title: Taming the fear of voice: Dilemmas in maintaining a high vaccination rate in the Netherlands.
abstract: In the context of international public debates on vaccination the National Institute for Public Health and the Environment (RIVM), the Dutch public health body responsible for the National Immunization Programme (NIP), fears that the high vaccination rate of children in the Netherlands obscures the many doubts and criticisms parents may have about vaccination. The question arises as to how the robustness of this vaccination rate and the resilience of the NIP can be assessed. To answer this question, we explore the vaccination practices and relationships between professionals and parents using qualitative methods. Drawing on Hirschman's concepts of exit, voice and loyalty, we distinguish between two different approaches to vaccination: one which enforces parental loyalty to the vaccination programme, and one which allows for voice. The analysis shows that due to their lack of voice in the main vaccination setting, parents' considerations are unknown and insight into their loyalty is lacking. We argue that the Dutch vaccination programme is caught between the insecurity of enforced parental loyalty to the NIP and the insecurity of enabling parental voice and negotiating space. We conclude that to increase the resilience of the NIP, experimenting with voice and exit is inevitable.
authors: Dep. Health, Ethics and Society, Research School Public Health and Primary Care (Caphri), Faculty Health, Medicine and Life Sciences, Maastricht University, The Netherlands. Electronic address: e.geelen@maastrichtuniversity.nl.
authors: Els
authors: E
authors: Geelen
authors: Centre for Infectious Disease Control, National Institute for Public Health and the Environment, P.O. Box 1, 3720 BA Bilthoven, The Netherlands. Electronic address: hans.van.vliet@rivm.nl.
authors: Hans
authors: H
authors: van Vliet
authors: Department for Vaccine Supply and Prevention Programmes, National Institute for Public Health and the Environment, P.O. Box 1, 3720 BA Bilthoven, The Netherlands. Electronic address: pieter.de.hoogh@rivm.nl.
authors: Pieter
authors: P
authors: de Hoogh
authors: Dep. Health, Ethics and Society, Research School Public Health and Primary Care (Caphri), Faculty Health, Medicine and Life Sciences, Maastricht University, The Netherlands. Electronic address: k.horstman@maastrichtuniversity.nl.
authors: Klasien
authors: K
authors: Horstman
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005239:Fear / Q000523:psychology*; D005260:Female; D006801:Humans; D017589:Immunization Programs; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009426:Netherlands; D010290:Parents / Q000523:psychology*; D011369:Professional-Patient Relations; D036301:Qualitative Research; D014611:Vaccination / Q000523:psychology* / Q000706:statistics & numerical data*
keywords: Exit; Experimentation; National Immunization Programme; Resilience; The Netherlands; Vaccination; Voice and loyalty