Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: https://www.tandfonline.com/loi/hhth20

Pro-Vaxxers Get Out: Anti-Vaccination Advocates

Influence Undecided First-Time, Pregnant, and
New Mothers on Facebook

Amanda S. Bradshaw, Summer S. Shelton, Easton Wollney, Debbie Treise &

Kendra Auguste

To cite this article: Amanda S. Bradshaw, Summer S. Shelton, Easton Wollney, Debbie
Treise & Kendra Auguste (2020): Pro-Vaxxers Get Out: Anti-Vaccination Advocates Influence
Undecided First-Time, Pregnant, and New Mothers on Facebook, Health Communication, DOI:
10.1080/10410236.2020.1712037

To link to this article: https://doi.org/10.1080/10410236.2020.1712037

Published online: 10 Jan 2020.

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HEALTH COMMUNICATION
https://doi.org/10.1080/10410236.2020.1712037

Pro-Vaxxers Get Out: Anti-Vaccination Advocates Influence Undecided First-Time,

Pregnant, and New Mothers on Facebook
Amanda S. Bradshawa, Summer S. Sheltonb, Easton Wollneya, Debbie Treisea, and Kendra Augusteb
a
Department of Advertising, College of Journalism and Communications, University of Florida; bDepartment of Communication, Media, &
Persuasion, Idaho State University

ABSTRACT
Social media has revolutionized health information-seeking behavior with crowd-based medical advice.
Decreased vaccination uptake and subsequent disease outbreaks have generally occurred in localized
clusters based on social norms; however, geographically unrestricted Facebook networks promote
parental vaccination refusal congruent with digital identity formation. Interactions within the largest
closed Facebook group for vaccination choice were analyzed through the lens of Social Influence
Theory. Anti-vaccination advocates impacted first-time mothers’ expressed vaccination intentions
through both informational and normative influence processes. Six overarching themes were identified
as strategies used by these individuals to persuade fence sitting parents to delay or decline vaccinations,
including: natural solutions, maternal empowerment, distrust of conventional medicine establishment,
fear appeals, ‘Russian Roulette’ risk benefit analysis, and misinformation and misunderstandings.

It has been said it takes a village to raise a child. In the digital
age, this ‘village’ goes far beyond geographic limitations and the
proximal relationships of friends and family. Social media, such
as Facebook, allow caregivers to tap into a constant supply of
emotional support from around the globe. Parents encourage
one another to inherently question healthcare providers and to
self-educate about decisions for their children utilizing now-
widespread “technologies of doubt” for improved health out-
comes (Sobo, Huhn, Sannwald, & Thurman, 2016). Facebook
use increases at the transition to parenthood (Bartholomew,
Schoppe-Sullivan, Glassman, Kamp Dush, & Sullivan, 2012),
with mothers of preschoolers being the most active users
(Tomfohrde & Reinke, 2016). Notably, mothers, rather than
fathers, are primarily responsible for making health decisions
for their offspring (Kaiser Family Foundation, 2014).
Digitized social media interactions inform health decisions,
such as whether or not to vaccinate a child, which extend past
the individual and impact society. Vaccination is a public
health intervention touted as secondary only to clean drinking
water in increasing life expectancy and reducing mortality,
morbidity, and health costs arising from infectious disease
outbreaks (Andre et al., 2008). However, the eradication of
smallpox and elimination of other deadly illnesses from
Western countries has made vaccination a victim of its own
success; parents may choose to focus on and fear perceived
risks of vaccine side effects, such as autism, rather than
vaccine preventable diseases. Anti-vaccination was declared
one of 10 global health threats in 2019 by the World Health
Organization (WHO, 2019), and refusal to vaccinate is leading
to clusters of disease resurgence (Ventola, 2016).
While overall vaccination uptake in the United States
remains high, continued, timely vaccination is needed to
maintain community immunity. Areas with low vaccination
coverage puts people at risk including the immunocompro-
mised, infants, and the elderly (Centers for Disease Control
and Prevention, 2017). For example, one study revealed as
many as one in four public school children of their sample in
New York state were following alternate vaccination schedules
(e.g. delaying or declining one or more vaccinations) (Nadeau
et al., 2015).
The World Economic Forum acknowledged massive digital
misinformation, such as the proliferation of unsubstantiated
anti-vaccination claims, as a major threat to modern society
(Bessi et al., 2016). Digital media’s capacity for user-generated
content allows anti-vaccination activists to propagate their
messages to an extensive, diverse audience, which is proble-
matic due to the shifting healthcare paradigm of decreased
trust in science, empowered patients, and redefined expertise
or vox populi. As online wisdom from the crowd is seen as
equally or even more credible than the advice of a physician
(Bäckström et al., 2017), more research is needed to under-
stand how mothers process conflicting health information
online (Carpenter et al., 2015). “Thought influencers” in the
anti-vaccination movement rely on social media to spread
their message, with more than 7 million Facebook followers
cumulatively (Smith, 2017).
The largest closed Facebook group centered on vaccine
choice, which appeared at the top of Facebook search results
for vaccine groups at the time of this study, originated in
May 2016, had ~33,000 members, and was linked to a public

CONTACT Amanda S. Bradshaw abradshaw1@ufl.edu University of Florida Weimer Hall 1885 Stadium Rd, Gainesville, FL 32611, USA.
© 2020 Taylor & Francis Group, LLC
2 A. S. BRADSHAW ET AL.
Facebook group with more than 100,000 members. The
group’s purpose was outlined as an international community
designed to provide education, support, inspiration, and
resources to help members oppose medical mandates and
vaccine ‘tyranny.’ As their top priority was proclaimed to be
(one-sided) information sharing, any individuals causing
trouble, known as trolls, or advocating for or sharing pro-
vaccine propaganda within this self-proclaimed echo chamber
were removed from the group immediately, according to a list
of rules by which members must abide. However, this declara-
tion did not stop many pregnant, new, and first-time mothers
from coming into the group, curious to hear both the pros
and cons of vaccination in order to make an informed deci-
sion. The authors could not locate any previous study obser-
ving the natural flow of social interactions within closed
Facebook groups centered on vaccination choice, presumably
due to obstacles with gaining access to these members-only
groups. Thus, the purpose of this study was to analyze how
undecided first-time, pregnant, and new mothers were treated
and influenced by anti-vaccine advocates in this closed
Facebook group.
Literature review
Social media informs maternal vaccination decisions for
children
Whereas three to seven percent of all children are under-
vaccinated due to intractable parental views, a much larger
group of “fence-sitting” parents has been identified as a target
population for real gains to be made in pro-vaccination com-
munication campaigns (Leask, 2011). Fence sitters are defined
as those parents who are wavering about whether or not to
vaccinate their child, perhaps weighing perceived pros and
cons (Nicholson & Leask, 2012). Childhood vaccination deci-
sion-making begins while the baby is in utero, and first-time
mothers have been identified as notably more vaccine hesitant
and undecided (Danchin et al., 2017; Dubé et al., 2016).
However, as many as one third of pregnant women reported
receiving inadequate information from healthcare providers
about vaccines during pregnancy (Danchin et al., 2017). In the
absence of evidence-based, vaccination education from
healthcare providers during pregnancy, undecided first-time,
pregnant and new mothers turn to social media for informa-
tion, support, and advice from other mothers. As the first
sequences of major childhood vaccinations are given prior to
a child’s entrance to kindergarten.
Facebook is a salient source for maternal health informa-
tion seeking regarding early childhood issues, such as vacci-
nations (Drentea & Moren-Cross, 2005; Kata, 2012; Sobo
et al., 2016). A clear need has been identified to understand
how social media interactions shape parental perceptions of
vaccine preventable diseases as well as potential side effects,
which may in turn influence vaccination childhood decision-
making (Leask, 2011). Facebook is the most used social media
platform with 2.2 billion active monthly users (Statista, 2018).
Three quarters of online parents reported using Facebook
compared to less than 30% of online parents using other
social media platforms (Pew Research Center, 2015).
Notably, user comments on social media have been reported
to carry more weight than official CDC and National Vaccine
Information Center texts (Sobo et al., 2016). Therefore, more
research is needed to explore the influence of peer-to-peer
Facebook interactions in childhood vaccination decision
making.
The need to study closed Facebook groups
Previous studies about digital childhood vaccination content
used publicly available data from channels such as Internet
discussion forums (Fadda, Allam, & Schulz, 2015), Twitter
(Salathe & Khandelwal, 2011), public Facebook pages
(Aquino et al., 2017), and openly available YouTube videos
(Covolo, Ceretti, Passeri, Passeri, & Passeri, 2017). Whereas
public pages facilitate the open sharing of information and all
opinions are welcome, closed and secret groups maintain
different levels of privacy, protecting both group affiliation
and dialogue (Facebook, 2018). These quasi-private virtual
villages inspire more in-depth discussions than open pages
and tend to be polarized in favor of science or conspiracy
(e.g. pro or anti vaccination). They may serve as echo cham-
bers which inform and/or reinforce parenting decisions (Bessi
et al., 2015). Administrators police the discussion threads to
delete dissenting comments, reiterate the rules, and kick out
the ‘trolls,’ (e.g. those who oppose in-group favoritism or
group think) (Ditrich & Sassenberg, 2017).
Existing research calls for understanding how information
acquired inside network discussions may impact opinion for-
mation (Lee, Choi, Kim, & Kim, 2014). In the realm of
political communication, Facebook activity was positively
associated with subsequent activism, and use of the network
was found to shape many personalized identities into
a “homogenized collective identity-block” through peer net-
work identification (Bene, 2017). Vaccine refusal has been
associated with a declaration of identification with a social
group that is important to the individual. Essentially, the
decision to decline is “more about who one is and with
whom one identifies than who one isn’t or whom one
opposes” (Sobo, 2016).
Theoretical framework
Social Influence Theory (Kelman, 1958), which explains how
one’s attitude, or evaluative orientation toward a person,
thing, or idea may be changed, emerged as an important
lens through which to analyze group interactions. Three levels
of attitude change based on Social Influence Theory include
compliance, identification, and internalization. First, those
who comply accept influence because they hope to gain
a favorable reaction from a person or group, not necessarily
because they believe the content. This is a base-level attitu-
dinal change that aims to gain rewards or avoid punishment
(e.g. affirmation vs. mom shaming). One level up, identifica-
tion is defined as conformity due to a desire to establish or
maintain a relationship with the group, in this case the in-
group closed Facebook network. Finally, internalization is the
highest level of change where individuals accept influence
congruent with their own value system (e.g. those who believe

in a natural parenting style may incorporate vaccination
refusal as an associative aspect of that preexisting belief
system).
As opposed to discussions on public Facebook pages,
members in closed groups may prefer and appreciate a quasi-
private setting where friends and family outside the group
cannot see any of the dialogue, which can lead to more open
disclosures and the potential for deeper relationships. Even
though mothers’ real names and pictures are attached to their
posts, the closed group setting gives members a perception of
collective, system-based trust and privacy that the information
they share will not be disclosed outside the group despite its
large size (Pan, Wan, Fan, Liu, & Archer, 2017). Recognizing
that some members simply participate in an effort to reinforce
their own beliefs (selection bias) through reading anti-
vaccination posts, shared articles, and discussion threads
(confirmation bias), it is perhaps more critical to understand
how this one-sided group could influence pregnant, first-time,
and new mothers who are on the fence or genuinely seeking
information on both sides about the safety and efficacy of
vaccinations. This study aimed to discover what effect, if any,
the closed Facebook group dialogue might have on these
particular mothers’ stated intentions to vaccinate their infants,
as articulated in the following research question:
RQ: How are expectant, first-time, and new mothers influ-
enced by interactions with anti-vaccine advocates in a closed-
Facebook group?
Methods
Qualitative content analysis was employed to understand the
“actual behavior and attitudes of the people being studied”
(Sandelowski, 2010, p. 78) based on posts in the largest closed
Facebook discussion group for vaccine choice. Prior to data
collection, the lead researcher searched Facebook for groups
related to “vaccine choice,” and asked, and was approved to
become a member of this Facebook group stating that she
wanted to “seek information.” University Institutional Review
Board (IRB) approval was granted with stipulations to main-
tain member and group anonymity including assignment of
a fictitious group name, aggregation of data, and paraphrasing
comments. In other words, no verbatim posts could be
reported in the study’s results. The researcher did not at any
time post in the group or interact with members.
The lead researcher then conducted a keyword search
within the Facebook group itself to locate posts containing
vaccine questions asked by expectant mothers, first-time
mothers, and new mothers who appeared to be on the fence
or still deciding about whether or not to vaccinate their infant.
Posts were identified using key words such as “pros and
cons,” “first-time mom,” “FTM,” “unsure,” “undecided,”
“on the fence” etc. Researchers identified 50 posts that fit
the search terms between the group’s inception in May 2016
and October 2017, offering more than one year’s worth of
data, which includes both prenatal and postnatal insights from
a few participants. This allowed for insight into follow up
posts, when available, of self-reported actual vaccination beha-
vior as compared with the questioning mother’s previously
HEALTH COMMUNICATION 3
stated intent. However, 15 of the identified 50 posts were
eliminated as they were not relevant to the topic at hand,
such as those related to decisions about circumcision. The
final total of 35 posts included 2,736 comments, and the post
thread was the unit of analysis.
Data analysis
The goal of the present study’s qualitative content analysis was
to identify themes or patterns present in the data (Hsieh &
Shannon, 2005) and to analyze the members’ interactions with
the original poster (OP). Five coders, trained in qualitative
data analysis, first analyzed the same four randomly selected
posts, which included 322 comments. These coders, using
open coding (Charmaz, 2004), first read the posts thoroughly,
line-by-line, highlighting indications of themes present, and
recording: pregnancy status, age of the child, current vaccina-
tion intentions, previous child vaccination history, and refer-
ences to research, books, videos, documentaries or links for
more information. The evolution of the OP’s mind-set
throughout the post was determined by reading each com-
ment starting with the initial post and noting how concerns
and tone changed in progressive comments generated by the
OP. Coders searched for direct statements attesting to
whether or not the OP expressed intentions to change child-
hood vaccination behavior based on commenters’ input.
Instances of bullying or shaming of the OP such as comments
in all caps, name calling, and profanity were recorded. Specific
Social Influence Theory questions were created using five-
point Likert scales; coders evaluated to what extent the OP
appeared to accept information obtained from others and to
what extent the OP appeared to give positive responses in
order to elicit group harmony.
A simultaneous and iterative thematic analysis approach
was employed in the coding process to discover patterns or
themes within the data in rich detail (Braun & Clarke, 2006;
Glaser & Strauss, 1967). Researchers repeatedly met to discuss
their findings, resolving differences, clarifying and reaching
shared agreement, thereby establishing the credibility of find-
ings through researcher triangulation (Corbin & Strauss,
2007). Finally, the remaining 31 posts, with an even distribu-
tion of comments, were randomly assigned to the researchers
to analyze. To arrive at the final set of codes, researchers
reviewed and read the posts several times incorporating emer-
ging themes.
In accordance with the evolving nature of qualitative
research (Wimmer & Dominick, 2006), the emergent themes
were combined, discussed, retained, or rejected. Analyses of
themes were conducted throughout the coding process and
continued during the writing of the final results (Strauss &
Corbin, 1998) until saturation occurred for each theme.
Results
Overview of demographics
Of the 35 original posters (OP), 12 mentioned directly that they
were currently pregnant at the time of the post, with two of
these specifying that this was their first pregnancy. Nineteen
4 A. S. BRADSHAW ET AL.
OPs specified that they were not pregnant and four did not
mention pregnancy status. In addition to pregnancy status,
coders explored the ages of the children that mothers directly
reported in their posts. No OP referenced a child older than
one year, and the majority of posters were asking about fetuses
and/or children born within the last eight weeks.
Coders also examined whether OPs directly identified as
being first-time mothers or having other children. Nine pos-
ters directly identified as being first-time mothers (including
expectant mothers with their first child); seven posters directly
mentioned having other children in addition to the child they
were inquiring about; and 19 posters did not directly mention
other children.
Social influence theory findings
Based on the original poster’s initial post in the group, the
majority of original posters (n = 22) expressed their stance on
vaccination to be on the fence or questioning, as they reported
posting in the group to learn about both the pros and cons of
vaccination in order to make a perceived informed decision.
One OP declared herself to be a decided pro vaxxer, while 10
original posters were already fairly decided anti-vaxxers in
that they expressed feeling comfortable delaying or declining
some or all vaccines and simply sought support and affirma-
tion of this decision from the group. Two OPs did not express
a clear enough stance on vaccination in their original post to
categorize.
Approximately 83 percent (n = 29) of original posters
responded to one or more of the comments in the thread
under their original post. Coders applied the foundational
lens of social influence theory to these responses to deter-
mine to what extent the OP appeared to accept information
from others (1- didn’t accept at all to 5 fully accepted); to
what extent the OP appeared to give responses with a desire
to elicit group harmony such as switching to in-group lan-
guage (1- didn’t do this at all [e.g. pushing back, questioning
advice] to 5- fully did this [gushing praise for insights,
resources and advice]); and whether or not the OP directly
stated intentions to change/alter vaccination behavior based
on dialogue in the group.
Normative influence
Normative influence generates attitude change by aligning an
individual’s thinking with the viewpoints of the group major-
ity in order to gain rewards or avoid punishment (Clark &
Goldsmith, 2006). Normative influence is based on a desire
for group harmony (Li, 2013). Coders found that OPs often
responded to commenters with answers likely designed to
achieve group harmony in accordance with social influence
theory. For example, when a new group member mistakenly
asked for “anti-vaccination” facts and figures, many com-
menters jumped in to correct her, emphasizing that every
mother was once a “pro-vaxxer” until their own children
were vaccine damaged. Thus, “anti-vax” labels were consid-
ered “name calling” in accordance with group norms.
Instead, group members explicitly stated that they were “ex-
vaxxers.” Some mothers within the group even described
themselves as “pro-safe vaccines,” qualified with the
disclaimer ‘if such a thing exists.’ In this instance, the poster
immediately apologized for her transgression and was wel-
comed back into the fold.
Fourteen posts (just over 35%) contained multiple com-
ments by “missionary posters,” defined by coders as indivi-
duals who repeated the same points at least three times on the
same comment thread. Often these were administrators or
group moderators, identified by a star or checkmark next to
their name. These five or six individuals contributed to the
echo chamber nature of the environment by policing threads
and working to remove or shut down dissenters or those not
using in group language.
While most members appeared to try to support one
another rather than to shame or bully, an undecided poster
received infinitely more support the more tentative and
advice-seeking her first post appeared to be and in cases
when she did not push back against any information from
commenters. A mother who expressed doubt in the group
arguments received harsh replies from multiple commenters.
For example, one mother who stated she was leaning toward
vaccinating was told in no uncertain terms to snap out of it, as
she had clearly been brainwashed, which is no excuse to
participate in mass genocide or to poison her baby.
Seven OP’s were perceived by coders to be bullied or
shamed by commenters in the group; bullying and shaming
was defined as responses in all caps, name calling, and belit-
tling language (e.g. you idiot!) Of the total 2,736 comments
analyzed, only five comments expressed a pro-vaccine opinion
(e.g. vaccines are good and protect against diseases), and five
expressed a vaccine-neutral opinion (e.g. I do not totally agree
that vaccines cause autism.) While many vaccine refusers
explained they made the decision not to vaccinate based on
gut instinct, no member reported being a pro-vaxxer in one’s
gut. This could be attributed to the lack of membership of
pro-vaccine mothers or to those members with differing opi-
nions feeling fearful to comment an unpopular viewpoint
within this group, which functioned largely as an anti-
vaccination echo chamber. These group members were either
ignored, belittled in a condescending fashion (e.g. you
obviously need to research a little more), or deemed ‘trolls.’
At least one was ejected from the group immediately follow-
ing her comment on a thread.
Informational social influence
In order to back up their claims, commenters frequently acted
as informational social influencers, directing original posters
to seek additional “research” based on links they provided for
the OP to follow. In this way, commenters could be seen as
the providers of greater experience or knowledge – making it
less likely that their statements would be questioned. The
majority of threads had five or more links to external pieces
of evidence to back up claims stated within the thread such as
YouTube videos (45.2%), other Facebook pages (35.5%), gov-
ernment websites (35.5%), alternative/green natural websites
(32.3%), blogs (19.4%), court cases (9.7%) and a few addi-
tional references. Books and movies were referenced in 22
threads, with the movie Vaxxed: From Cover Up to
Catastrophe and Vaccines Revealed documentary series repeat-
edly referenced as a comprehensive “starting place.” At least

20 posts also referred to physicians and/or celebrity endorsers
as authoritative sources opposing vaccination, such as
Suzanne Humphries, Dr. Sears, Paul Thomas, and Roby
Mitchell.
In some cases, the OP’s mind-set seemed to evolve during
the course of just one post. In the tone and wording of their
original post, 85% of OPs were on the fence or questioning.
However, the tone of many OPs’ comments changed with
each subsequent response, with the focal point often shifting
from their original fear of vaccine-preventable diseases (e.g.
measles) to fear of the perceived side effects of vaccines (e.g.
autism.). For example, one OP first joined the group to ask if
she should give consent for her baby to receive MMR vaccine.
She stated she was worried about fewer people getting vacci-
nated, recurrent outbreaks of measles, and potential compli-
cations from the disease, including meningitis, especially after
speaking with her child’s doctor. The post received 67 com-
ments, and the OP responded 12 times. Commenters assured
the OP that all vaccine-preventable diseases are benign, easy
to treat, and nothing to worry about, proposing that the worst
case scenario would be her child would contract measles and
would need a few days at home in bed. A few comments later,
after explaining that she had followed some of the recom-
mended links posted by commenters, the OP expressed irony
that she had been worried about something as benign as
measles when the vaccine had much more harmful side
effects. In her last comment, she vowed never to vaccinate
and thanked the group for their input.
Two on-the-fence posters directly stated that information
from the group convinced them not to vaccinate, and at least
three OPs directly stated that advice from the group rein-
forced some initial hesitance about vaccinating. Two addi-
tional mothers even posted in the group after the fact, one
three months later, with photos of their happy, healthy,
unvaccinated children and sincere expressions of thanks to
the group for ensuring their baby would never be injected
with “poisonous toxins.” They attributed their decision mak-
ing and willingness to hold firm to that decision to the peer
support and affirmation received from their original Facebook
post and the ‘helpful’ information presented in the form of
external resources.
Notably, coders did not perceive that any of the original
posters did not appear to accept information from the group
or seemed unlikely to accept information from the group.
Rather, 12 OPs seemed likely to accept this information stat-
ing intentions to look into the suggestions and recommenda-
tions while six posters seemed to completely accept
information from commenters based on their follow up
responses (e.g. wow, I did not know that! Thank you so
much for telling me before I made a mistake). Twelve posters
gave neutral responses (e.g. thank you) while seven OPs did
not indicate any further intentions following comments from
the group. Nine of the 35 original posters directly stated
intentions to change or alter their behavior toward vaccinat-
ing after interactions in the group (e.g. I am a non vaxx
mommy now; thank you for the support).
In the thematic analysis, coders uncovered six overarching
themes, which emerged from the data relating to social influ-
ence. Commenters utilized a number of differing influence
HEALTH COMMUNICATION 5
strategies to sway original posters away from vaccinating their
children. These strategies included: natural solutions, mater-
nal empowerment, distrust of conventional medicine estab-
lishment, fear appeals, ‘Russian Roulette’ risk benefit analysis,
and misinformation and misunderstandings.
Natural solutions
The first theme, natural solutions, is defined as group mem-
bers’ consensus that as opposed to vaccinations and other
medical interventions, health can be achieved naturally at
home. Whereas vaccinated children were portrayed as
‘damaged’ or sickly due to the toxins injected into the
body, many reported that, in contrast, their unvaccinated
children were the healthiest children in their respective age
cohort. Group members valued natural immunity, which can
only be obtained when children contract ‘normal’ childhood
illnesses. Unconcerned with the dangers of these vaccine-
preventable diseases, group members explained babies natu-
rally build up their own immune systems and can easily fight
off what were depicted as minor infections (e.g. a case of the
measles was portrayed to be a “fun” day at home in bed with
a coloring book and a chance for mother and child to bond).
Frequently recommended treatments for sickness included:
a healthy GMO-free diet, sunshine, vitamin supplements,
essential oils, sleep, and exercise. More holistic or “crunchy”
parenting styles that include practices such as co-sleeping
and breastfeeding were touted as superior, with the notion
that anything that can be done to reduce exposure to toxins
or carcinogens should be employed.
One repeated suggestion was that, with the exception of
acupuncture, natural health never comes from a needle. A few
group members adamantly believed that doctors of any kind
are not needed, and repeatedly exhorted mothers never to
take their baby to a wellness checkup, which was described
as a guise for a financially-motivated vaccination appoint-
ment. However, if a parent was convinced to obtain medical
care for one’s child, chiropractors were promoted as superior
to pediatricians, particularly on the issue of respecting par-
ental vaccine choice and accommodating alternate vaccination
schedules. Most mothers in the group took a more moderate
stance on balancing healthy lifestyle choices with appropriate
treatment for sickness. For example, when a news article was
posted in the group charging a mom with neglect for not
taking her flu-ridden child to a hospital to seek medical
treatment after experiencing symptoms for many days, multi-
ple commenters expressed that home remedies can only go so
far, and enough is enough. Many seemed to realize the value
in seeking medical reinforcement in dire circumstances, at the
very least.
Mother knows best: Maternal empowerment
Maternal instincts, or the reported feeling of a unique bond
with one’s offspring, was a source of empowerment for group
members. Universally, group members expressed simply
wanting the best for their child, something the consensus
agreed can ultimately only be determined in one’s gut. In
response to news articles about flu-related deaths, those
6 A. S. BRADSHAW ET AL.
adamantly opposed to vaccination expressed relying on their
gut as the deciding factor to stay the course, even when fear
crept in about whether they were making the right choice to
refuse the vaccine.
Mothers repeatedly expressed gaining a sense of autonomy
about childhood vaccination decision-making after research-
ing the topic in depth. Group members who had done their
own online research on vaccines and provided lengthy lists of
external links were often portrayed as more knowledgeable
than doctors or nurses who have completed medical training.
Thus, questioning parents were advised to do their own
extensive online research to acquire more knowledge before
vaccinating their children, starting with the threads contained
in the Facebook group. However, the threshold for what met
the requirements for sufficient knowledge about vaccines was
never mentioned, though there seemed to be an underlying
assumption, stated explicitly in some cases, that critically
thinking parents would ultimately decide not to vaccinate.
The group repeatedly referenced a “better safe than sorry”
mantra with mothers seen as the foremost experts regarding
their child’s best interests. Likewise, parental autonomy was
praised in the context of increasing one’s own knowledge to
manage conflict with doctors, extended family members, and
friends with differing opinions, including other Facebook
posters.
Distrust of conventional medicine establishment
Group members frequently called into question the credibility
of doctors, large pharmaceutical companies such as Merck
and Bayer, and governmental health agencies such as the
CDC. Some group members accused doctors of encouraging
parents to vaccinate children for the sole intent of making
a profit. Others speculated that certain diseases, such as polio,
do not actually exist – pharmaceutical companies only pushed
these vaccines to make money.
The education of medical professionals was denounced as
inadequate, and providers were compared to sheep blindly
recommending vaccinations about which they have limited
knowledge. Commenters also expressed concern that the
CDC’s evidence for recommending vaccines as
a preventative tool is not sufficient, called into question the
ethics of the agency, and summarized evidence that attempted
to discredit the CDC’s recommended vaccine schedule.
Anger was directed at pediatricians in the form of name-
calling (e.g. liars, fear-mongerers, bullies). Stealth vaccinating,
or the belief that healthcare workers would secretly vaccinate
a newborn against the parents’ expressly stated wishes, was
something commenters seemed alarmed by and referenced
repeatedly. Mothers-to-be were advised never to let their
newborn out of their sight at the hospital. Members also
shared anecdotes of healthcare providers’ attempts to openly
bully them into vaccinating their children. Not vaccinating
was acknowledged as going against the mainstream. Some
suggested keeping vaccination decisions private to avoid con-
frontation, while others recommended standing up for vacci-
nation refusal and using the opportunity to educate pro-
vaxxers. Some parents attempted to relay courage to others
by recounting a step-by-step replay of how they stalwartly
resisted a provider’s plea to vaccinate. On the other hand,
a more conflict-avoidant strategy was proposed to request
delayed vaccinations. This easy strategy of extricating oneself
from an uncomfortable medical encounter with a pro-
vaccination provider was presented as a way for the mother
to gracefully exit the room and find a new pediatrician who
would be supportive of her choices. The importance of find-
ing a doctor that accepts the family’s beliefs was mentioned
several times. This dialogue went beyond stressing shared-
decision making between doctors and patients and instead
framed the physician as an employee of the family, one who
should ultimately respect all wishes of the parent, as that is
what the doctor is ‘paid to do.’ In fact, some commenters
expressed a positive view on doctors – as long as those doctors
agreed with the parent and executed their wishes.
Fear appeals
Posters asking about the pros and cons about the decision to
vaccinate were traditionally met with fear-based responses
attempting to sway their decision in the form of anecdotal
evidence, hearsay (e.g. my neighbor’s friend’s sister suffered
this side effect), and empirical evidence from a variety of
sources, such as government websites and vaccine inserts.
Vivid descriptions and pictures of children killed, damaged,
or made extremely ill, allegedly by vaccines, were prevalent
throughout the posts. A few, more rare commenters alluded
to obituaries and tombstones, as a result of vaccinating one’s
child.
“Ex-vaxxers” who had partially vaccinated their children
provided detailed descriptions of the perceived adverse side
effects their children experienced as a result. Those children
were deemed “vaccine damaged” and reported to experience
side effects including: SIDS, which this group classifies as
VIDS (vaccine-related infant death syndrome); sensory issues,
autoimmune disorders, chronic ear infections, allergies (some
life-threatening), autoimmune skin issues, asthma, severe aut-
ism, mood disorders, and other chronic mental and physical
conditions. On the other hand, unvaccinated children were
portrayed as more capable, more advanced in their motor
skills, and generally happier. Group members often posted
photos of their unvaxxed children and cited their bright,
unglazed eyes as proof of health in stark contrast to vacci-
nated kids, who were said to have dull, vacant stares.
Group members repeatedly emphasized the toxicity of the
ingredients found in extensive ingredient lists from vaccine
inserts. Of particular concern on the ingredient list seemed to
be mercury and aluminum adjuvants, formaldehyde, and gly-
phosate, colloquially known as Round Up. Some mothers,
from a moral and religious standpoint, expressed concern
about aborted fetal cells, which were utilized in the original
development of vaccinations and perceived by group mem-
bers to be still used in ongoing vaccine development. Injecting
any of these toxins into a child’s body, especially all at once,
was feared by the group to create ‘overload’ which purport-
edly can lead to a host of health problems and side effects. In
response to fear appeals, pregnant, first-time, and new
mothers typically expressed sympathy for the member(s)
who described a horrible experience, fear of potential vaccine

side effects, gratitude for finding the group ‘before it was too
late,’ and a renewed commitment to research before vaccinat-
ing. For example, in response to one mother’s statement that
her child’s pediatrician reported never having seen an adverse
reaction to vaccinations in many years of practice, multiple
commenters jumped in stating that of course not – the indi-
viduals most likely to witness these catastrophes work at the
morgue. She was then advised to find someone who wasn’t
a “poison pusher.”
‘Russian roulette’ risk benefit analysis
Group discussions centered on an overwhelming sense of
turmoil in vaccination decision-making. Many mothers
reported feeling torn between following the guidance of doc-
tors in order to protect their children from dangerous, poten-
tially life-threatening diseases or trusting the experiences
shared by their peers on Facebook to protect their children
from horrific, seemingly worse, vaccine side effects. More
than 200 side effects were postulated to stem from vaccina-
tion, many of which were depicted as being much more
harmful than ‘minor’ vaccine-preventable diseases. Thus, the
group’s overall risk-benefits analysis favored ‘fighting through
the polio’ if need be to avoid perceived vaccine-induced side
effects.
When undecided mothers voiced fears about their child
contracting a vaccine-preventable disease, such as measles,
unvaccinated influencers in the group anecdotally explained
how easy ‘minor childhood illnesses’ are to treat. One discus-
sion thread deemed vaccination ‘Frankenscience,’ stating that
this intervention does not improve nature but rather distorts
and destroys it. Vaccine-induced immunity was considered to
be an illusion. In fact, some group members stated vaccina-
tions actually led to increased disease outbreaks as a whole,
and they believed that many diseases would have been eradi-
cated naturally by now had vaccinations not been invented.
Thus, mothers should avoid the “cocktail of toxins,” which do
not even work since vaccinated children still get sick. Instead,
they should take the lesser of two evils and risk purportedly
minor infections if and when they happen.
There was an underlying tone of blame and guilt issued
with statements such as if a mother were to kill, maim or
poison her own child through even just one vaccine, she
would be to blame. Expressing that babies are born with
perfect immune systems, which should develop responsively
as they grow, commenters explained that if a mother vacci-
nates, she is inflicting trauma on her newborn. If a mom does
this and she is lucky, the permanent damage to the baby’s
immune system and neurological system would be only mini-
mal (but not non-existent). If unlucky, however, the baby
could be terribly injured or possibly even die. Thus, vaccina-
tion was described by many group members as a game of
‘Russian Roulette.’
Frequent commenters warned undecided mothers that they
could easily become just another statistic. ‘It only takes one
vaccine to inflict permanent damage,’ and ‘all vaccinations are
gambling with your child’s life’ were oft-repeated mantras,
discounting the more moderate group members who
HEALTH COMMUNICATION 7
recommended delayed or alternate vaccination schedules to
limit the possibility for ‘toxin overload.’
Misinformation and misunderstandings yield influence
Overall there appeared to be frequent sharing of misinforma-
tion and misunderstandings about vaccinations among group
members, which led to many undecided OPs expressing
intentions to delay or forego one or more vaccinations for
their child. The criteria for misinformation and misunder-
standings, for the purposes of this study, was simply informa-
tion presented that appeared to contradict standard childhood
vaccination recommendations as issued by the CDC and
American Academy of Pediatrics (e.g. commenters advocating
for delayed schedules with no scientific backing, purported
side effects which scientific consensus finds are not caused by
vaccines such as autism, and the recommendation to decline
one or more vaccines that have been recommended for both
individual and societal wellbeing).
In addition to anecdotal or empirical evidence, the three
most prevalent primary sources that group members stated
convinced them ultimately to avoid or cease vaccinating their
child included: Facebook (primarily this group), documen-
taries explicitly warning parents not to vaccinate, and links
to additional websites, such as Green Med Info and Natural
News. Missionary posters repeatedly referred OPs on the
fence about vaccinating to various sources of online research
that would convince them never to vaccinate or to discon-
tinue vaccinating immediately. One missionary poster had
compiled an 88-page document with links to external
resources purported to persuade parents not to vaccinate.
Twenty-five of the first 30 links within this document were
simply links to other Facebook pages, videos, and posts that
promote vaccination refusal. Yet, each time the missionary
poster provided this document, women responded in awe of
the substantial amount of information. Instead of questioning
the credibility and veracity of the resources provided, posters
expressed commitment to read the recommended resources
before vaccinating their children (further.)
In addition to Facebook, documentaries were frequently
referenced as ‘life changing’, such as the nine-part mini doc-
umentary series Vaccines Revealed, which was pinned to the
top of the home page and touted as the most important series
mothers could ever watch to learn more about vaccination.
Other recommended anti-vaccination documentaries
included: Vaxxed: From Cover-Up To Catastrophe, Trace
Amounts, The Truth Aboout Vaccines, Autism: Made in the
USA, and Vaccination: The Hidden Truth. In cases of familial
conflict about vaccination, spouses or partners turned to the
group to generate ‘evidence’ to build a case around the dan-
gers of vaccination to present to the pro-vaccine family mem-
ber. In more than one case, these posters responded they were
able to convince their partners not to vaccinate or to at least
delay vaccinations based on viewings of these resources.
In some cases, posters shared clearly skewed scientific
findings such as Andrew Wakefield’s spurious correlation
between autism and MMR vaccine, which has been refuted
by the scientific community. It was unclear whether scientific
studies such as this were intentionally misconstrued or simply
8 A. S. BRADSHAW ET AL.
misinterpreted by the group. However, it is important to note
that on the surface, many of the hundreds of external website
links presented within comment threads appeared credible,
such as Pub Med references, NIH links, news stories from
CNN, Science Daily articles, and vaccine injury court cases
mixed in with the less credible social media sources, green
parenting websites, and blogs. Due to the sheer volume of
external references, a mother who chose to read through all of
the links before making a vaccination decision, as group
members often encourage, would likely never be able to feel
safe vaccinating.
Discussion
Threads of Facebook comments, particularly within a closed,
quasi-private group provide an unprecedented look into the
social influence that a group of vaccine refusers may have on
undecided fence sitting parents. Posts were frequent, robust,
and personal. Pregnant, first-time, and new mothers specifi-
cally came to this group, which emphasized the importance of
choice, to learn the pros and cons of vaccinating. These OPs
asked questions geared toward objectively learning both sides
of the issue. In accordance with the guiding research question,
this study aimed to understand the strategies used by group
members to influence the vaccination decisions of expectant,
first-time, and undecided new mothers.
Theoretical implications
Social influence refers to how an individual in a social net-
work conforms to community behavior patterns based on the
behavior of others (Li, 2013). Moreover, identity development
has been found to take place on Facebook (Moreno, Kota,
Schoohs, & Whitehill, 2013). Perceived pressures from social
networks impact decision-making in two ways: first, norma-
tive social influence occurs when people conform to experi-
ence social support through acceptance in a group setting (Li,
2013); alternately, informational social influence occurs when
people attempt to reach a correct answer for themselves by
conforming to peer views.
Normative social influence has been highly linked with
compliance and identification, while informational social
influence has been strongly related to internalization, the
highest level of attitude change (Kelman, 1958; Li, 2013).
The fact that this Facebook group was found to contain
both types of social influence leads to the perception that
persuasion was particularly strong. Coders determined that
all OPs appeared to accept information from this group to
some extent, some more strongly than others, but none expli-
citly rejected the information. In fact, many of the undecided
OPs described above declared themselves avid anti-vaxxers in
subsequent comments just hours after their initial open-
minded post seeking to learn the pros and cons.
Limitations
Analysis of a closed Facebook group for vaccination choice
allowed for observation of unobstructed dialogue between
undecided mothers and anti-vaccine advocates without
researcher interference or social desirability bias. However, as
is the case in qualitative content analysis, this method is purely
descriptive, and cannot address the unexpressed rationale for
the material analyzed (in this case, comments and posts).
Similarly, researchers did not interact with group members.
This natural observation functioned as a strength of the study
design by allowing for more natural observations in a group
which, by its own admission, would not welcome a researcher
into its midst, but could also be classified as a weakness by the
inability to probe or ask follow-up questions to group members.
Being able to provide direct quotations from group participants
would have also allowed for a richer, more contextual reporting
of the major findings than the aggregation and paraphrasing of
conversations would allow. However, in accordance with IRB
requirements, the aggregation and paraphrasing served to pro-
tect the anonymity of the women’s lived experiences.
Another limitation of this research, as is inherent to qua-
litative research, was its lack of generalizability. However, it is
worth nothing that many of these findings are consistent with
existing literature on vaccine hesitancy (e.g. anecdotal fear
appeals, alternative and natural medicine links, belief in stu-
dies that have been debunked, the right of parents to make
individual vaccine choices for their children, etc. See Bean,
2011; Kata, 2010, 2012;
Martinez, Spitzberg, Tsou, Issa, & Peddecord, 2017).
Finally, this study did not allow for actual measurement of
behavior. While research expanding the theory of reasoned
action supports that the most immediate determinant of
a person’s behavior is their expressed intention to do some-
thing (O’Keefe, 1990), and many studies have empirically
demonstrated the strength of behavioral intentions in predict-
ing behavior, there is no guarantee that mothers did or did
not vaccinate their children based on their stated intentions in
the Facebook group.
Future research and practical implications
The need to study more closed Facebook groups as opposed
to open, public groups has been identified as a key area of
understanding social influence. Perhaps due to the illusion of
privacy within the closed group, in-depth conversations were
found to be richer, more numerous, and revealing of the
vaccination decision-making process than those held on the
affiliated public page. While posts on the closed group num-
bered in the dozens per day, the public group often had three
to five posts per week and mostly consisted of article sharing,
which generated likes and shares. Despite having more than
100,000 members, these articles received few comments in
comparison to the closed group, mostly tagging Facebook
friends to read the content. Therefore, researchers should
seek IRB approval to investigate these closed settings as
opposed to solely evaluating easily accessible public pages.
Future research should also explore the link between
parental and provider immunization beliefs with social net-
work group membership as a moderating factor. It cannot
simply be assumed that all healthcare providers advocate for
the CDC-recommended vaccination schedule, as some of the
resources used to lend credibility to anti-vaccination argu-
ments were physicians who endorse a more natural

approach to medicine. However, educating first-time, new,
and expectant mothers about the safety and efficacy of
vaccination should be at the forefront of medical practice,
particularly in the wake of various disease outbreaks.
Providers, such as OBGYNs, midwives, and pediatricians,
should be aware of the persuasive strategies that exist that
might elicit doubt about vaccination according to CDC and
AAP recommendations – particularly for first-time and
expectant mothers – and initiate conversations about infant
and childhood vaccination during pregnancy. By taking the
time to recommend scientifically based resources during the
prenatal period, the vaccination decision becomes
a collaborative, ongoing discussion as opposed to fait
accompli. Providers who take a stance that a pro-
vaccination viewpoint is a given, and only uneducated
mothers would refuse or delay vaccinations, may miss
a golden opportunity for shared decision making. Likewise,
as mothers appear to be attuned to a risk benefit analysis
approach, openly communicating the possible but minor
side effects of vaccinations (e.g. fever, rash, soreness at the
injection site etc.) may help to build trust.
Finally, a delayed vaccine schedule appeared to be the gate-
way for parents who would later decline all vaccinations for one
or multiple children. Delaying vaccines was presented by pos-
ters in this Facebook group as less confrontational, more in line
with social norms, and an easier step for questioning parents.
Those willing to delay vaccinations were seemingly more con-
cerned with ‘toxin overload’ and questioned the science behind
the number of injections associated with the CDC-
recommended immunization schedule at once, while adamant
vaccine refusers stated no vaccine was safe at any time.
Therefore, providers should understand that agreeing to delay
a child’s vaccines or abide by an alternative schedule preferred
by the mother may simply reinforce stronger anti-vaccine
beliefs. Future research could construct the process of persua-
sion from mere maternal vaccine hesitance to outright refusal
of one or more vaccines.
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