopt them).

Mandatory vaccination represents protection of the public good through prevention and health promotion, but it should not be taken in its absolute form; flexibility is always possible in cases where non-vaccination does not pose relevant public health risks. It involves a conflict between individual freedom and public health that should always be weighed in light of the legal principles of reasonability and proportionality, insofar as possible balancing health protection with the protection of individual freedoms.

Thus, the legitimacy and symbolic capital of vaccination in participants' eyes appear to extrapolate and/or precede the legal norm, by means of social identification with Brazil's "culture of immunization" ²⁴24. Hochman G. Vacinação, varíola e uma cultura da imunização no Brasil. Ciênc Saúde Coletiva 2011; 16:375-86.. The country's public immunization policies help build and strengthen this culture. According to the study's findings, is experienced as a moral value by couples that vaccinated or selectively vaccinated their children. For couples that did not vaccinate, the overriding moral value was their way of life - assigning to vaccination of children a sense of risk or an unnecessary intervention in a healthy child - experienced with hostility and social coercion.

The study's findings corroborate the deconstruction of the view of vaccines/vaccination as univocal, timeless, and ahistorical ²⁷27. Moulin AM. A hipótese vacinal: por uma abordagem crítica e antropológica de um fenômeno histórico. Hist Ciênc Saúde-Manguinhos 2003; 10 Suppl 2:499-517.. On the contrary, vaccines display multiple facets whose reproduction and perpetuation of norms and different reactions reinforce vaccination as a human and social construct, thus relational and socially and historically contextualized ²⁵25. Couto MT, Barbieri CLA. Cuidar e (não) vacinar no contexto de famílias de alta renda e escolaridade em São Paulo, SP, Brasil. Ciênc Saúde Coletiva 2015; 20:105-14.^{), (28}28. Donnangelo MCF. Saúde e sociedade. São Paulo: Duas Cidades; 1976..

Acknowledgments

The authors wish to acknowledge the financial support from the Brazilian National Research Council (CNPq; grant 480024/2011-1).

References

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