Artigos

Introduction

Vaccination and vaccine hesitancy in Brazil
Brazil is internationally acknowledged for its National Immunisation Program (PNI), implemented since the 1970s, which offers 45 immunobiologicals free of charge, including 28 vaccines 1. Its successful implementation resulted in the establishment of a consistent “culture of immunisation” in Brazil 1.
Despite these achievements, vaccination coverage has been falling in Brazil in recent years. Studies also suggest a change in the socioeconomic profile of Brazilian vaccination coverage: while in 1982 vaccination coverage was higher among children in wealthy families, in 2015 this pattern changed, with higher coverage among poorer children 2.
While management and logistical issues in the supply of vaccines, opening hours of vaccination rooms, and underfunding of SUS are relevant determinants of noncompliance 3, it is noteworthy that vaccine refusal motivated by personal fears and beliefsvaccine hesitancy is an additional important reason for the recent decline in vaccine coverage in Brazil 4.
Vaccine hesitancy is a term established by the World Health Organisation (WHO) to standardise the way of referring to all these forms of non-vaccination. WHO first defined vaccine hesitancy, in 2012, as the delay in acceptance or the refusal of vaccination despite availability of vaccination services 5. In 2022More recently, the concept has been rethought an and defined as , especially due to the contributions of the Social Sciences in Health through WHO Working Group on Behavioral and Social Drivers of Vaccination, which defined vaccine hesitancy in 2022 as "a motivational state of being conflicted about, or opposed to, getting vaccinated; this includes intentions and willingness" 6.
Some of the vaccine hesitancy drivers found in Brazil are the same as those found globally, such as: doubts about the real efficacy/effectiveness and safety of vaccines; questioning the financial gain and commercial interest of the pharmaceutical industry; criticism of the composition of vaccines and their mechanism of action; fear of adverse events; the belief that immunity acquired through infection is better than that generated by the vaccine; and the belief that lifestyle habits (such as healthy eating) are protective against disease7,8. Furthermore, vaccines are victims of their own success: thanks to the control or eradication of various vaccine-preventable diseases (VPD), vaccine adverse effects are now perceived as greater than the harm of the diseases 4.
Also, some hesitant families criticize the Brazilian vaccination schedule, either because of the high number of vaccines and doses or because of the belief that vaccines are administered at too early age 5. Couto and Barbieri's study showed that families that vaccinate their children consider that protecting means vaccinating, whereas hesitant families consider that they should protect their children from the vaccines 8.
Political challenges concerning COVID-19 pandemic and COVID-19 vaccines in Brazil
All the challenges mentioned so far were already a concern for immunisation policies before the COVID-19 pandemic. After it, and especially after its mismanagement by the then Brazilian federal government, the challenges became even greater 9.
Transmission of SARS-CoV-2 started in Brazil in early March, 202010. A few days after SARS-CoV-2 transmission started in the country, later, President Jair Bolsonaro made his first public statement. During his tenure, cContrary to current health recommendations, he referred to the disease as a “minor flu” and advised people not to adhere to social distancing 13. The then president also repeatedly dismantled declarations supporting COVID-19 prevention strategies issued by the Brazilian Ministry of Health, leading to distrust in official statements and the replacement of the health minister twice in 2020 alone 9.
The implementation of COVID-19 vaccines faced additional challenges. The former Brazilian president issued several statements of disbelief and distrust regarding COVID-19 vaccines, refused to take the vaccine, and kept his vaccination record confidential; later, he declared that he would not allow his daughter to be vaccinated 10. Operational aspects were also hindered with the federal government's delay in purchasing vaccines, leading to shortages of vaccines and supplies 9.
COVID-19 statistics reveal the consequences of this regrettable governance: Brazil holds the third-highest number of COVID-19 cases (behind USA and India) and second-highest number of COVID-19 deaths worldwide (behind USA only) 19.
Theoretical ReferenceFrom the context presented above, in this research’s analysis the COVID-19 pandemic will be interpreted as an event, that is, an experience linked to the social and political fields that threatens dominant certainties 11. While the pandemic and its vaccines centralized attentions globally, a fertile ground for the politicisation of vaccines emerged; vaccines changed from 'an issue from health' to 'a political issue' 10,12. The discursive disputes around the pandemic highlights transcended the issues of health and sanitary measures, highlighting disputes between worldviews about human relations, the organization of society, the role of governments, and the economy, to name a few 11.
By science politicisation, we refer to situations when ‘political interests shape the presentation of scientific facts to fit distinct models of “reality” for self-interested reasons’ 13.
Discussions about interactions between vaccines and politics are supported by Moulin 14, who highlighted that the complexity of vaccination must be interpreted within its scientific, political, and social contexts. According to Moulin, (non)vaccination confronts individuals with conflicting themes such as the marking of bodies, collective memory, and the individual-group-State relationship.
Considering the historical and cultural dynamics around vaccination in Brazil, and the exacerbation of vaccine hesitancy in the context of the event represented by the COVID-19 pandemic 11, this article explores the politicisation of vaccines from the point of view and narratives of caregivers of young children in different Brazilian sociocultural contexts.

Methods
This manuscript results from a comprehensive study entitled ´Vaccine hesitancy and childhood (non)vaccination: an intersectional approach'. We used a qualitative approach to explore the opinions and understandings of Brazilian caregivers of young children about routine childhood vaccines and the COVID-19 vaccine.
Municipalities in the study
The projectfieldwork took place in two Brazilian capitals: Sao Luis (State of Maranhao, in the northeastern region of Brazil) and Florianopolis (State of Santa Catarina, in the southern region of Brazil). Among the 5 capitals with the lowest vaccination coverage recorded in Brazil in 2019, Sao Luis ranked first and Florianopolis fourth 15. These two cities were also chosen over the other three because they are in different regions (Northeast and South) and have the greatest disparitydiversity in social, cultural, geographical and economic terms: The two cities present quite different demographic, socioeconomic, and cultural contexts. Florianopolis has a high Human Development Index (HDI; 0,847), a low infant mortality rate (7.78 per 1,000 live births-year), and high percentage of proper water sanitation (87.8%). Most inhabitants in Florianopolis are white (84.8%). Contrastingly, Sao Luis has a lower HDI (0,768), a higher infant mortality rate (13.09 per 1000 live births-year), a lower rateonly 65.4% of adequate water sanitation 16., a predominant black and brown skin population (69.6%) and a higher percentage of mothers who are heads of households, without complete elementary education 18. In addition, Sao Luis has a higher percentage of mothers who are heads of households, without complete elementary education, and with a child under 15 years of age 23,24. Also, in Florianopolis, childhood vaccination rates registered in socioeconomic stratum A was significantly lower than in stratum E. Sao Luis registered overall low vaccination coverage, with no statistically significant differences according to socioeconomic strata 17.
Both capitals have recently registered lower than recommended levels of vaccination coverage for the childhood schedule 26.
Inclusion criteria
Families invited to participate in the study were those living in Sao Luis or Florianopolis who had child(ren) up to six years old. We selected families with distinct opinions regarding childhood routine immunisation: families with (1) fully or (2) partially vaccinated child(ren), the latter comprising the group that selected some vaccines, as well as with (3) unvaccinated child(ren). We separately interviewed two family members identified as the principal caregivers of the child, i.e., those responsible for their daily care and decision-making regarding their health. In some families, it was only possible to interview one of the principal caregivers (usually the mother), either because we failed in contacting the other caregiver or because this caregiver (usually the father) was not available.
Regarding the composition of families included in the study, we favored the diversity of characteristics, seeking to contemplate upper, middle, and lower socioeconomic levels; different racial groups; participants with high and low schooling; and participants residing in different neighborhoods of the two cities.
Sampling and recruitment
Participants were recruited using snowball sampling 18, a strategy that facilitates inclusion of hard-to-reach populations, such as families that select, postpone, or do not vaccinate their children. Starting from initial sources, each family indicated others to participate in the study. The initial interviewees were families with no relation to the researchers, indicated by people from the personal and professional circles of the study investigators. Figures 1 and 2 (supplementary files) detail the steps undertaken to reach the final sample.
Data collection
We extracted empirical data from in-depth interviews. A trained, experienced researcher conducted the interviews in Portuguese, using a pre-established and tested script. Due to the COVID-19 pandemic,, we conducted interviews virtually or in-person, according to the participant’s preference. O only one interview occurred in person at the interviewee's home; all others took place in a virtual environment using the Zoom® platform.
We interviewed 48 caregivers in 33 families, 15 of whom residing in Sao Luis and 18 in Florianopolis (19 caregivers in Sao Luis and 29 in Florianopolis). These caregivers were: mothers (n=30), fathers (n= 16), aunt (n=1) and grandmother (n=1). The average interview time was The interviews lasted from 18 to 108 minutes (average 48.1 minutes), totaling 38 hours and 29 minutes of recordings. All interviews were fully audio-recorded and transcribed by the manuscript’s first author.and Tthe names of all interviewees were replaced by codes to protect participants' anonymity.
The fieldwork started in March 2021 in both cities; we finalized data collection in June 2021 in Florianopolis, and in April 2022 in Sao Luis. The difference in time needed for data collection was due to a much higher adherence to the snowball recruitment among participants in Florianopolis 26. The final definition of the number of interviews in both cities was based on the information produced during the data collection, according with the saturation criterion 19.
Data analysis
We analyzed empirical data evaluated and interpreted the interviews using the step-by-step theme development proposed by Vaismoradi and team 20 and the iterative categorization technique proposed by Neale 23, focusing on the content of caregivers' narratives', as well as contextual meaning. After an immersive reading of the transcriptions, highlighting the meaning units, we listed the codes. A spreadsheet was used both to list the codes, after abstracting participants’ accounts, and for grouping codes into categories, from which the themes emerged. We carried out the final synthesis of relating themes to established knowledge.
The fifteen categories found were grouped into three themes. The theme ‘Impacts of COVID-19 pandemic on parental meanings and representations about childhood vaccination and COVID-19 vaccines’ encompasses the following six categories: Vaccines as a collective pact; The pandemic reinforces the importance of vaccines; The rapid development of vaccines against COVID-19; COVID-19 vaccines: uncertainty about safety; Fear of COVID vaccines side effects; COVID-19 vaccines polemic reaffirm previous anti-vaccines beliefs. The theme ‘The concrete impacts of the COVID-19 pandemic on routine childhood immunisation’ encompasses four categories: Access to routine services in health facilities during the pandemic; Fear of exposure to SARS-Cov-2 leads to avoiding health facilities; Children are less exposed to vaccine-preventable diseases because of social distancing; Private health facilities as a better option than public ones. And the theme ‘Political ideology, government, and governance as drivers of (non)vaccination’ comprises five categories: Vaccination as a political position/decision; COVID-19 vaccine hesitancy associated to supporters of Jair Bolsonaro; Distrust of the mainstream media; Vaccines choice depends on the manufacturer country; The SARS-Cov-2 was purposely created by scientists and the vaccines were ready beforehand. The first two themes were analyzed based on national and international literature on childhood vaccine hesitancy in COVID-19. The last theme was analyzed according to the politicization of science and the critical and anthropological approach to the vaccine phenomenon 10,11,13,14.
All data were produced and analyzed in Portuguese, with quotes selected to illustrate categories in the results section later translated to English.

Ethical Statement
The Ethics Review Board of University of Sao Paulo revised and approved this study (CAAE nº 37536320.2.0000.0068). All participants signed an informed consent form. Data anonymity and confidentiality were maintained throughout the study.

Results
We interviewed 48 caregivers in 33 families, 15 of whom residing in Sao Luis and 18 in Florianopolis (19 caregivers in Sao Luis and 29 in Florianopolis). These caregivers were: mothers (n=30), fathers (n= 16), aunt (n=1) and grandmother (n=1). Tables 1 and 2 (supplementary file) show the complete characterization of interviewees.


Results
Impacts of COVID-19 pandemic on parental meanings and representations about childhood vaccination and COVID-19 vaccines
The COVID-19 pandemic has had mixed effects on caregivers’ views about routine vaccination. We categorized these caregivers into two large groups: one including caregivers claiming that their previous opinion about routine vaccines was reinforced by the pandemic – either highlighting their belief on the importance of vaccines, or their refusal/hesitation; and another including caregivers who modified their previous opinions – either moving from a previously hesitant position and pondering on the importance of vaccination, or hesitating/refusing routinely recommended vaccines in which they previously trusted following to the controversies surrounding vaccines against COVID-19.
In both citiesFlorianopolis and Sao Luis, we found caregivers who regularly vaccinate their children, acknowledge the importance of vaccination, and consider that the COVID-19 pandemic only reinforced the meaning of vaccines as a responsibility that must be accomplished to protect the child and honor a collective pact.

From my point of view, not much has changed. I've always had a settled position regarding vaccines. I know it's a very important thing, it helps us, and, of course, as a mother, I will always want to protect my daughter. (S-V-01.Mother)

We found families who were hesitant to follow the routine childhood immunisation schedule only in Florianopolis. These families had their hesitancies about vaccines maintained or reinforced after the onset of the COVID-19 pandemic. In Sao Luis, specific hesitant perceptions towards COVID-19 vaccines included their fast pace of production and fear of adverse events. In addition, for some families, hesitations towards COVID-19 vaccines were accompanied by reluctancies about routine vaccines that, until then, had never been questioned.

It is like a little light turns on at the back, 'Wow, now what? What will happen? Do these other vaccines also have sequelae for us?'. (S-H-08.Mother)

Contrastingly, for other families with hesitant opinions about the COVID-19 vaccine, routine vaccines remained unquestioned, because unlike vaccines against COVID-19, these “older” vaccines were accurately assessed before being implemented.

Because the other vaccines are already so established, right? We were born with them. And this one was a new thing that happened and as I told you, short production time, I don't know. And not the others, they were already in our culture, right? (S-H-08. Father)

Among families from Florianopolis with previously hesitant beliefs concerning routine vaccination, we observed three types of effects after the pandemic: one, more often observed in families that do not fully vaccinate, was the posture of reaffirming fears, reservations, and criticisms of vaccines; another, more often seen among hesitant caregivers who select some vaccines, was the attitude of understanding the importance of vaccines against COVID-19, without changing attitudes or previous opinions, reinforcing that the child's context must be considered in the decision to vaccinate; and, finally, a less expressive stance was the reflection on previous decisions about the routine vaccination calendar, with a possible change in conduct.

I think it ends up going back a little bit to that old story, huh? Is this vaccine not a form of control? (F-H-08.Father)

(...) reinforced the importance of both vaccination and the Unified Health System, etc. But I honestly don't think I would make a different decision than we did, I think if I had another child I would have the same attitude of not giving all vaccines in the first year. (F-H-02. Father)

I agreed at the time because the arguments convinced me, right? [...] But currently, I would research more and be much more resistant to not vaccinating because, for me, the need for the vaccine became more explicit. (F-H-01.Father)


The concrete impacts of the COVID-19 pandemic on routine childhood immunisation
The COVID-19 pandemic had two concrete effects on the pediatric routine immunisation in both cities: delays in administration of vaccines and an increase in vaccines administered in private facilities.
Delays in routine vaccination occurred due to difficulties in accessing primary healthcare units for eligible procedures, or due to intentional deferral as caregivers feared exposing the child to SARS-CoV-2 in health services. Furthermore, parents emphasized the perception that social distancing, imposed by the pandemic, also reduced the child's exposure to other vaccine-preventable illness.

So now in the pandemic I didn't vaccinate, I didn't take her to the doctor, nothing. [...] Because she's at home, she's safe, she's not being exposed to anything, so I didn't think it was necessary. (F-H-08.Mother)

Issues related to lower access to health facilities as drivers of delays in vaccination were more pronounced in Sao Luis. Caregivers reported facing mandatory restrictive measures to prevent the spread of SARS-CoV-2 (such as the lockdown enacted in Sao Luis); and difficulties related to the new organization of vaccination services in health units (for example, the need for a prior online registration in Florianopolis and the centralization of immunisation services in a few health units).

This matter of not knowing, 'will it be open?', 'will it be closed?', 'Will them be attending?', 'I am exposing myself?', right? […] so it delayed [the regular vaccination] a little, yes. (F-H-01.Father)

The use of private facilities to avoid higher exposure to SARS-CoV-2 in public services was quite pronounced among families that vaccinate, especially the ones from Sao Luis.

[...] at the height of the pandemic, and I was too afraid to go out, so I went to see [the public health unit] because he [the child's father] kept insisting we should have [the vaccines] in the SUS; then I got scared. Then I saw this huge line, went back, and called the [private] clinic, and the girl came to apply it the next day. (S-V-07. Mother)

Political ideology, government, and governance as drivers of (non)vaccination
The associations between vaccination, political ideology, and political management were significant aspects that emerged spontaneously from caregivers' narratives. Statements on politics were mostly associated with a negative assessment of President Jair Bolsonaro and the anti-vaccine position of his supporters. Even the caregivers who were hesitant about routine vaccines often underpinned that their opinions were distinguishable from that of the former president's supporters, reaffirming that they are neither anti-science nor anti-vaccine.

Today it is a political decision more than ever, right? It shows a lot about political side the person is on, right? If the person doesn't want to be vaccinated, they don't need to say anything else, you can already tell who they voted for, at least in the last election. (F-H-02. Father)

Only the families from Sao Luis who were hesitant about COVID-19 vaccines made the inverse association: they related COVID-19 vaccines to a political opposition to the former President and reproduced some of his anti-science arguments (i.e., the virus was created, and vaccines had been developed beforehand, as it was a planned pandemic). These families reported some common attitudes, such distrust of the press and other media resources that they considered hegemonic; the differential (dis)trust of vaccines depending on the manufacturer and country of origin; the belief that SARS-CoV-2 had been created purposefully, and that vaccines serve an ulterior purpose (either profit for laboratories or harm to the population).

Because today the press is publishing more things that negatively affect the current government. [...] As the government has always been against the vaccine, then it’s clear that if the vaccine has the opposite effect on some people, of course, the media will not disclose this because they will not want to give this advantage to the government. (S-H-07. Mother)


Discussion
In this qualitative study Wwe found that the event of COVID-19 pandemic has influenced beliefs, meanings, and attitudes on childhood vaccination. Moreover, our results uncover the influence of vaccine politicisation on vaccine hesitancy, in the extent that (dis)trust in vaccines is sometimes connected to ideologies and opinions of political leaders.
Several epidemiological studies have pointed to a significant drop in vaccine coverage in the routine childhood calendar during the pandemic period 21,22. Added to the difficulties in accessing immunisation services during the pandemic 23, beliefs and behaviours supporting vaccine hesitancy are a significant problem, amplified in the pandemic context 24. A WHO report estimated that at least eighty million children will be vulnerable to vaccine-preventable diseases due to such drops in vaccine coverage 32.
Added to the difficulties in accessing immunisation services during the pandemic 33, beliefs and behaviours supporting vaccine hesitancy are a significant problem, amplified in the pandemic context 34.
Over the last four decades, Brazil has developed and mostly sustained a robust culture of immunisation, with a national vaccination schedule that is universally available and free of charge 1,3. Nevertheless, the downward trend in vaccine coverage registered since 2000, much before the COVID-19 pandemic, is a multicausal phenomenon 4,17. Following the COVID-19 pandemic, studies suggest that this scenario can become even more delicate 23.
The PNI has broad credibility and adherence among Brazilians in all socioeconomic conditions 1. Some vaccines are only available in the PNI, and their incorporation in the national vaccination schedule drastically reduces commercialization in the private network 25. Accordingly, we found that even families with high income and schooling primarily use vaccines that are available free of charge within the PNI. However, one of the unexpected precedented findings of this study was the migration from public units to private immunisation services during the pandemic. This finding deserves attention since Brazilian children vaccinated in the public network are more likely to be fully vaccinated at 18 months old than those vaccinated in private clinics 17.
The health crisis surrounding the COVID-19 turned the eyes of all social actors to science, putting all its nuances, contradictions, procedures, and methods under the spotlight 26. Although none of the questions in the script pointed directly to the politicisation of health and science, this theme emerged and marked the empirical field.
In the first months of the COVID-19 pandemic, when vaccines were placed as the main solution allowing human lives to return their course, some authors hypothesized that the collective desire for a return to normality – which the vaccine was to provide – would be a driving factor for vaccination 31. Shortly after the initiation of testing and production of potential immunizers, stakes reversed: uncertainties and contradictions that are inherent elements in scientific development were used to promote insecurity and foment fake news 31,32.
Overall, families with hesitant beliefs concerning the routine vaccination schedule maintained their opinions despite acknowledging the importance of COVID-19 vaccines. These caregivers, who do not define themselves 'anti-science' or 'anti-vaccine', believe that vaccines should be selected according to the child's socio-environmental context, contrasting the perceived risk of exposure to the disease and the potential risks associated with vaccination. Advocacy for adapted vaccination schedules tailored to the needs of each child has already been documented in previous Brazilian studies with hesitant families 7. Similarly, studies have shown that caregivers weight the perceived potential severity of COVID-19 and the perceived risk associated with the vaccine before deciding on their child’s vaccination 24,27. Moulin, in a manuscript exploring the 'anthropology of vaccines', emphasized that this tailored vaccination, often desired by the modern citizen, “leads to flirt with the idea, epidemiologically valid but morally unsustainable, that the ideal would be for everyone to be vaccinated, except me” 14.
On the other hand, we observed a concerning phenomenon in some families that fully complied with routine vaccination schedules: controversies surrounding COVID-19 vaccines instigated uncertainties concerning the safety and efficacy of other childhood vaccines. A cross-sectional population-based study conducted in Sao Luis island found a 20.7% prevalence of hesitancy regarding vaccines against COVID-19. In this scenario, the distrust of regular vaccines caused by skepticisms about the COVID-19 vaccine could significantly impact on routine vaccination coverage 28. A study conducted in India with mothers of children up to six years old showed an increase in vaccine hesitancy from 5% before the pandemic to 38% during the pandemic 29.
A remarkable finding of our study is the characterization of the 'politicisation of vaccines', a new phenomenon with unforeseen challenges for public health stakeholders, including the PNI. Until very recently, reductions in vaccine coverage seemed to be independent of political affiliations and ideologies 30. Several studies have shown that vaccine hesitancy is often justified by ideological motivations that existed long before COVID-19, including skepticism about the medical-pharmaceutical industry, adherence to a more ‘natural´ lifestyle, affiliation to principles such as anthroposophy and homoeopathy, among others 7,31,32. What COVID-19 inaugurated in Brazil was the attribution of vaccines (dis)thrust to statements issued by political leaders – President Jair Bolsonaro in particular. In this context, one’s opinion on the COVID-19 vaccine can also very accurately inform his/her political position 10,12,33.
We propose the notion of ‘vaccine politicisation', from the spatio-temporal location of the event 11 - the COVID-19 pandemic in Brazil. We define it as the influence of political interests and ideologies over technical or scientifical evaluations on vaccine policies, aiming to define or modify public opinions in favor of a political interest.
The 2018 election of President Jair Bolsonaro ratifies the neoliberal and conservative wave underway in Brazilian politics. In line with a far-right wing denialist discourse, Jair Bolsonaro (president from 2019-2022) underestimated the severity of the pandemic, discredited prevention and mitigation measures recommended by health organizations, disallowed his first the minister of health (who tried to issue official acts following scientific recommendations), and alleged 'hysteria' on the part of the media; Bolsonaro also made several statements against COVID-19 vaccines, particularly for children 9,34.
As a populist leader, Bolsonaro ascended the Brazilian political scene at a time of crisis and popular discontent, creating the false dichotomy between “us” (the people, the dominated) and “them” (the dominant, the elite, in the form of institutions) 10,11,35. In the pandemic scenario, Bolsonaro and his supporters ratify that the State 19 must not restrict the citizens’ liberty. Based on this populist logic, he the former president built the narrative that individuals should be free to choose whether or not to be vaccinated 10. Previous researches have shown that the support for populist parties could be used as a proxy for vaccine hesitancy 36.
Institutions such traditional media, universities, and scientific organizations were subsequently labeled as discordant entities which should be viewed as mistrustful or ill-intentioned 11,35. This atmosphere of distrust leads to the growth of conspiracy theories and authoritarian speeches, raising up the State Denialism 37.
In this same context, the opposition to China and communism, as well as the ideological and political dispute between Bolsonaro and the governor of the state of Sao Paulo, fueled the distrust towards CoronaVac 10,12. Accordingly, the country of origin of a COVID-19 vaccine became a distinctive reason to reject vaccination reported by hesitant Brazilians 34. The "ranking" of vaccines according to their country of origin and the specific distrust of the Chinese vaccines were recurrent among hesitant respondents in our study as well as in previously published manuscripts 24,27.
Nuances of this scenario emerged in the narratives of some participants in our study, who were reluctant regarding recommendations of institutions such as WHO and Anvisa; distrusted traditional media; and refused to believe that universities and laboratories could produce a safe and effective vaccine in such a rapid pace. It is known that vaccine trust is associated with high trust in these institutions (Universities, health departments and mainstream news sources, for instance) 38.
Reasons for COVID-19 vaccines hesitancy identified in our study were similar to those reported in other national and international studies. The main reasons for vaccine rejection were the rapid production and testing time, distrust of their efficacy, and fear of side effects 27,36,38. Another finding of this study that confirms national and international results is the so-called "wait-and-see” attitude, i.e., the decision to wait for the progression of vaccination and only then decide whether or not to vaccinate one’s children 24,27. The belief in conspiracy theories, such as that China created the virus and that the vaccine was part of an alleged Chinese war, has also been demonstrated previously 12,24. In Ireland and the United Kingdom, COVID-19 vaccines hesitant persons were more distrusting of authorities and institutions and more likely to hold conspiratorial beliefs 39.
These findings suggest a general distrust of institutions, and a shift to decisions based on emotions, beliefs, and experiences 10. While science offers a concrete and probabilistic approach, human experience builds unique perceptions that may influence behaviors and attitudes 27. Also, risk perception is a great factor in the decision making process 36.
Our finding resemble those reported in the United States, where increasingly conservative political ideology was association with low vaccine trust 38. COVID-19 vaccines have produced a similar phenomenon in Brazil: endorsement of far-right ideologies was strongly associated with hesitancy towards COVID-19 vaccination 33. Accordingly, in a survey conducted in January 2021, only 58% of President Bolsonaro's voters indicated that they would get vaccinated, whereas the intention to vaccinate was 78% among other respondents 48. Furthermore, another study revealed that self-declared right-wing or center-right people were more likely to answer that they would only take the COVID-19 vaccine “depending on the vaccine” 40.
The percentage of votes for Jair Bolsonaro, for both the elections of 2018 and 2022, was inversely associated with COVID-19 vaccine uptake after adjustment for the sociodemographic characteristics, showing significant association 30. Also, Brazilian municipalities that supported Jair Bolsonaro in the 2018 elections had higher COVID-19 mortality rates –probably due to being also less compliant with social distancing measures 50,51.
It's important to point out that the two cities where the fieldwork was carried out have very different political scenarios: while Maranhao was the third state with the highest voting rate for then-candidate Luís Inácio Lula da Silva, Santa Catarina was the fourth state with the highest voting rate for Jair Bolsonaro. In Sao Luis, Lula received 60.38% of the votes in the second round; in Florianopolis, Bolsonaro was the candidate with the most votes (53.33%) 44. Despite this, the families interviewed don't necessarily fit into the hegemonic group in each city: in Florianopolis, as previously mentioned, hesitant families to childhood vaccines were rigidly against then-president Jair Bolsonaro. In line with global literature, these families are characterised by a naturalistic worldview, use alternative medicines and pedagogies and position themselves as anti-system, criticising the pharmaceutical industry 7,41,42. These families, although hesitant about childhood vaccines, emphasise that they don't want to be compared to Bolsonaro's supporters, whom they describe as "anti-vaccine" or "anti-science". In Sao Luis, the families that reproduced hesitant narratives also escape the municipal hegemony and are those who supported then-president Bolsonaro. This fact can be supported by Seara-Morais et al. 30 and Murphy et al. 39 studies, that show that the more socioeconomic vulnerable municipalities (less HDI) are more susceptible to the pervasive influence of political ideologies on COVID-19 vaccination in Brazil and that income level is associated with COVID-19 vaccine hesitancy.
Our study had a few limitations. The protocol was designed before the onset of COVID-19 pandemic and aimed to investigate vaccine hesitancy in the context of routine childhood vaccination. The pandemic scenario had to be adapted into the initial design, adding a vast content of narratives about COVID-19 vaccination and its influence on beliefs and attitudes concerning routine immunisation. and Mmost interviews were conducted remotely through video conferences, which may have interfered with the quality of interviewer-interviewee interaction. In some cases, the second caregiver was not available to participate in the study. However, this limitation is unlikely to impact our main results, as in most families we found no major disagreements between the main caregivers. The study was conducted by researchers from academic institutions, which may have inhibited more radical anti-science manifestations.

Conclusion
In conclusion, tThe COVID-19 pandemic prompted a scenario of general distrust of institutions (both scientific ones and the traditional media) disbelief in science, distrust in health institutions, dissemination of fake news about vaccines, and a strong influence of political ideologies on the decision to vaccinate. Jointly, these factors are threats to the culture of immunisation that prevailed in Brazil until recent years.
The politicisation of medical issues can reduce the credibility of official sources of scientific information 26, directly affecting people’s attitudes towards health 43. Our findings are important warnings for the development of vaccination policies in Brazil. In order to formulate immunisation policies that are appropriate to the local reality, it is important to understand the profound impact that the social and political landscape has on health decision-making. As the findings of this study reveal, the COVID-19 pandemic and its political management in Brazil have led to an unprecedented scenario of attributing the decision to (not) vaccinate to one's political affiliation. This scenario is a warning for the development of future vaccination policies in Brazil. On the other hand, a government policy to encourage vaccination can positively affect the decision to get vaccinated. We therefore emphasize that all government decision-making is political: what defines whether the consequences of the politicisation of vaccines are positive or negative is the management of these decisions.



References
1. Hochman G. Vacinação, varíola e uma cultura da imunização no Brasil. Ciência & Saúde Coletiva. scielo; 2011. p. 375–386.
2. Silveira MF, Buffarini R, Bertoldi AD, Santos IS, Barros AJD, Matijasevich A, Menezes AMB, Gonçalves H, Horta BL, Barros FC, Barata RB, Victora CG. The emergence of vaccine hesitancy among upper-class Brazilians: Results from four birth cohorts, 1982–2015. Vaccine [Internet]. 2020;38(3):482–488. Available from: https://www.sciencedirect.com/science/article/pii/S0264410X19314598
3. Pan American Health Organization. 30 anos de SUS, que SUS para 2030? [Internet]. 2018. Available from: https://iris.paho.org/handle/10665.2/49663
4. Sato APS. What is the importance of vaccine hesitancy in the drop of vaccination coverage in Brazil? Revista de Saúde Pública. scielo; 2018. p. 96.
5. World Health Organization. Report of the SAGE Working Group on Vaccine Hesitancy [Internet]. Geneva; 2014. Available from: https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf
6. World Health Organization. Behavioural and social drivers of vaccination: tools and practical guidance for achieving high uptake [Internet]. Geneva; 2022. Available from: https://apps.who.int/iris/handle/10665/354459
7. Couto MT, Barbieri CLA. Cuidar e (não) vacinar no contexto de famílias de alta renda e escolaridade em São Paulo, SP, Brasil. Ciência & Saúde Coletiva. scielo; 2015. p. 105–114.
8. Brown AL, Sperandio M, Turssi CP, Leite R, Berton VF, Succi RM, Larson H, Napimoga MH. Vaccine confidence and hesitancy in Brazil. Cad Saude Publica. SciELO Public Health; 2018;34(9):e00011618.
9. Martins-Filho PR, Barberia LG. The unjustified and politicized battle against vaccination of children and adolescents in Brazil. Lancet Reg Heal. Elsevier; 2022;8:100206.
10. Monari ACP, Sacramento I. A “vacina chinesa de João Doria”: a influência da disputa política-ideológica na desinformação sobre a vacinação contra a Covid-19. Rev Mídia e Cotid. 2021;15(3):125–143.
11. Romano JO, Bittencourt TP, Uema L, Aguiar CBO, Ferreira LR. La pandemia COVID-19 como acontecimiento y la disputa política de los discursos negacionista y científico. In: Bosco E, Igreja RL, Valladares L, editors. A América Lat frente ao Gov da COVID-19. 1st ed. Brasília, DF: Faculdade Latino-Americana de Ciências Sociais; 2022. p. 353.
12. Guerreiro C, Almeida R de. Negacionismo religioso: Bolsonaro e lideranças evangélicas na pandemia Covid-19. Reli Soc. SciELO Brasil; 2021;41(02):49–74.
13. Bolsen T, Druckman JN, Cook FL. How frames can undermine support for scientific adaptations: Politicization and the status-quo bias. Public Opin Q. Oxford University Press UK; 2014;78(1):1–26.
14. Moulin AM. A hipótese vacinal: por uma abordagem crítica e antropológica de um fenômeno histórico. História, Ciências, Saúde-Manguinhos. scielo; 2003. p. 499–517.
15. Brasil. Informações em saúde (TABNET) - DATASUS [Internet]. Ministério da Saúde. 2019 [cited 2022 Aug 4]. Available from: http://tabnet.datasus.gov.br/cgi/menu_tabnet_php.htm
16. Instituto Brasileiro de Geografia e Estatística (IBGE). IBGE Cidades [Internet]. Brasília; 2022. Available from: https://cidades.ibge.gov.br/
17. Barata RB, Ribeiro MCS de A, de Moraes JC, Flannery B. Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008. J Epidemiol Community Health. 2012 Oct;66(10):934–941. PMID: 22268129
18. TenHouten WD. Site sampling and snowball sampling-Methodology for accessing hard-to-reach populations. Bull Sociol Methodol Méthodologie Sociol. SAGE Publications Sage UK: London, England; 2017;134(1):58–61.
19. Fontana A, Frey JH. The interview: from structured questions to negotiated text. In: Denzin N, Lincoln Y, editors. Handb Qual Res. 2nd ed. Thousand Oaks, CA: Sage Publications; 2004. p. 61–106.
20. Vaismoradi M, Jones J, Turunen H, Snelgrove S. Theme development in qualitative content analysis and thematic analysis. J Nurs Educ Pract. Sciedu Press; 2016;6(5):100–110.
21. Hirabayashi K. The impact of COVID-19 on the routine vaccinations: refletions during World Immunization Week 2020 [Internet]. Bangkok; 2020. Available from: https://www.unicef.org/eap/stories/impact-covid-19-routine-vaccinations
22. Silva TMR da, Sá ACMGN de, Prates EJS, Rodrigues DE, Silva TPR da, Matozinhos FP, Vieira EWR. Yellow fever vaccination before and during the covid-19 pandemic in Brazil. Rev Saude Publica. SciELO Public Health; 2022;56:45.
23. Sato APS. Pandemia e coberturas vacinais: desafios para o retorno às escolas. Rev Saude Publica. SciELO Public Health; 2020;54:115.
24. Tibbels NJ, Dosso A, Fordham C, Benie W, Brou JA, Kamara D, Hendrickson ZM, Naugle DA. “On the last day of the last month, I will go”: A qualitative exploration of COVID-19 vaccine confidence among Ivoirian adults. Vaccine. Elsevier; 2022;40(13):2028–2035.
25. Temporão JG. O mercado privado de vacinas no Brasil: a mercantilização no espaço da prevenção. Cad Saude Publica. SciELO Brasil; 2003;19(5):1323–1339.
26. Jones-Jang SM, Noland C. The politicization of health and science: Role of political cues in shaping the beliefs of the vaccine-autism link. Health Commun. Taylor & Francis; 2022;37(5):608–616.
27. Chaney D, Lee MSW. COVID?19 vaccines and anti?consumption: Understanding anti?vaxxers hesitancy. Psychol Mark. Wiley Online Library; 2022;39(4):741–754.
28. Oliveira BLCA de, Campos MAG, Queiroz RC de S, Alves MTSS de B, Souza BF de, Santos AM dos, Silva AAM da. Prevalência e fatores associados à hesitação vacinal contra a covid-19 no Maranhão, Brasil. Rev Saude Publica. SciELO Brasil; 2021;55:12.
29. Shwethashree M, Vanmathi A, Narayanamurthy MR, Gopi A. Did this pandemic trigger a spike in mothers? hesitancy over their children’s routine immunizations?-A cross sectional study. Clin Epidemiol Glob Heal. Elsevier; 2022;15:101023.
30. Seara-Morais GJ, Avelino-Silva TJ, Couto M, Avelino-Silva VI. The pervasive association between political ideology and COVID-19 vaccine uptake in Brazil: an ecologic study. medRxiv. Cold Spring Harbor Laboratory Press; 2022;23(1606):2010–2022.
31. Matos CC de SA, Barbieri CLA, Couto MT. Covid-19 and its impact on immunization programs: reflections from Brazil. Rev Saude Publica. SciELO Brasil; 2020;54:114.
32. Matos CC de SA, Gonçalves BA, Couto MT. Vaccine hesitancy in the global south: Towards a critical perspective on global health. Glob Public Health. England; 2021 Apr;1–12. PMID: 33843459
33. Paschoalotto MAC, Costa EPPA, Almeida SV de, Cima J, Costa JG da, Santos JV, Barros PP, Passador CS, Passador JL. Running away from the jab: factors associated with COVID-19 vaccine hesitancy in Brazil. Rev Saude Publica. SciELO Brasil; 2021;55:97.
34. Gramacho WG, Turgeon M. When politics collides with public health: COVID-19 vaccine country of origin and vaccination acceptance in Brazil. Vaccine. Elsevier; 2021;39(19):2608–2612.
35. Fleury S, Fava VMD. Vacina contra Covid-19: arena da disputa federativa brasileira. Saúde em Debate. SciELO Brasil; 2022;46(spe1):248–264.
36. Troiano G, Nardi A. Vaccine hesitancy in the era of COVID-19. Public Health. 2021 May;194:245–251.
37. Fernandez M, Matta G, Paiva E. COVID-19, vaccine hesitancy and child vaccination: Challenges from Brazil. Lancet Reg Heal – Am [Internet]. Elsevier; 2022 Apr 1;8:100246. Available from: https://doi.org/10.1016/j.lana.2022.100246
38. Latkin CA, Dayton L, Yi G, Konstantopoulos A, Boodram B. Trust in a COVID-19 vaccine in the US: A social-ecological perspective. Soc Sci Med. Elsevier; 2021;270:113684.
39. Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, McKay R, Bennett K, Mason L, Gibson-Miller J. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun. Nature Publishing Group UK London; 2021;12(1):29.
40. Barberia LG, Rosa ISC. De que maneira a ideologia afeta a disposição a se vacinar contra o Sars-Cov-2? Rev USP. 2021;(131):47–64.
41. Kuan C. Vaccine hesitancy and emerging parental norms: A qualitative study in Taiwan. Sociol Health Illn. Wiley Online Library; 2022;44(3):692–709.
42. Verger P, Botelho-Nevers E, Garrison A, Gagnon D, Gagneur A, Gagneux-Brunon A, Dubé E. Vaccine hesitancy in health-care providers in Western countries: a narrative review. Expert Rev Vaccines. Taylor & Francis; 2022;21(7):909–927.
43. Fowler EF, Gollust SE. The content and effect of politicized health controversies. Ann Am Acad Pol Soc Sci. Sage Publications Sage CA: Los Angeles, CA; 2015;658(1):155–171.