who can help me?

Health professionals and the vaccine narrative: ‘the power of the personal story’ and the management of medical uncertainty

Terra Manca*

Department of Sociology, University of Alberta, Edmonton, Canada

(Received 16 September 2015; accepted 12 May 2016)

Some vaccine supporters interpret vaccine uncertainties as a form of public ignorance caused by patients’ online research, failed physician–patient relationships, or inade- quate knowledge translation. These interpretations often portray health professionals as homogeneously accepting of all scheduled vaccines for all patients. Nonetheless, health professionals may have limited knowledge about vaccines because the demands of their profession require them to have a broad understanding of a variety of health topics. In this article, I draw on data from interviews with twenty-six physicians and seven nurses in Alberta, Canada between 2013 and 2014, to examine how they used narratives to convey confidence, uncertainty, or doubts in vaccines. All interviewees supported the culturally dominant vaccine narrative that vaccines are essential to population health, yet they also spoke about uncertainties. Interviewees managed their uncertainties through tactics that confirmed accepting vaccination was the most desirable course of action. With each of these tactics, interviewees shared narratives about communicable diseases, vaccine benefits and risks to individual patients, and their reasons for trusting in medical science. When these narratives did not fully resolve medical uncertainties, health professionals often explained that either vaccina- tion was beyond their professional responsibilities or that their uncertainties were irrelevant.

Keywords: public health; risk; risk perception; uncertainty; vaccination

Introduction

In this article, I aim to explore sociological understandings of medical uncertainty and medical progress, and how the creation of an ‘illusion of certainty’ in the health profes- sions relates to the vaccine narrative. Using data from the Canadian province of Alberta, I review how various disease outbreaks in Alberta have been attributed to patients’ vaccine uncertainties. I analyse some of the uncertainties that professionals experienced and the tactics they used to manage uncertainties and knowledge gaps about something they called (in various wordings) as simple as vaccines.

Vaccination, risk, and health professionals

Vaccination rates in some high income countries, such as Canada and the United States, appear to have declined due to vaccination anxiety and ambivalence (Heller, 2008, p. 3; Keane et al., 2005, p. 2486; Public Health, 2006a). In 2013, almost 70% of parents in Canada expressed concerns about potential vaccine side effects. That year, uptake rates for

*Email: [email protected]

Health, Risk & Society, 2016 Vol. 18, Nos. 3–4, 114–136, http://dx.doi.org/10.1080/13698575.2016.1190319

© 2016 Informa UK Limited, trading as Taylor & Francis Group

individual childhood vaccines were lower than needed to maintain population immunity – rates ranged from 73% (varicella) to 90% (polio [Government of Canada, 2015]). Most young parents and physicians have encountered countless narratives about the risks of vaccine side effects, but they have limited experience with vaccine-preventable diseases (Keane et al., 2005, p. 2486). Vaccine risk narratives are prevalent in the media (Bean, 2011; Hilton, Hunt, Langan, Bedford, & Petticrew, 2010; Kata, 2010). Anti-vaccination campaigns promotion of these narratives has coincided with increasing parental doubts in vaccine safety (Blume, 2006, p. 638; Casiday, 2007). Even so, most parents who refuse vaccines do so because they have unresolved concerns about vaccine safety (Blume, 2006; Poltorak, Leach, Fairhead, & Cassell, 2005, p. 716). Health professionals are expected to address these vaccine concerns, but health professionals belong to social worlds within which rumours and uncertainties around vaccination and medical risks circulate.

Researchers who investigate medical uncertainties have tended to focus on areas where there is no professional consensus about the best course of action, such as hormone replacement therapy or breast cancer screening (see Gerrity, Earp, DeVellis, & Light, 1992; Gigerenzer, 2002; Griffiths, Green, & Bendelow, 2006). By investigating subjective talk about vaccines, it is possible to examine the medical discourse surrounding a widely accepted treatment, vaccination, as a social and cultural phenomenon:

Vaccination anxieties are a lens for understanding how biomedical knowledge is interpreted on the ground. Health risks are constructed not only in biological terms but also as a product of relationships among the state, providers, patients, and international health policy makers. (Bazylevych, 2011, pp. 451–452)

Previous literature about vaccine uncertainties and narrative investigated topics relating to various conceptualisations of vaccine knowledge and risk involving primarily public (and occasionally health professional) uncertainties, non-compliance, and resistance (see Casiday, 2007; Heller, 2008; Hobson-West, 2003, 2007; Kitta, 2012; Leach & Fairhead, 2007; Levi, 2007; Poltorak et al., 2005; Skea, Entwistle, Watt, & Russell, 2008; Streefland, Chowdhury, & Ramos-Jimenez, 1999; Wolfe & Sharp, 2002). Studies that target vaccine uncertainties addressed controversial vaccines such as the human papilloma virus (HPV) (Mamo & Epstein, 2014, p. 160). Most studies have not examined the uncertainty associated with the safety or necessity of more widely accepted vaccines (exceptions include Bazylevych, 2011; Chen, 2005). Some researchers have addressed nurses’ vaccine ambivalence, but research about physician ambivalence is rare (see Bazylevych, 2011 and selected medical research [see Dubé et al., 2011; Loulergue et al., 2009]).

Medical uncertainties and health narratives

Health professions have traditionally practiced as though they are certain of the outcomes from their actions (Atkinson, 1984). Nevertheless, in an early stage of medical training, students learn that uncertainty is common to medical practice. As Knight and Mattick (2006, p. 1085) argued:

The development from lay conceptions of knowledge, where science is considered to be a place of certainty and ‘truths,’ to an understanding of knowledge as being more contextual, contingent and fluid is an important transition for effective medical practice. (see also Gerrity et al., 1992)

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Even treatments that have highly predictable outcomes can involve some uncertainty (Knight & Mattick, 2006). Furthermore, health professionals work with the incomplete information because patients are rarely aware of the full information or the relevance of the information they have. Knight and Mattick (2006) found that medical residents learn to navigate uncertainty surrounding what patients share with them when applying population-based medical research to individual patients (pp. 1085, 1088). Likewise, popular beliefs influence health professionals’ knowledge, uncertainty, and recommenda- tions to patients and families (Bazylevych, 2011; Blume & Zanders, 2006, p. 1833; Chen, 2005, p. 39; Gerrity et al., 1992; Skea et al., 2008). As such, uncertainties about some aspects of medicine are common to daily medical practice and patient encounters, regardless of one’s awareness of them (Gerrity et al., 1992; Griffiths et al., 2006; Fox, 2002; Knight & Mattick, 2006; Schattner, 2009).

I use uncertainty to describe what health professionals placed beyond their own knowledge regardless of expressions of doubt, though doubt may indeed accompany uncertainty and create difficulty deciphering the best course of action.

Fox (1959) used the concept uncertainty, in a similar way, proposing three broad sources of uncertainty: gaps in individuals’ knowledge, limitations of the medical field, and difficulties distinguishing between the two. Fox (2002) expanded upon these cate- gories. First, she divided intellectual or scientific uncertainties between uncertainties that were internal to the professional (that is mastering skills or recognising ignorance) and those that fit within the broader professions of medical knowledge (the gaps and limita- tions of medicine). These uncertainties comprise such issues as: the impossibility of mastering the entirety of medicine’s knowledge and skills; difficulties recognising perso- nal ignorance and ineptitude; gaps and limitations inherent to medical knowledge and effectiveness; recognising gaps in personal knowledge and medical knowledge; the con- fines and inabilities of the medical practice; and the constant changes and updates to medical knowledge (Fox, 2002, pp. 237–238). Fox (2002) also identified existential uncertainties, such as cultural and ethical concerns, pertaining to medicine, which are beyond the scope of this article. These include any uncertainties that accompany human illness, its meanings, and associated human suffering, life, and death (Fox, 2002, p. 238).

Atkinson (1984) criticised Fox’s findings. He argued against aggregating different types of uncertainty, so that they appear to be pervasive in medical practice (p. 951). Atkinson (1984, p. 954) cautioned against the tempting view that:

medical knowledge and practice are inherently ‘uncertain,’ while the ‘certainty’ of dogmatism and personal judgment are responses to that on the part of the clinician.

Instead, he argued medical education involves ‘training for certainty,’ which frees doctors from doubting their actions (Atkinson, 1984, p. 952). Particularly, Atkinson (1984) argued that doctors learn to bracket off any uncertainties that permeate their profession so as to practice with certainty in their judgement.

This bracketing off creates what some scholars have termed ‘an illusion of certainty’ (Gigerenzer, 2002; Sunstein, 2002). As a profession, medicine produces abstract scientific knowledge that appears to resolve various health problems without acknowledging short- comings or uncertainties (Abbott, 1988, p. 55). In textbooks, scientific and professional knowledge can be assembled into full and fully rational systems (Abbott, 1988, pp. 55–56; Kuhn, 1962). Textbooks tend to narrate about rapid transformations in scientific ingenuity as an impossible linear progression towards truth with few errors (Kuhn, 1962, p. 137). They overlook how the role of health professionals who were

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committed to older, and often ineffective treatments often resisted the adoption of newer practices (Wootton, 2006, p. 17).

Moreover, the expansion of medical knowledge generates new uncertainties (Gerrity et al., 1992; Knight & Mattick, 2006, p. 1085). As Schattner (2009, p. 76), a medical researcher noted:

Contrary to all expectations, the spectacular advances in our knowledge and capabilities have not reduced uncertainty regarding the individual patient. The practice of medicine is not only becoming increasingly complex, but paradoxically, even more uncertain.

Any health initiative has the potential for unforeseen consequences, such as indirect side effects, over medication, or iatrogenic diseases. Therefore, advancing medical knowledge, creates what Fox (1988) called a ‘risk of risk’ (p. 548). Advances in knowledge could result in actual risks (side effects or other unforeseen outcomes) and a perception that there are more risks (such as a perception that vaccines could cause unknown side effects).

Governments, health professions, and affiliated agencies seek to investigate and regulate such risks. Even so, some risks are not investigated due to the costs involved (both financial expenses and the risk of delaying programmes): ‘the costs of investigation and inquiry are never zero; in fact, they are often very high’ (Sunstein, 2002, p. 142). Some vaccine safety regulations reflect public opinion because many people refuse vaccines that popular discourses label unsafe (Chen, 2005, p. 49; Phipps, Noyce, Walshe, Parker, & Ashcroft, 2011, p. 286). Vaccine manufacturers removed many con- troversial components from vaccines, regardless of the lack of evidence that these components cause harm and so the risk classified in official Canadian government documents as ‘theoretical’. Still, the removal of these components could increase vaccine uptake by allaying patient and parent fears.

Health professionals may practice with an illusion of certainty that emerges due to professional cultural pressures and their ‘training for certainty’ (see Atkinson, 1984, p. 952). This illusion simplifies medicine in ways that obstruct decision-making by falsely promoting precise outcomes to patients who experience inconsistent results (Gigerenzer, 2002). Gigerenzer (2002) explained that this illusion creates falsehoods, ‘such as that treatments have only benefits but not any harm; that there is one and only one best treatment; that a diagnostic test is absolutely certain’ (p. 21). Health professionals may speak and practice with certainty that particular treatments produce precise and predictable outcomes. Likewise, Rapp (1999) described the suppression of uncertainties in her study of amniocentesis. She explained the containment of ‘ambiguity, uncertainty, and stabiliz- ing judgment calls’ was acknowledged as part of ‘normal and normalizing cytogenetic practice’ (p. 209). This containment, Rapp (1999) explained, enabled experts to proceed with ‘routinized diagnoses,’ and therefore, to practice as though they have certainty (p. 209).

As such, many professionals practice as if they can access ‘truth’ even though they learn very early that their profession is teeming with uncertainties. Because of such uncertainties, many social scientists have dismissed the view that experts have access to the truth (Collins & Evans, 2002). Similarly, individuals often refuse to trust government and experts unless they feel involved in the decision-making process (Alaszewski & Harvey, 2001, p. 306). Nevertheless, Collins and Evans (2002) argued that expertise needs to maintain some authority: ‘we have to treat expertise in the same way truth was once treated – as something more than the judgement of history, or the outcome of the play of competing attributions’ (Collins & Evans, 2002, p. 237).

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They note the benefits of including ‘experience-based experts’ during the research process (Collins & Evans, 2002, p. 239). For example, they note how in the aftermath of the Chernobyl nuclear accident, sheep farmers in Cumbria could explain to radia- tion specialists the likely impact of the radioactive using their knowledge of the landscape and movement of water and sheep over the landscape (Collins & Evans, 2002, p. 255).

Most health professionals work in space between scientific experts and lay people. They have expertise beyond that of ‘experience-based experts,’ but less than vaccine experts (those who specialise in identifying and counteracting communicable diseases, such as immunologists). Consequently, health professionals often trust in dominant knowledge within their profession and use it as a way of avoiding the immobilisation that can accompany their uncertainties (Schattner, 2009). This trust involves a ‘kind of suspension’ rather than knowledge, which means bracketing off uncertainties (Hobson- West, 2007, p. 200). In addition, health professionals rely on both what Collins and Evans (2002) called experiential knowledge and their professional training. Professionals fill knowledge gaps with narrative and public understandings (Kitta, 2012, p. 117). Most researchers have overlooked how such information appears in health professionals’ dis- cussions of what they know.

Few narratives about medical successes appear as powerful as the culturally dominant vaccine narrative. Other examples include the advent of the germ theory or the discovery of penicillin. In The Vaccine Narrative, Heller explained vaccines as a cultural (rather than exclusively medical or scientific) phenomenon with important meanings in American society. The vaccine narrative, like all narratives, depicts a sequence of events with specific outcomes (Heller, 2008, p. 9):

The cultural narrative of vaccines tells the story of a deadly disease that exerts a terrible toll in human suffering and death. Heroic researchers, working altruistically, marshal the forces of modern science to develop a simple intervention to ready the body’s own defenses: a vaccine. Properly prepared, we can defend ourselves, just as our science demonstrates human mastery of death. (p. 22)

Recognising this narrative construction, one can question whether events unfolded in a way that resemble the common conventions of a story. Most happenings include contradictions to any simplistic narrative, but contradictions – such as evidence that preliminary versions of some vaccines have harmed people – are absent from this simplistic rendition of events (Heller, 2008, p. 7). Without contradictions, this narrative asserts the moral that ‘vaccines are the best and only way to contend with infectious disease’ (Heller, 2008, p. 13). Therefore, any supporter of health would support vaccination.

Similarly, Kitta (2012) discussed the roles of rumours, legends, and other narra- tives in the perception of risk in Canada. She offered insights into the multiplicity of small vaccine narratives, which contradict or support the dominant vaccine narrative. Kitta (2012) detailed how such narratives are prevalent amongst public social net- works and outlined how different stories exist within different health profession cultures. Such narratives simplify our understandings, hide contradictory information, and offer a guiding moral (Heller, 2008, p. 8). That is, these narratives support the appearance or ‘illusion’ of certainty that guides many health professionals’ decision- making.

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Vaccine uncertainties in Alberta and Canada

Vaccine programmes also could be guided by an illusion of certainty based on govern- mental analysis of costs and benefits. For instance, Canadian government vaccine guide- lines supported the guiding morals of the vaccine narrative. The Canadian Immunization Guide contextualised the vaccine narrative as an ongoing story in which vaccines continue to rid the world of disease:

Eradication of smallpox has been achieved. Currently, global efforts are directed at the eradication of polio and the elimination of measles. (Public Health, 2006a, p. 3)

In this excerpt, the eradication of more diseases is depicted as an inevitable outcome of vaccine uptake and progress. Similarly, the Alberta Immunization Strategy (2007–2017) stated that:

Immunization has often been cited as one of the greatest medical success stories in human history. [….] In fact, research shows that with the exception of clean drinking water, no other human intervention surpasses the impact immunizations have had on reducing infectious disease and mortality rates – not even antibiotics. (Alberta Health, 2007, p. 3)

Alberta’s guide stated the need for ongoing immunisation to overcome recent outbreaks. It presented itself as authoritatively basing its policy in vaccine research and progress, and claimed that ‘Alberta has the most comprehensive immunization program in Canada’ (Alberta Health, 2007, p. 3).

At the time I was conducting my interviews (2013–2014), Alberta’s resource-based economy was strong and its population was relatively diverse. In 2011, Alberta boasted the highest employment rates and highest median family income in Canada (69% of the population who was over 15 years old had some form of employment (Alberta Treasury, 2013b, p. 1; 2013c, p. 2). Men and women generally worked in gendered sectors with the highest wage gap in the country (Alberta Treasury, 2013c, p. 3). Over 2015, this employ- ment rate declined because the economy is largely dependent upon oil prices, which have been falling. Compared to other provincial averages, Alberta’s population is young (average 36.1 years old), with relatively high household incomes, and high rates of home ownership (Alberta Treasury, 2013c, p. 1). Eighteen per cent of Alberta’s population are first-generation immigrants, 84% of whom have settled in urban regions (Alberta Treasury, 2013a, p. 1). Similarly, about 18% of Alberta’s population can be classified as from an ethnic minority background (Alberta Treasury, 2013a, p. 2). Conversely, Alberta’s rural communities were ageing, struggling to recruit immigrants, and per capita income is well below urban averages (Arcand, 2013, p. 13–14, 41).

In Alberta, public health nurses provide vaccines and vaccine information at public health offices and in schools (Matkin, Simmonds, & Suttorp, 2014). The measles, pertussis, and influenza vaccines are among those that are freely provided, but also among those most commonly refused in Alberta. The HPV vaccine has remained con- troversial, especially because the province first only covered its cost for girls. In the Autumn of 2014, Alberta extended its HPV programme to include boys. In Canada, most vaccine-preventable diseases peaked before 1955 (Public Health, 2006b). Nonetheless, Alberta has experienced disease outbreaks in recent years (Franklin, 2015; Mertz, 2015; Public Health, 2014). For instance, between October and November of 2013 there was an outbreak of 43 cases of measles (Alberta Health, 2015a). A second outbreak followed this outbreak in April and May of 2014, which spread throughout the province (Alberta

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Health, 2015a). Cases in Edmonton, Calgary, and southern Alberta received the most media attention.

Vaccine uptake is lower than the rates that public health experts in the province deem necessary to sustain herd immunity – especially with measles, pertussis, human papilloma virus, and influenza vaccines. For instance, because measles is highly contagious, the target rate for the measles, mumps, and rubella (MMR) vaccine is 98% for the first dose (before two years of age) and 99% for the second dose (before 7 years of age) (Matkin et al., 2014). Reports of uptake rates varied between government publications and regions, but Alberta Health (2015a) stated that provincial rates for the first dose of the measles vaccine dropped to 85.7% for children under 2 years old at the time I was conducting my interviews. One news article estimated that 10–20% of Alberta children are incompletely immunised (MacDonald interview in Southwick, 2015). Moreover, one study found that in June 2013, 42.8% of children under 2 years old in southern Alberta had not received the first dose of their measles vaccine (Matkin et al., 2014). This study found only 77.6% of children younger than 7 years old were fully immunised, and that vaccination rates varied from under 55% to over 90% in Albertan communities (Matkin et al., 2014). The rates in some schools, especially private schools that supported particular religious/ cultural backgrounds, were below those in the surrounding communities (Matkin et al., 2014).

News coverage in the province appeared to emphasise parental uncertainties about vaccine safety as the most significant influence on vaccine uptake. There is evidence that patient uncertainties are problematic. For instance, a 2015 poll of 2838 Albertans found that about one in five Albertans believe that vaccines may cause autism (Southwick, 2015). Scholarly research about vaccine compliance suggested that higher-income parents are more likely to refuse vaccines due to vaccine ambivalence (Heller, 2008, p. 15; Reich, 2014). In Alberta, however, other barriers to vaccination may be greater determinants than ambivalence because Alberta’s vaccine uptake is positively correlated to income level (Alberta Health, 2015b).

As such, government guidelines centred ideas about how to raise vaccination rates with assumptions that health professionals support governmental vaccination goals and are well prepared to educate the public. For instance, the Alberta Immunization Strategy (2007) reported that health providers ‘require time and resources for role modelling and knowledge transfer to new health professionals, and for counselling clients about immu- nization’ (Alberta Health, 2007, p. 9). By implication, the guide assumes that health professionals who are not ‘new’ are knowledgeable and intent on sharing information.

Given the dominant public health vaccine narrative, in this article I examine how health professionals talk about vaccination. I am particularly interested in how they deal with the situation in which the provincial administration expects them to confidently relay vaccine information to patients, even though some of these professionals stated concerns about the efficacy of the vaccines. I found that some professionals use their own small stories from personal and professional experiences. These small stories relate to their understandings of various medical interventions, medical progress, and their professional role.

Methodology

In this article, I draw on data from a study, which I undertook in Alberta between 2013 and 2014 to investigate how health professionals expressed their uncertainties, and how they used narratives to convey confidence, uncertainty, and/or doubts in vaccines. Kitta

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has observed people express their beliefs about vaccines as contemporary legends, personal narrative, or some combination of these (Kitta, 2012, p. 21). Similarly, I sought to investigate how health professionals used narrative to depict their knowledge of vaccines, express any emotional responses to vaccine controversies, and situate their experiences as professionals and vaccine consumers within the context of Alberta. With approval from the Health Research Ethics Board at the University of Alberta, I inter- viewed health professionals (33 participants). Narrative analysis guided my investigation of professional knowledge, common narratives, and uncertainties about vaccines.

Recruitment and interviews

I targeted professionals who provided immunisation advice to patients, regardless of whether they also vaccinated patients. Patients compile vaccine information through the combination of sources, such as speaking with various professionals, reading informa- tional materials, and conducting their own research. I particularly targeted family physi- cians, paediatricians, and family clinic nurses who refer patients to public health clinics for most childhood vaccines, because patients tend to highly regard advice from these professionals (Keane et al., 2005, p. 2489). I also recruited four public health nurses so as to include the perspectives of those who provide the majority of vaccines and information to Alberta’s population. Moreover, I included one specialist physician and one operating room nurse who heard of my study through acquaintances and wanted to share their perspectives.

I found recruitment advice in previous research was helpful, but inadequately addressed the context of Alberta (Asch, Connor, Hamilton, & Fox, 2000; Ellis et al., 2007). Over the first 4 months, I interviewed only four participants through informal social networks, emailing medical faculty, and hand-delivering information sheets to clinics. After these initial failures, I met a pharmaceutical representative who shared effective methods for gaining access to physicians. Her career involved convincing busy health professionals in Alberta to spend 30–60 minutes discussing pharmaceutical interventions. With the help of a research grant from the University of Alberta’s Department of Sociology, I incorporated some of the recruitment tactics that the pharmaceutical representative knew to be effective for recruiting physicians. Specifically, I attempted to schedule lunch meetings for which I provided the food. In addition, I incorporated one practice that the Code of ethical practices in Canada forbids pharmaceutical representatives, which is that I provided edible treats for the clinic staff (chocolate, cookies, or donuts [Innovative Medicines, 2016, p. 32]). When I was able to speak to the professionals at these clinics, I would ask to book an interview with them and offer to provide a lunch. Otherwise, I would leave an information sheet with the administrative staff. Through these tactics, I recruited additional 29 participants making a total of thirty-three participants.

Due to convenience, I began recruitment in Edmonton. Then, I travelled to southern and rural communities that had experienced a recent measles outbreak and were experi- encing a pertussis (whooping cough) outbreak when I was conducting interviews. I wanted to hear from professionals who were experiencing the consequences of lower vaccination rates as well as those who practiced in relatively disease-free locations. Participants in this project practiced in at least one of the 14 localities within which I managed to recruit. Major urban centres included Edmonton, Calgary, Red Deer, and Lethbridge. Due to population size and confidentiality, I am withholding details specific to individual participants and to the smaller centres.

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Interview recordings ranged from under 13 minutes to over 55 minutes. Only 2 interviews were under 20 minutes, and 18 interviews were over 30 minutes. Interviewing physicians (more so than the nurses who partook in this project) upset traditional research power relationships. As Bloom (1998, p. 35) has noted:

One effect of having power reified into an authoritative discourse is that we talk as if researchers inherently have more power in the research relationship. (emphasis in original)

I was the subject with less authority during interviews with physicians.

The participants

Most doctors in this study were generalists, but three (including two paediatricians) were specialists. Doctors who participated came from variety of backgrounds, whereas all the nurses appeared to be white women. Sixteen of twenty-six doctors were women and at least one-third of doctors were ethnic minorities. Seven doctors said they completed medical school overseas and immigrated to Canada. Another nine trained in other provinces. Most interviewees practiced in or near urban settings, but five doctors and four nurses practiced in rural communities. Participants’ ages ranged from their early 30s to 70s with a wide range of professional experience. (Some had practiced exclusively in Alberta, whereas others had practiced in other provinces or countries.) To conceal participants’ ethnic backgrounds and avoid using only English names, I refer to physicians with names that are used in two or more cultures.

Only the four public health nurses routinely administered childhood vaccines. Other interviewees administered selected vaccines to patients over 9 years old or referred patients to public health clinics. Unlike the nurses in this study, doctors had somewhat diverse views concerning the efficacy, necessity, and safety of specific immunisations. The biases within this sample possibly reflected how busy participants’ practices were (some clinic staff told me their physicians could not participate due to business), levels of doctors’ burnout (it is likely that burnt-out doctors opted-out of the study), the degree to which professionals were concerned with vaccines, and their openness to research.

Analysis

For this article, I focused analysis on health professionals’ uncertainties about vaccines in relation to the vaccine narrative and their use of personal narratives. These narratives took the form of stock images, which in this case, involved sharing an event rather than a life story (Maynes, Pierce, & Laslett, 2008). These images provide snapshots about health professionals’ experiences with immunisations, vaccine anxieties, and other issues relating to the operation of medical knowledge and practice (see Bazylevych, 2011, pp. 451–452). Recurrent small stories and other forms of explanation are stock images, which can explain the prevalence of a social phenomenon. Maynes and colleagues (2008) used the term stock images to refer to the similar events that emerge when various people from a similar social position speak about their experiences (p. 81). I analysed relevant stock images and small stories in relation to the vaccine narrative (see Heller, 2008, p. 13) and the management of uncertainties.

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Findings

All the interviewees in my study supported the general notion that vaccination was a means to sustaining population health. About one-third of the participants expressed some concern regarding other health professionals’ uncertainties or non-compliance with vac- cine schedules. The nurses I interviewed each strongly supported vaccination, but one was unsure about the longevity of the herpes zoster vaccine (shingles), and two had previously held doubts regarding the efficacy of the influenza vaccine. Doctors overwhelmingly supported the use of vaccines, but about half of them stated ambivalence about specific vaccines or the use of specific vaccines for certain populations. In some instances, this ambivalence led doctors to prioritise counselling about some vaccines over others (for example, several emphasised the necessity of the tetanus vaccine in comparison to rotavirus, varicella or influenza, which they implied were less dangerous viruses). Likewise, some doctors questioned the efficacy of what they perceived to be newer vaccines or vaccines that were incompletely covered by provincial funding (for instance: HPV, herpes zoster, influenza, rotavirus, or varicella). Most doctors, however, stated that they followed Alberta’s vaccine schedule for their children and recommended their patients do the same.

Most interviewees utilised personal experiences and stories about vaccines to justify their support of vaccines rather than relying upon purportedly more objective medical discourses. While using subjective stories and experiences to illustrate their views, some interviewees stated that they were unaware of further details about vaccines.

For instance, interviewees who stated that research had proven vaccine efficacy, often provided personal narratives to highlight the risks of disease. Ren, an urban family physician and grandfather, shared a family narrative about deaths from vaccine- preventable diseases:

Ren: I think once they make that decision [not to vaccinate] they stick with […] that. And really, it’s not a very intelligent decision, because four generations ago, my grandmother had ‘acceptable losses’ in my extended family of four out of sixteen children before school age died of infectious diseases that kids get pre- vaccination. That was acceptable losses. [….] So I mean I think a lot of our patients don’t get what the real world is like without vaccinations. And I think a lot of the naysayers right now are depending on all those who do get vaccinations to protect their families. And they are part of that vaccinated pool and once we get below 80% vaccination now we’ve got risk of sub- epidemics going on.

Terra Manca [interviewer]: Do you think it’s below 80% for all vaccinations that causes that?

Ren: I don’t know. I don’t know the details yeah. That’s why we have immunologists.

Ren exemplified some issues that emerged during interviews. He asserted that vaccines would offset the risks of disease, but indicated he was not familiar with all the evidence. For example, in his interview he identified a target figure to ensure collective or herd

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immunity. But, when I questioned him, he stated that he was unsure about that figure and that in this area he trusted the experts (immunologists). He endorsed the commonly stated view that vaccine refusers would probably change their minds if the real world changes and epidemics became more commonplace. In his interview, he tended to use stories from his personal family experience as supporting evidence rather than referring to medical journals, government documents, or other authoritative knowledge.

Types of uncertainties

Health professionals talked about various types of uncertainties. Most interviewees explained that their uncertainties about vaccine safety were trivial compared to the risks of vaccine non-compliance. These uncertainties included those that Fox (2002) stated could be internal to the professional, broader issues with medical knowledge, and potentially an intersection of personal knowledge gaps with the limitations of medical knowledge.

For instance, Kian was a young rural family physician who claimed he learned more about vaccines from deciding to fully vaccinate his own children than his medical training. He freely shared knowledge gaps with me, which coincided with his perception of the limitations of medical knowledge. He described growing up with parents who refused vaccines and explained that he had maintained limited scepticism throughout his career:

Lots of nurses are against vaccines and most of it’s quasi-scientific, well all of it I would say. […] [S]ome of it is […] a bigger dose of my cautions. [….] If you’re like me and you start looking for problems, then eventually you might say, ‘Well I think that we should just get rid of them all together.’ I think that’s very irresponsible because I think that in the present age, you must vaccinate your children.

Kian’s story epitomised health professionals’ social position as conveyers of information between vaccine experts and the public. He reiterated the vaccine narrative, but he included glimpses at the uncertainties that arise from hidden contradictions to that narrative. For example, he explained that he was suspicious about the pharmaceutical industry and he said, ‘I’m not necessarily a firm believer in the Western medical system either’. He stated that he avoided the annual influenza vaccine, thought that vaccine had low efficacy, and questioned whether reported deaths from influenza had been inflated. Likewise, he listed the mumps vaccine as less effective than others because years ago his brother had contracted mumps, and then spread the virus to 15 of his classmates and one teacher who had all been vaccinated. He expressed concerns that the chickenpox (var- icella) vaccine would actually decrease herd immunity to both chickenpox and shingles (herpes zoster) because he perceived vaccine immunity to be more fleeting than ‘natural immunity’. Each of these statements contradicted his proclamation that ‘you must vacci- nate your children’.

Some interviewees’ uncertainties may reflect personal knowledge gaps, but many explained them as being inherent to medical practice. For instance, Anita, a young family physician who was establishing a new practice at an urban clinic, expressed that she was unsure about some vaccine risks, but that she knew vaccines improved safety overall:

Anita: I’m sure there’s stuff that we don’t know, but again it’s risk-benefit. [….] It’s the autism where we say, […] game over because of Wakefield right? But […] the

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patient I saw with the seizure. Will we ever know if it was related to [the vaccine], or was it just bad timing because you got a cold [….] Also I was reading some- thing about which one was associated with um … shoot, was it sleep? […]

Terra Manca [interviewer]: Oh the narcolepsy? Anita: The narcolepsy, yes yes yes. Terra Manca: H1N1 Anita: Thank you. The H1N1 right, so if that’s associated that

really sucks. But again it’s to look at the numbers and see when a patient takes something their aware. […] if that actually causes that risk and it happens to them, that would really suck, but it would suck more if they got the H1N1 went in the ICU [Intensive Care Unit] and then they die. […] We can allow for a few things that happen with a treatment. We do it all the time. We give someone any medication for blood pressure and we’re assuming someone’s going to get some type of side effect right? [….] You get much more side effects with the 10 billion medications we give say, ‘Oh we’ll treat 10 people and maybe it’ll help 1 or 2,’ but somehow we’re totally fine with that as opposed to the thousands we help with vaccine and the one person gets affected.

At the start of her discussion of vaccine risk, Anita referred to the case of Andrew Wakefield, a physician and researcher, who claimed in an article published in the Lancet in 1998 to have found a link between autism and the MMR vaccine. In 2010, the Lancet editors withdrew the article as the findings could not be replicated and appeared to be fraudulent (see Alaszewski, 2011; Goodlee, Smith, & Marcoitch, 2011). Anita explained that patient concerns regarding vaccine safety baffled her. She placed concerns about arthritis and childhood narcolepsy (which emerged in Canadian news near the time of interview) within the realm of the unknown while emphasising the necessity of vaccines (CTV, 2013).

Furthermore, other interviewees expressed uncertainty about rare side effects that they associated with limitations inherent to medical knowledge. When stating these uncertain- ties, interviewees maintained that (most) vaccines were beneficial. One urban paediatri- cian, Javen, who had practiced for decades and had grandchildren, mentioned a family physician who attributed his daughter’s disability to vaccination:

Javen: I met one family physician that his child had some kind of neurological thing […]. [E]ven the specialist they thought that it could have had something to do with early vaccines and well, she died eventually […] completely brain damaged, and you know, they had to care for her up to six years. So […] those Family Med. understandably they’ve, you know, seen some of the bad sides.

Terra Manca [interviewer]: […] do you think that it could’ve been linked to the vaccine […]?

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Javen: It can have […]. Metabolic, but it’s rare, but it’s there. It’s definitely there easily, like if you get the disease naturally, then […] I know with measles, then you have a bigger chance of getting the neurological thing.

Javen listed the risks associated with measles as outweighing those from vaccination, but suggested the impossibility of determining whether that disability resulted from the vaccine. Underlying metabolic disorders have been linked to rare, but severe, vaccine side effects in the past, most notably regarding the whole-cell diphtheria, tetanus, and pertussis (DTP) vaccine. DTP was controversial before it was replaced with an acellular version of that vaccine (Centers for Disease Control [CDC], 1996).

Many interviewees lamented their inability to master the entirety of medical knowl- edge. Some claimed ignorance of Alberta’s vaccine guidelines, provincial immunity levels (which vary by vaccine), or the effects of their counselling. They also listed some mundane knowledge gaps that accompany any patient encounter. For instance, Nisa, a family physician who worked in an urban clinic, lamented her difficulty obtaining accurate adult vaccine records:

Well I ask them, but you can’t trust – I mean first of all, they don’t know what Tdap [a vaccine that stimulates immunity to tetanus, diphtheria and pertussis] is, and they might know I had measles, but if I say did you have Tdap, they say well what’s that? But if I ask if they have pertussis [vaccine], they may say, ‘Yes I had pertussis, but I don’t know if I had tetanus with it’.

Apart from public health nurses, most interviewees did not feel they had adequate access to accurate adult vaccine records. They argued that inaccessible patient records prevented them from ensuring adults’ vaccines were appropriately updated.

Moreover, interviewees said they were unsure whether patients accepted their referrals to other health professionals or organisations that provided vaccines and information, such as public health clinics, travel clinics, or pharmacies. Monica, who was a young family physician in a large urban setting, said that she wished she received feedback on her referrals: ‘I would want be able to know whether or not [counselling] does make a difference because yeah, I have no idea. It seems to at the time.’ Although Monica appeared optimistic, some health professionals said that they felt speaking to patients who strongly opposed vaccines wasted time and energy. Some used their general experience of advising patients to interpret the likely success of their vaccine counselling. For instance, Kai, who had practiced for decades as a family physician in an urban centre, described her failed efforts to persuade diabetic patients to follow healthier diets. Most interviewees prioritised informed consent over pushing vaccine uptake onto those who opposed vaccines. Yet, some health profes- sionals doubted whether vaccine refusers made informed decisions about immunisation, using the term informed to refer to the knowledge of medical science.

Practicing with uncertainty

Interviewees managed their uncertainties through various tactics designed to support what they felt was the most desirable course of action. Most health professionals reaffirmed the dominant vaccine narrative even if they acknowledged some uncertainties. They often relied upon their own personal narratives and subjective sources of information to demonstrate certainty that vaccination was desirable. Health professionals often referred to authoritative knowledge from medicine, government policies, or their trust in the

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progress of medical science. They drew on the vaccine narrative asserting that vaccines saved lives, especially children’s lives. For instance, Aalia, an urban physician who practiced for a few years presented herself as well informed about vaccinations. She stated that an immediate family member worked in public health and that she had vaccine training beyond her medical degree. She drew on the dominant vaccine narrative in the following statement:

It’s revolutionised infectious diseases. I had a visiting doctor from Pakistan a few weeks ago. And, there they really don’t have the same types of immunisations […] she said there, as a family doctor, most of her time is spent on infectious diseases. And here it’s just so different. I mean I focus more on screening and preventative care, that sort of stuff. […] I mean don’t get me wrong, there are other new emerging things, you know problems in our health as a population, which are no better, no worse that the infectious diseases we prevent with immunisations. But, I think that people don’t always think or realize the huge wide impact that vaccines have. You know, the number of theoretical lives that have been saved (Aalia).

Thus, Aalia drew on a narrative in which vaccines are safe and there are no concerns about their efficacy. During the interview, she expressed slight uncertainties – for example she voiced a suspicion that the introduction of the varicella vaccine coincided with rising rates of shingles – but she asserted that such efficacy concerns were inconsequential compared to the risks of disease.

Some interviewees in my study acknowledged uncertainty and noted limitations in the dominant vaccine narrative. One middle-aged paediatrician, Chandra, who had worked in urban health centres, explained her practice had more ambiguity and was less straightfor- ward than the progress of science model underpinning the vaccine narrative, which she had been taught in medical school:

when I was in medical training and residency, the way in which the curriculum is delivered around immunisations is sort of […] These [diseases] used to be a worldwide problem, now these vaccines have been developed, everyone gets them, isn’t life grand. I think in clinical practice, and the clinical research, and the colleagues, and the healthcare settings that I’ve worked in – I don’t think it’s quite that straightforward. I think in particular there’s misgivings.

Chandra told stories that supported scepticism of the vaccine narrative. She preferred more nuanced explanations of vaccines, but emphasised she recommended parents follow Alberta’s vaccine guidelines, which she and her children followed. She explained that she was ‘supportive of evidence’. Then, she elaborated by stating that she would answer questions patients have, but clarified, ‘that’s very different from feeling like I am an evangelist that it is my job’. As such, Chandra presented her job as to inform parents rather than convert them into accepting vaccines.

Many of the interviewees in my study appeared to be unable to explain all the details about how vaccines work, but supported the view that they should be used in most circumstances. That is, they admitted that safety is always a matter of degree, but that vaccines were safer than lowered population immunity.

Most of the interviewees in my study refined the basic claims made for vaccines, namely that the benefits outweigh the risks. For example, Nisa stated: ‘[…] I think there are limitations in the efficacy, but I don’t really worry about [that], I mean that’s the best we have.’ Interviewees often supported narratives that vaccines were the safest option with stories about the dangers of refusal. Taran, a paediatrician who practiced in a city and

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nearby town discussed a child becoming severely ill with H1N1 after his family missed his flu vaccine:

[T]he one kid who had asthma and was very well controlled on medicines, but then got H1N1, and got too sick, and too sick to the point that this child had to go to ICU [Intensive Care Unit]. And after ICU he was in incubator and then afterwards on ventilator and then he has to go on ECMO [Extracorporeal Membrane Oxygenator]. [….] The survival rate is very, very low after that. [….] Luckily, he came out well. He survived and I saw him in a follow-up clinic and was very happy to see him again walking and though he has some weakness in his arms now.

Taran quoted the child’s family’s statement that they had provided the flu vaccine the year before, but had failed to get it the year their son became ill. He admitted, ‘[…] with everything the efficacy is not a hundred per cent’, but he argued the flu vaccine prevented severe illness and death with limited safety risks.

Other health professionals stated that extremely rare risks were an unavoidable cost of maintaining population health. Ren, who practiced family medicine, talked about a patient who became disabled after a measles vaccination:

I have one patient in my practice who is a group home patient, he’s a dependent adult. He developed an encephalopathy [inflammation of brain tissue causing dysfunction] after a measles vaccination as a child and that was the cause of his permanent disabling brain injury. It’s real, it can happen. And that person got hurt and maimed for life to save other lives. So for my individual it’s a disaster, for the rest of the population it’s a measure of healthcare.

He analysed the statistical risk (to child) and the benefit (to rest of population) to justify the vaccination. He stated that vaccine safety was backed because of what ‘The statistics say […],’ then he stated, ‘I’m confident that by the time it’s gone to market it’s passed a certain process criteria […] I shouldn’t have to worry about that stuff’. He restated his family narrative about his grandmother losing children and listed common minor side effects and vaccine-related risks as including fever, which he said can last up to 3 days.

Health professionals in my study indicated that they either had extensive knowledge about vaccines (public health nurses and those who had attended vaccine courses or training), or that they trusted other (more expert) professionals to make vaccines as safe as possible. Such trust indicated that the interviewee was aware that she or he could not master the entirety of medical science. For instance, Damian, an urban family physician, who practiced for almost 20 years, acknowledged the practical limits of the time required to research each vaccine. Rather than conduct such research, he was willing to accept the efficacy of most vaccines as he experienced the harm on not being vaccinated:

I haven’t really put any effort into researching vaccines. I’m interested in travel vaccines, so I got some information into that. From my perspective, I have a hearing loss in both ears and I wear hearing aids and that’s because I was born before [a specific childhood] vaccine became available. So I never had the […] vaccine and I had [the disease] when I was eighteen months old and have a consequent problem.

Because of his experience with hearing loss, Damian implied that he trusted most vaccines, then admitted to holding previous doubts about the influenza vaccine. Similar stories emerged in interviews about vaccine-preventable illness, death, and disabling side effects that interviewees, their families, or their patients experienced.

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Doctors often complemented these narratives by asserting their trust in public health nurses and policies. Olivia, a registered nurse who practiced in an urban family medicine clinic expressed completed faith in scientific medicine, the production of vaccines, and the policies behind them:

I trust that there’s people know a lot more about this than me and that’s what their job is and that’s what they went to school and trained for. So why would I presume that I knew any more than they did.

When I asked if there were moments that she would hesitate to trust scientific results, Olivia answered, ‘Nope’. Similarly, Ren explained: ‘So, the concept of immunisation is my job’ but the details were for other professionals to manage.

Likewise, interviewees supported both the vaccine narrative and myths of progress by conflating progress with improvement. When I asked if vaccines had become safer over time, Makenna, a rural public health nurse with about 10 years of experience explained:

You know in the past there was, not problems, but probably more side effects with some of the vaccines, just because they were newer, and anyway they refined them and oh boy, it’s just so much better [….]. I think they’re just getting better and better and safer and safer.

Makenna noted that improvements included combining vaccines so that children needed fewer injections for the more immunisations. The changes that she cited might have signified improvements, but they also ignored the influence of various social, economic, and corporate forces.

Along with this progress, interviewees – especially those who expressed distrust of newer vaccines – often suggested that vaccines deemed safe, effective, and economically feasible should be integrated into the public health agency of Canada’s recommendations and Alberta Health’s vaccine schedule. Their advocacy of progressive incorporation means that they saw the vaccine narrative as an unfinished story of ongoing success. The climax of the culturally dominant vaccine narrative was the eradication of smallpox, but the narrative is unfinished because science continues diminishing the prevalence of more diseases. Interestingly, some interviewees included such changes to vaccines as the removal of thimerosal (a mercury-based preservative), as improving public perception of risk, and therefore vaccine uptake.

Most health professionals based their story of learning about vaccines on the narrative of progress. Learning, in this sense involved placing new information alongside pre- viously known facts. Maya, a family doctor who had been practicing for less than a decade in an urban centre and overseas said:

I would say yeah it [my knowledge] has been changed because […] I have seen changes in the vaccine schedule: The duration, the number of vaccines and the time period at which it should be given, so definitely.

Maya also discussed concerns about her own children’s exposure to preventable illnesses due to other parents’ refusal to have their children vaccinated. She did, however, express some uncertainty about the accessibility of vaccinations, particularly regarding the flu vaccine. Very few interviewees mentioned moments that they had changed their minds about vaccines or how they learnt about the benefits of vaccines except perhaps in the case of the flu vaccine.

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Some interviewees suggested that progress could be a source of uncertainty. These professionals (excluding public health nurses) recognised how progress could create personal knowledge gaps and uncertainty over the timing of vaccinations. For instance, Nisa maintained her trust in vaccine progress, while admitting to personal knowledge gaps:

I do rely on Public Health, […] to make sure that the vaccines that I’m giving are safe right? I mean […] they have access to a body of information and research. And so, I don’t keep as close track because [….] I trust the organisation.

Nisa said she trusted public health to follow scientific progress because the details of vaccine updates were beyond the scope of her already busy practice. As such, she relied on general understandings of vaccines when promoting treatments to her patients.

Despite their use of subjective evidence, general information, and personal narratives, most interviewees criticised patients for relying on such information. Almost all health professionals responded to my asking what constituted Alberta’s biggest vaccine-related issue with a comment about misinformation, vaccine uptake, or vaccine refusal. These responses often involved emotional investment, which I took as an evidence of their certainty about the necessity and value of vaccine uptake. Olivia, a family clinic nurse who had selected vaccine-related topics for various undergraduate papers, detailed her frustrations. She told me about her reaction to the measles outbreak in southern Alberta in the following way:

I kind of want to choke the person that came over from Holland […] and brought this [measles outbreak] here. It’s infuriating. It’s just infuriating that we’re so close. So close to eradicating so many of these childhood diseases and the ignorance of people is bringing them back. […] Infuriating is the best word I can use to describe it. And […] when I hear stories of children that couldn’t be vaccinated because of something and then they get sick, I feel so helpless. [….] But, it’s the scientific method, […] this is how we remove emotion from it, we find out scientifically that the benefits outweigh the risks. And, I try to like get this into people’s heads that intellectually this – [….] just sometimes [I] feel like I’m yelling to a wall and nobody’s listening.

Her claim that science removes emotion from vaccine research contrasted with her expression of anger. She demonstrated a greater trust in science than the other health professionals I interviewed. Nonetheless, her criticism of patients relying on non-objective information was endorsed by other interviewees in my study.

Discussion

Health professionals’ knowledge is limited by the breadth of existing medical knowledge, which means that they must rely on and trust the expertise of professionals in medical sub-specialisms. Medical uncertainty and the means through which health professionals navigate it has received limited, but increasing recognition from medical practitioners and researchers (see Eborall & Will, 2011; Knight & Mattick, 2006; Lingard, Garwood, Schryer, & Spafford, 2003). Researchers have predominantly examined treatments that lacked expert consensus (Gerrity et al., 1992; Griffiths et al., 2006). In this article, I have investigated topics pertaining to routine vaccinations, procedures that are widely accepted in medicine and nursing as safe and effective. I found that even with this simple preventative treatment, health professionals relied on various tactics to manage their

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own uncertainties. This management is necessary because physicians are experts only in their area of specialisation (see Prior, 2003, p. 51).

These tactics included referring to authoritative information sources (such as government documents or medical specialists), relying on the culturally dominant vaccine narrative, and using personal narratives. Health professionals grounded their confidence through their own assumptions about authoritative cost-benefit analysis. They reiterated various phrasings of Nurse MacDonald’s statement to the CBC: ‘These diseases are the thing to be afraid of and the vaccines are just by and far the safest option’ (quoted in Griffith-Greene, 2014, para 43). Nonetheless, regulatory agencies cannot investigate every potential risk (Sunstein, 2002, p. 142), which means that the possibility of risk exists with every health intervention. In fact, vaccine developments and advancements in medical knowledge create a ‘risk or risk,’ meaning that as interventions become ‘safer,’ there is always a possibility of overlooked dangers, manufacturing errors, or other mishaps (Fox, 1988, p. 548). Health professionals can practice with uncertainty by acknowledging that safety cannot be absolute or with an illusion of certainty by denying the possibility of any danger (Gigerenzer, 2002).

Some interviewees recognised the possibility that certain vaccines were unneces- sary or that under rare circumstances, they could cause harm. Some interviewees demonstrated that medical progress could help decrease perceptions of risk by eliminating components that patients fear. Conversely, others acknowledged that progress can be a source of uncertainty. As Alaszewski and Harvey observed ‘in the twenty-first century it has become apparent that modernization and the develop- ment of science and technology actually increase uncertainty and can be seen as threats to individual well-being’ (Alaszewski & Harvey, 2001, p. 302). Even so, participants explained that vaccines were by far the safest option to ensure health. All interviewees spoke about most vaccines as though they were risk free even when they recognised the limitations of their own knowledge, or medical science.

Rather than rely exclusively on what they knew of scientific data, the professionals I interviewed tended to accept the implied moral of the vaccine narrative that individuals should accept vaccination as a means of protecting themselves and others by developing immunity to specific infectious diseases (Heller, 2008, p. 11). Professionals often used personal stories about patients, their families, or their own health to bolster this narrative with small stories. Health professionals’ use of narratives could reflect the centrality of experience to the accumulation of expertise (Collins & Evans, 2002, p. 260), as well as explain vaccines within a social and cultural context. Furthermore, sharing subjective narratives may engage patients more so than such statements as ‘the benefits outweigh the risks’ or utterances of poorly interpreted statistics (see Gigerenzer, 2002). Most health professionals whom I interviewed lacked specific expertise about vaccines, but they demonstrated professionalism by recognising the limits of their knowledge, interpreting medical discourse in relation to their practice, and expressing the ability to refer patients to colleagues or locate information as needed.

Conclusion

In this article, I have shown how the health professionals I interviewed presented certainty in the necessity of vaccines and how they managed personal uncertainties, the limitations of medical knowledge, and gaps in the information that patients provided. Many dis- missed their uncertainties by emphasising the benefits of vaccination, minimising the

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risks, and by using the culturally dominant vaccine narrative. In addition, interviewees shared narratives with me that included their personal experience with vaccines, and which resulted in various simplistic explanations of the importance of vaccines.

Interviewees explanations fell short of filling the assumptions of the Canadian Immunization Guide and Alberta’s Immunization Strategy, which positioned experienced health professionals as knowledgeable and keen to share their understandings of vaccines. Rather, interviewees demonstrated some subjective understandings of vaccines, which usually complemented their professional knowledge. They used narratives to covey that knowledge, which enabled them to personalise the risks of disease, appeal to the same emotions that fuel others’ perceived risks of vaccines, and fill any gaps in their own knowledge with palpable explanations.

Professionals’ use of narrative to convey vaccine information could create the appearance that health professionals’ knowledge is equally subjective as patients’ knowledge. Much sociology of health research has highlighted the ‘democratisation of knowledge’ (often as a desirable form of progress) along with the increasingly recognised role of uncertainty (Hobson-West, 2007, p. 211; Lankshear, Ettorre, & Mason, 2005, p. 362; Leach & Fairhead, 2007, p. 4; Prior, 2003, p. 43; Streefland et al., 1999, p. 1712). Some researchers are cautious to avoid equalising knowledge to include ‘lay expertise because a ‘reckless extension of expertise has many well-known dangers – the public can be wrong’ (Collins & Evans, 2002, p. 271). Any equalisation of these types of knowledge can reduce health professionals’ expertise to ‘just another opinion’ (Kata, 2010, p. 1715). Overprivileging lay expertise ignores advances in medicine that may save lives, and the fact that patients often desire health professionals’ advice when making health decisions (especially potentially life- determining decisions (Sinding et al., 2010, p. 1097; Wootton, 2006).

Furthermore, health professionals’ use of personal stories may reflect uncertainties that emerge from their social position between experts and the public. Blume (2006) proble- matised the dichotomisation of vaccinators and anti-vaccinators for placing health profes- sionals ‘behind a banner of reason’ where vaccines are understood as impossibly risk free, and patient concerns are treated as irrelevant. He argued that labelling anti-vaccination a ‘movement’ trivialises important concerns that patients have because the number of parents who oppose vaccines is small compared to the number who avoid immunisation for other reasons (Blume, 2006, p. 635). As such, anti-vaccine narratives could represent broad problems in healthcare, understandings of risk, and the production of medical rationality (see Bazylevych, 2011, pp. 451–452; Blume, 2006, p. 639; Chen, 2005, p. 39; Hobson-West, 2007, p. 211; Poltorak et al., 2005, p. 711; Streefland et al., 1999, p. 1714). Alberta’s health professionals’ narratives about vaccines and risks offer an opportunity to peer behind that ‘banner of reason’ and to observe the uncertainties accompanying a widely accepted and well-established preventative treatment.

Acknowledgements Thanks are extended to Dr. Stephen A. Kent, who supervised this project and offered initial comments on the manuscript. I also appreciate the guidance I received from my candidacy committee members Dr. Tim Caulfield, Dr. Amy Kaler, Dr. Robyn Braun, and Dr. Laurel Strain. Finally, I extend gratitude to Dr. Patrick McLane for reading and commenting on a draft of this article.

While undertaking the research on which this article is based I received the following funding: Izaak Walton Killam Memorial Trust (Izaak Walton Killam Memorial Scholarship), the Social Sciences and Humanities Research Council of Canada (Joseph-Armand Bombardier Canada

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Graduate Scholarships), the University of Alberta (President’s Doctoral Prize of Distinction and the Dissertation Fellowship), and the Department of Sociology research grant.

Disclosure statement No potential conflict of interest was reported by the author.

Funding This work was supported by Izaak Walton Killam Memorial Trust (Izaak Walton Killam Memorial Scholarship), the Social Sciences and Humanities Research Council of Canada (Joseph-Armand Bombardier Canada Graduate Scholarships), the University of Alberta (President’s Doctoral Prize of Distinction and the Dissertation Fellowship), and the Department of Sociology research grant.

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