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Understanding and explaining the link between anthroposophy and vaccine hesitancy: a systematic review

BMC Public Health volume 23, Article number: 2238 (2023) Cite this article

Abstract

Background

Due to low vaccination uptake and measles outbreaks across Europe, public health authorities have paid increasing attention to anthroposophic communities. Public media outlets have further described these communities as vaccine refusers or “anti-vaxxers”. The aim of this review was to understand the scope of the problem and explore assumptions about vaccination beliefs in anthroposophic communities. For the purpose of this review, we define anthroposophic communities as people following some/certain views more or less loosely connected to the philosophies of anthroposophy. The systematic review addresses three research questions and (1) collates evidence documenting outbreaks linked to anthroposophic communities, (2) literature on vaccination coverage in anthroposophic communities, and (3) lastly describes literature that summarizes theories and factors influencing vaccine decision-making in anthroposophic communities.

Methods

This is a systematic review using the following databases: Medline, Web of Science, Psycinfo, and CINAHL. Double-blinded article screening was conducted by two researchers. Data was summarized to address the research questions. For the qualitative research question the data was analysed using thematic analysis with the assistance of Nvivo12.0.

Results

There were 12 articles documenting 18 measles outbreaks linked to anthroposophic communities between the years 2000 and 2012. Seven articles describe lower vaccination uptake in anthroposophic communities than in other communities, although one article describes that vaccination coverage in low-income communities with a migrant background was lower than in the anthroposophic community they studied. We found eight articles examining factors and theories influencing vaccine decision making in anthroposophic communities. The qualitative analysis revealed four common themes. Firstly, there was a very broad spectrum of vaccine beliefs among the anthroposophic communities. Secondly, there was a consistent narrative about problems or concerns with vaccines, including toxicity and lack of trust in the system. Thirdly, there was a strong notion of the importance of making individual and well-informed choices as opposed to simply following the masses. Lastly, making vaccine choices different from public health guidelines was highly stigmatized by those outside of the anthroposophic community but also those within the community.

Conclusion

Continuing to further knowledge of vaccine beliefs in anthroposophic communities is particularly important in view of increasing measles rates and potential sudden reliance on vaccines for emerging diseases. However, popular assumptions about vaccine beliefs in anthroposophic communities are challenged by the data presented in this systematic review.

Peer Review reports

Background

Vaccines save lives [1]. Vaccine hesitancy has been considered one of the top 10 public health threats of our time [2]. For the purpose of this study, we define vaccine hesitancy as the delay or refusal of vaccines despite their availability [3]. In recent years, public health agencies and researchers have paid increasing attention to vaccination beliefs of anthroposophical communities. For example, the Public Health Agency in Sweden has identified an anthroposophic community outside of Stockholm as a group of concern regarding low vaccination uptake [4]. The interest in this group’s vaccination beliefs and behaviours is mainly due to a growing number of measles outbreaks in anthroposophic communities across Europe [5]. In this study, we provide an overview of existing published evidence that examines the relationship between anthroposophy and vaccine beliefs. We focus on individuals and groups who follow an anthroposophical lifestyle or are inspired by anthroposophy. This includes communities that attend Waldorf/Steiner schools. It is important to note that the scope of adherence to principles on anthroposophy varies significantly between individuals and we recognize the diversity within this community.

Anthroposophy is a spiritualist movement that was established by scientist and philosopher Rudolf Steiner born in 1861 in Austria [6]. Anthroposophy literally implies wisdom about man, and stipulates that through meditation and concentration, individuals can utilize the physical world to connect with the spiritual world [6,7,8,9,10]. Steiner believed that man’s (sic) own thinking was the path to spiritual and inner observations [9, 10]. The spiritualist movement began in Germany in the early twentieth century and ideas of anthroposophy have been applied to many areas of life such as education, art, architecture, and healthcare [6] and led to the creation of now well-established Waldorf schools and anthroposophic medicine worldwide [7]. For example, there are over 1000 Waldorf schools (also referred to as Steiner schools) in around 60 countries around the world [2].

Anthroposophic medicine was founded in the early 1920s by Rudolf Steiner and Ita Wegman [6]. Drawing on anthroposophic philosophy it incorporates a holistic approach to the understanding of illness and approaches to healing [6, 7]. Anthroposophic medicine addresses a broad spectrum of health issues (family medicine, chronic disease, paediatric disease and palliative care) and is offered in combination with mainstream medicine or in anthroposophic medical practices [6]. It offers medicines derived from herbs, minerals, animals, eurythmy and art therapy, massage, and, counselling and psychotherapy [11]. Anthroposophic medicine can be studied at accredited schools by medical doctors, movement and mental health therapists and nurses [7].

Anthroposophic medicine is practiced in 78 countries worldwide, predominantly in Central Europe. There are circa 24 anthroposophic medical institutions – these include hospitals, departments in hospitals, rehabilitation centres, and other inpatient healthcare centres in six countries (Germany, Switzerland, Sweden, Italy, The Netherlands, and The United States) [7]. Moreover, there are around 180 anthroposophic outpatient clinics globally where anthroposophic physicians work in collaboration with biomedical approaches to health care. In addition, anthroposophic physicians work in their own practices or in collaboration with other complementary health care providers [7]. In Germany, Latvia, and Switzerland, anthroposophic medicine is considered a distinct and specialized therapy. In Germany, it is overseen by its own committee at the Federal Institute for drugs and medical devices. Anthroposophic medicine is popular and in some instances revealed higher patient satisfaction compared to conventional health care [7].

Anthroposophic medicine and vaccination

The 2019 official statement of the international centre of anthroposophic medicine, the Medical Section of the Goetheanum, and the International Federation of Anthroposophic Medical Associations (IVAA) clearly states that they do not support the anti-vaccine movement. Rudolf Steiner did not oppose vaccines, however, vaccination and anthroposophic medicine constitutes a somewhat contentious point [11]. This is partly because Rudolf Steiner argued that childhood illnesses are important for growth and development of a child, leading some to question the necessity of vaccines [6, 11]. In the past decade, concerns have been raised by the scientific community on the role of the anthroposophic movement in measles outbreaks [12,13,14]. Consequently, in some countries such as Sweden and Germany, anthroposophic communities have been labelled as a community that refuses vaccines, particularly by popular media and during the COVID-19 pandemic [15,16,17]. Despite this attention from public media and science, there is no comprehensive review on the scope of the problem, in terms of number of outbreaks and vaccination coverage in anthroposophic communities. Whilst there are a number of qualitative studies that elucidate the factors influencing vaccine decision making in anthroposophic communities, there is no systematic and comparative review of this evidence.

Therefore, this review aims to understand the scope of the problem and explore popular assumptions about vaccine beliefs in anthroposophic communities. To achieve this, this systematic review summarizes the existing literature that investigates the relationship between anthroposophy and vaccination beliefs.

Methods

Design

This is a systematic review, including both quantitative and qualitative studies. The review is based on current best practices utilising the Joanna Briggs Institute systematic review framework [18, 19].

We used the population/concept/context (PCC) framework to guide the development of our research questions [18]. The population being anthroposophic communities; the concept vaccine hesitancy or vaccine confidence/trust; context including a global setting. This framework as well as the literature review culminated in three research questions:

  1. 1.

    What are the documented outbreaks associated with low vaccination coverage in anthroposophic communities?

  2. 2.

    What is the evidence for vaccination rates in anthroposophic communities?

  3. 3.

    What is the evidence that describes factors and theories for low vaccination uptake in anthroposophic communities?

Protocol and registration

No review protocol exists, and the systematic review has not been registered.

Search strategy

A systematic literature search was performed by two researchers in the following databases: Medline, Web of Science, Psycinfo, and CINAHL. The last search was conducted 2022–09-05. The search strategy was developed in Medline (Ovid) in collaboration with librarians at the Karolinska Institutet University Library. For each search concept Medical Subject Headings (MeSH-terms) and free text terms were identified (see appendix). No language restriction was applied. Databases were searched from inception. The strategies were peer reviewed by another librarian prior to execution. De-duplication was done using the method described by Bramer et al. [20]. One final, extra step was added to compare DOIs to ensure no duplication. The full search strategies for all databases are available in the Appendix.

Study selection and inclusion and exclusion criteria

Independent study selection was completed by two reviewers (SHvW and KA). Inclusion criteria for the first round of screening (title and abstract) were all articles that discussed anthroposophy and vaccination (this was conducted by KA and SHvW). Articles in Swedish and German were only reviewed by SHvW due to language restrictions. Inclusion criteria for the second and more in-depth round of screening – conducted double-blinded by KA and SHvW were all papers relevant to the three research questions, including both quantitative and qualitative studies. Exclusion criteria were, not peer-reviewed papers, opinion pieces, systematic reviews, nor papers that were not relevant to the research question (for example there were a number of articles that examined the relationship between anthroposophy, vaccination, and allergy).

Quality assessment

A quality assessment of the selected papers was conducted double-blinded by two researchers (KA and SHvW). For the qualitative studies, we used the JBI Critical Appraisal Tool for Qualitative Research [19]. This is a quality control checklist. For the quantitative studies, we applied the Effective Public Health Practice Project quality evaluation tool to assess the quality of all quantitative publications that were included as references in this work [21]. Each article received a final rating at the conclusion with one of the following scores: 1 (Strong), 2 (Moderate), or 3 (Weak), based on an assessment of study design, methods used, sampling, and bias [19, 20]. We then calculated the average of the results (from reviewers KA and SHvW), which represents the overall evaluation of the quality of all quantitative papers. The articles included received an overall score of 1.9. This indicates that there was a moderate quality of research papers presented in this review.

Analysis

To address research questions one and two, the data was summarized in Tables 1, 2 and 3. To address research question three, the qualitative research data of the articles included in this review (Table 4) were analysed using Braun and Clarke’s thematic analysis [22] with the support of Nvivo12. The data (Results from articles) were imported into Nvivo12, coded and categories from the grouping of codes were created (double blinded) by KA and SHvW. The creation of themes was discussed between KA and SHvW. The coding tree is presented in Table 5.

Table 1 Measles outbreaks linked to anthroposophic communities
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Results

The search revealed 27 papers (see Fig. 1). Twelve papers describe 18 outbreaks associated with anthroposophic communities. Seven papers describe vaccination coverage/personal belief exception rates associated with anthroposophic beliefs. Eight papers describe factors influencing vaccine decision-making among anthroposophic communities and anthroposophic providers.

Fig. 1
figure 1

Prisma flowchart

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Outbreaks in anthroposophic communities

Table 1 describes 18 measles outbreaks that occurred between 1997 and 2011 in European countries, which were described in 12 studies (Table 2 summarizes the papers).Footnote 1 Table 1 describes the location, the outbreak year, the number of cases, the source of the outbreak, and any catch-up strategies (where described). The studies show that eight out of 18 measles outbreaks started at Waldorf schools throughout Germany, Switzerland, Austria, Netherlands, and the UK [8, 17, 20, 22]. Although data from community reporting is limited, in the articles described, the measles cases at Waldorf schools are predominantly higher than in mainstream private or state schools across the five countries. Offering measles vaccination catch-ups by public health authorities (which is an effective way to manage a measles outbreak) was described in several articles but was largely refused by both parents and Waldorf schools. The most effective outbreak control strategy was the immediate closure of the Waldorf school and strict rules regarding entry to the school upon reopening.

Table 2 Summary of 12 articles describing outbreaks associated with anthroposophic medicine/Waldorf schools
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Table 2 summarizes 12 articles that describe outbreaks in Europe linked to anthroposophic communities. Eleven articles describe the 18 measles outbreaks identified, and some of the outbreaks are mentioned in several papers. One article describes a mumps outbreak in Switzerland in the 1990s.

Vaccination coverage in anthroposophic communities

Table 3 summarizes six articles that describe vaccine coverage in anthroposophic communities, and one article describes the personal belief exception (PBE) rate at Waldorf school in the USA. The papers focus predominantly on diphtheria, pertussis, tetanus and poliomyelitis (DPTP), and mumps, measles and rubella (MMR) vaccines. Two studies studying the vaccination coverage at Waldorf pre-schools/schools, demonstrate overall low immunization coverage at those schools [30, 31]. One article focusing on PBE rates demonstrates a proportionally high rate at Waldorf schools in California [32]. Three studies from the Netherlands measure vaccination coverage in general and focus specifically on whether there are special groups that show specifically low coverage [33,34,35]. In these studies, anthroposophic communities are identified as showing low coverage [14,15,16]. However, one study highlights that anthroposophic communities are not as significant in terms of low coverage as low-income groups [33]. One paper describes rates of vaccination refusal in Switzerland [36]. It highlights that complementary alternative medicine (CAM) users, including people who draw on anthroposophic medicine, are more likely to refuse vaccination. However, the paper also shows that this group was more likely to vaccinate against tick-borne diseases and encephalitis than the general population [36].

Table 3 Summary of seven articles describing vaccination coverage and uptake in anthroposophic communities
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Factors and theories influencing vaccine decision making in anthroposophic communities

The systematic search revealed eight articles examining factors and theories influencing vaccine decision-making in anthroposophic communities (see Table 4). Five articles focused on parents of children attending Waldorf schools or who considered themselves part of an anthroposophic community. Three articles focused on the perspectives of anthroposophic healthcare providers [37, 38], although two of those articles mixed and compared views with other alternative/complementary providers or allopathic health providers. Of the eight articles, two were quantitative [33, 39] and did not provide an in-depth discussion. The qualitative findings from six articles [23, 38, 40,41,42] were summarized in-depth and revealed four themes (see Table 5).

Table 4 Summary of eight studies addressing factors associated with vaccination decision making in anthroposophic communities
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Table 5 Coding tree from thematic analysis of qualitative data that explores factors influencing vaccine decision making in anthroposophic communities
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Broad spectrum of vaccine decisions

All studies describe a broad spectrum of vaccine decisions [theme 1] [23, 37, 40,41,42]. There are those who delay vaccines, and the primary reason is to not overburden a young child’s body [23]. There are those who are positive towards some vaccines [23]; for instance, the tetanus vaccine appears to be accepted in several studies, yet often with a delay [41]. There are also some people who vaccinate according to individual need; for example, if they live on a farm, they vaccinate all their children against tetanus or if they do not think they can care for their child at home they vaccinate against MMR [41]. Similarly, several studies mention that parents vaccinate because there is an absence of disease and they would vaccinate their children in a setting with a high risk of the disease, e.g. when travelling abroad [23, 41].

Lastly, all six articles mentioned some groups in the anthroposophic community who decline vaccines altogether. Primarily this is due to the belief that childhood diseases are natural, natural immunity is better than vaccines, and because of concerns about vaccine content [23, 38, 40, 41]. Some anthroposophic health providers share the belief that diseases and fever are good for children and that they protect against allergies [38, 42]. The articles describe very little information about how vaccine decisions are made, apart from mentioning the important role and influence of peers and the community [41]. Sobo describes how some participants express authority and clear reasoning in their vaccine decision-making by drawing on scientific evidence [41]. However, the quality of that evidence is questioned, but not examined in detail.

Consistent narrative about problems with vaccines

The articles describe a consistent narrative about problems with vaccines [theme 2], particularly concerns over side effects of vaccines [23, 41,42,43]. Some papers expressed participants’ concerns with long-term side effects that may affect the brain due to aluminium found in some vaccines [42] and links to autoimmune diseases [41, 42]. Some anthroposophic health providers share the concerns about long-term effects on brain health and also add that vaccinated children are more likely to develop allergies and asthma [42]. Parental concerns about toxicity and how they interfere with long-term health were mentioned [40, 41]. A common argument against vaccine use expressed by both parents and anthroposophic healthcare providers was that vaccines interfere with children’s natural and necessary disease progression [23, 41,42,43]. Distrust in those producing vaccines for the sole purpose of profit was expressed in several papers [23, 41, 42].

Agency and independent thinking

All studies consistently highlight that for both the anthroposophic community and anthroposophic healthcare providers, independent thinking and agency is an essential part of vaccine and health decision-making [theme 3]. Moreover, the development of an individualized vaccination schedule is highly important [23, 38, 40,41,42]. Parents see themselves as making a well-informed choice and they take pride in their choice. Sobo summarises this idea by stating that Alternative choices were taken to symbolize one’s capacity for independent thinking [41]. Similarly, anthroposophic healthcare providers highlight the importance of a tailored approach that allows for individual freedom of choice [38, 42]. Individualized vaccination schedules were strongly advocated in all papers [23, 38, 40,41,42], as put by Sobo “going along with the herd is not in keeping with the Waldorf ethos” [41]. Due to ample scepticism towards vaccines and parents wanting to select the diseases to vaccinate against, some papers advocated for the importance of offering single rather than combined vaccines [38, 41].

Stigma and social cohesion

Participants in the studies describe two types of stigma associated with their vaccine beliefs [theme 4]. On the one hand, they describe stigma regarding their vaccine choices from the community outside of their anthroposophic community as well as from mainstream health professionals [23, 40, 41]. Participants in the studies describe a sense of security they gain by sticking together in their communities: "I have chosen to live here [an anthroposophic community] to be surrounded by people who have similar beliefs so that I do not have to stand up for myself all the time." [23] In several papers, participants describe pride, hard work, and courage in that they are not simply following mainstream ideas. To summarize this in the words of a participant: "committing to Waldorf education “takes courage” because it is so unconventional …It shows that the parents are individual thinkers... it takes a lot of work to go against the grain of society” [40, 41]. Paradoxically, Sobo describes a stigma to conform from within the anthroposophic community, particularly in a Waldorf school setting. Parents describe that they actually do have different thoughts about vaccines than the community but fear to share those because they would threaten the social cohesion of the Waldorf identity. In Sobo’s words: “Waldorfian identity make it harder and harder to contravene the norm without threatening one’s sense of group membership, or creating cognitive dissonance” [39].

Discussion

This systematic review showed that there have been a number of measles outbreaks associated with anthroposophic communities throughout Europe between the late 1990s and 2012 and one mumps outbreak. Vaccination catch-up was not a popular strategy in the anthroposophic community, but instead, the importance of school closure was highlighted. Outbreaks were not reported after 2012, it is unclear whether this is because there is a lack of research or no new outbreaks occured. This review further suggests that vaccination coverage is lower in anthroposophic communities compared to other communities, but evidence for this was somewhat weak and most focusing on MMR vaccines. The focus on MMR was arguably due to numerous measles outbreaks associated with anthroposophic communities. It would be important to understand specific vaccination coverage in more detail. For example, there would be value in understanding coverage for adolescent vaccines such as the human papillomavirus (HPV) vaccines and meningitis vaccines. Recent studies have highlighted the important effect the HPV vaccine on the reduction of cervical cancer – therefore understanding the views of parents from the anthroposophic community on the HPV vaccine would have important public health implications.

In terms of the qualitative findings, the review revealed a broad range of vaccination beliefs and highlighted the importance of individual choice in the vaccine decision process. Although parents consider themselves well-informed, it is unclear from the studies where they obtain their information, although some refer to the use of scientific information. Understanding knowledge and information sources in greater detail would be helpful to understand how certain rumours are maintained. The challenge of reliance on poor information sources to make a vaccine decision was particularly noted during the COVID-19 pandemic and arguably hindered COVID-19 vaccine uptake [44]. Some information, for example, the assumed link between low vaccination coverage and the development of allergies has been scientifically addressed and disproven [45]. Yet, the argument that a link persist was described in the literature. This arguably highlights that scientific results have not been effectively shared.

Although there are currently 27 articles that have investigated the relationship between vaccines and anthroposophy, it remains somewhat nebulous why anthroposophy as a religion or belief system is often considered as an anti-vax movement by popular media. Anthroposophical medicine does not reject vaccines, nor does it reject modern medicine. This was clearly stated at the inception of anthroposophical medicine and it has been a clear statement by Gotheanum. In 1925, Dr Rudolf Steiner and Dr Ita Wegman clearly stated “It is not a matter of being in opposition to the school of medicine that is working with the accepted scientific methods of the present time. We fully acknowledge its principles. …we therefore feel compelled to work for an extension of clinical medicine, based on these wider insights into the nature of the world and the human being” [46].

Sobo’s article described in this review was the only paper that engaged with the anthroposophic movement, particularly the Waldorf school context that arguably cultivated vaccine hesitancy [41]. The notion of building social cohesion through vaccine beliefs and decisions is an interesting and understudied concept. Understanding this further could perhaps help inform strategies to empower individuals to make their own decisions. For example, health providers engage with the question of how to address pressure to not vaccinate during their consultations. It would be interesting to further understand how stigma surrounding vaccine choices has changed in the context of COVID-19 vaccine decision-making. Furthermore, if the school and community context is a strong factor influencing vaccine decision-making, public health communication efforts should prioritize collaboration with the broader community rather than only health professionals working in that community. Given the low trust in public health authorities described in several studies in this review, this process will require a sensitive approach to avoid further alienation of the group.

The anthroposophic community prides itself on being different, communal, and supportive as opposed to following principles of consumerism and individualism. However, none of the studies, except briefly by Sobo, mentioned vaccines as a means for social action and to protect the vulnerable [41]. Distrust and the feeling of exclusion may be one of the reasons for this but perhaps it is a limited understanding of how vaccines actually work.

Lastly, the stigma this group experiences highlights a problem that requires careful attention. This could also be an important finding for other so-called vaccine hesitant groups [47]. One could argue that the more the anthroposophic group gets labelled as anti-vaxxers in public media or identified as vaccine hesitant by Public Health Agencies, the stronger their views become. Vaccine decision making, therefore, is no longer about individual and public health but rather linked to group identities. The research on the anthroposophic community has been somewhat limited in recent years. It would be important to continue to monitor vaccine sentiments in the anthroposophic community, particularly in view of the introduction of the COVID-19 vaccine and hesitancy linked with political sentiments [48, 49] and in view of emerging vaccines.

Limitation

There are some limitations to this systematic review. The review only includes peer-reviewed articles; this means that there have probably been other disease outbreaks linked to anthroposophic communities, which were only described in the grey literature. Moreover, some of the studies purely described the outbreaks rather than conducted an analysis; therefore, it is difficult to analyse in depth what actually happened. Regarding the thematic analysis of the qualitative studies, there are limits to conducting such an analysis of results of existing studies, since we could not base our analysis on the full data set.

Conclusion

This systematic review showed that there have been several measles outbreaks linked to anthroposophic communities in Europe. Although studies on vaccination coverage in anthroposophic communities are limited, it appears that coverage is lower than in the general population. Monitoring outbreak numbers and vaccination coverage could be important. Popular beliefs about the anthroposophic communities’ vaccination beliefs are challenged in this review. As the evidence shows the communities are not categorically against vaccines. Moreover, there are a myriad of factors that influence vaccine decision-making of parents belonging to an anthroposophic community. The importance of experiencing childhood illnesses and concerns over long-term side effects were mentioned. Moreover, parents want to be able to individually select vaccines for their children. They consider themselves actively engaged in vaccine decision-making and well-informed. Stigma regarding vaccine choices was mentioned repeatedly mostly by people outside of the anthroposophic community but also by people within the community. This review calls for a better understanding of vaccine choices and beliefs for vaccines beyond MMR, in particular HPV vaccines. The review also highlights a potentially important research gap, which constitutes understanding not only a belief system but the role that stigma may play in making decisions about vaccines.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Notes

  1. Note that some papers discuss several outbreaks in one paper.

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Acknowledgements

We would like to thank the systematic literature search team at Karolinska Institute library Jonas Pettersson & Emma-Lotta Säätelä for their invaluable contribution to this project. We also thank Elisa Gobbo for proofreading this manuscript. Lastly, we thank the reviewers of BMC Public Health for constructive feedback that helped improve this paper.

Funding

Open access funding provided by Karolinska Institute. SHvW is funded by FORTE (2021–01299) to work on vaccine confidence in Sweden.

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Authors and Affiliations

  1. Department of Global Public Health, Karolinska Institute, Stockholm, Sweden

    Sibylle Herzig van Wees & Khadija Abunnaja

  2. Department of Global Health and Development, London School of Hygiene and Tropical, London, UK

    Sandra Mounier-Jack

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  1. Sibylle Herzig van Wees
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  3. Sandra Mounier-Jack
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Contributions

S.H.vW and S.M.J wrote the main manuscript text and K.A prepared Tables 2, 3, 4 and 5. S.H.vW and K.A. screened the full text articles, conducted the quality assessment and coded the qualitative data. All authors reviewed the manuscript.

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Correspondence to Sibylle Herzig van Wees.

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Herzig van Wees, S., Abunnaja, K. & Mounier-Jack, S. Understanding and explaining the link between anthroposophy and vaccine hesitancy: a systematic review. BMC Public Health 23, 2238 (2023). https://doi.org/10.1186/s12889-023-17081-w

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BMC Public Health

ISSN: 1471-2458

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