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The internet enables access to information and the purchasing of medical products of various quality and legality. Research and regulatory attention have focused on the trafficking of illicit substances, potential physical harms of pharmaceuticals, and possibilities like financial fraud. However, there is far less attention paid to antibiotics and other antimicrobials used to treat infections. With online pharmacies affording greater access, caution around antibiotic use is needed due to the increasing health risks of antimicrobial resistance (AMR). The COVID-19 pandemic has helped to normalise digital healthcare and contactless prescribing, amplifying the need for caution. Little is known of how antibiotics are consumed via digital pharmacy and implications for AMR prevention. To expand insight for AMR prevention policy in Australia and internationally, we use digital ethnographic methods to explore how digital pharmacies function in the context of health advice and policy related to AMR, commonly described as antimicrobial stewardship. We find that digital pharmacy marketplaces constitute 'pastiche medicine'. They curate access to pharmaceutical and information products that emulate biomedical authority combined with emphasis on the 'self-assembly' of healthcare. Pastiche medicine empowers the consumer but borrows biomedical expertise about antibiotics, untethering these goods from critical medicine information, and from AMR prevention strategies. We reflect on the implications of pastiche medicine for AMR policy, what the antibiotics case contributes to wider critical scholarship on digital pharmacy, and how medical humanities research might consider researching online consumption in future.

ISSUE ADDRESSED: Coverage of maternal influenza and pertussis vaccines remains suboptimal in Australia, and pockets of low childhood vaccine coverage persist nationwide. Maternal vaccine uptake is estimated to be between 35% and 60% for influenza vaccination and between 65% and 80% for pertussis vaccination. Australian midwives are highly trusted and ideally placed to discuss vaccines with expectant parents, but there are no evidence-based interventions to optimise these discussions and promote maternal and childhood vaccine acceptance in the Australian public antenatal setting. METHODS: We gathered qualitative data from Australian midwives, reviewed theoretical models, and adapted existing vaccine communication tools to develop the multi-component P3-MumBubVax intervention. Through 12 interviews at two Australian hospitals, we explored midwives' vaccination attitudes and values, perceived role in vaccine advocacy and delivery, and barriers and enablers to intervention implementation. Applying the theory-based P3 intervention model, we designed intervention components targeting the Practice, Provider and Parent levels. Midwives provided feedback on prototype intervention features through two focus groups. RESULTS: The P3-MumBubVax intervention includes practice-level prompts and identification of a vaccine champion. Provider-level components are a vaccine communication training module, learning exercise, and website with printable fact sheets. Parent-level intervention components include text message reminders to receive influenza and pertussis vaccines in pregnancy, as well as online information on vaccine safety, effectiveness and disease severity. CONCLUSIONS: The P3-MumBubVax intervention is the first Australian antenatal intervention designed to support both maternal and childhood vaccine uptake. A pilot study is underway to inform a planned cluster randomised controlled trial. SO WHAT?: Barriers to vaccine acceptance and uptake are complex. The P3 model is a p

© 2018, © 2018 The Author(s). Published with license by Taylor & Francis Group, LLC. Maternal and childhood vaccination decisions begin during pregnancy, and midwives are an important information resource. Their role is set to increase with the expansion of maternal immunisations into new jurisdictions, and new maternal vaccines in development. Meanwhile, other health providers are orienting parents towards vaccine acceptance, using strategies at odds with midwifery norms around information provision and maternal autonomy. To better understand and address the implications of these developments, we conducted a pilot study to ascertain how midwifery students in Australian universities are taught about immunisation, including dedicated time, assessment, who teaches it, and when. We also analysed teaching materials, looking for messaging regarding the importance of vaccination and whether midwives should be advocating for it. We found that education on immunisation comprises less than four hours of the degree, and encountered the norm of midwives informing about rather than recommending vaccination. The considerations we brought to our small project, and what it illuminated, suggest that midwifery university education is an important arena for developing future vaccine advocates. However, midwifery ideology and professional practice mean that such efforts will be challenging, and must commence from a position of respect for the values midwives hold.

This unique book provides a critical perspective on identity to question how Israeli Jews manage and manifest their concern for the Palestinian Other, eschewing presenting identities as concrete and, rather, examining their creation through discourse. Considering the construction of Israeli Jewish national identity in the context of a state that has institutionalized a ressentiment discourse, this book examines how alternative discourses try, and sometimes fail, to re-imagine Israeli Jewish national identity in non-oppressive forms. It combines a rigorous theoretical analysis of nationalism and an engaging examination of the identifications and contradictions of eleven Israeli Jewish individuals.

Introduction: Maternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood. Method(s): Women attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR). Result(s): Between October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value < 0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake. Conclusion(s): First time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian pu

Vaccine hesitancy in industrialised countries is an area of concern. Health professionals play a significant role in parental vaccination decisions, however, to date the role of midwives has not been widely explored. This review sought to describe the attitudes and communication practices of midwives in developed countries towards childhood vaccines. Medline, Cinahl, PsychInfo, Embase and the grey literature were searched. Inclusion criteria were qualitative and quantitative studies reporting midwives’ beliefs, attitudes and communication practices toward childhood vaccination. The search returned 366 articles, of which 359 were excluded by abstract. Two additional articles were identified from the grey literature and references, resulting in nine studies from five countries included in the review. Across the studies, the majority of midwives supported vaccination, although a spectrum of beliefs and concerns emerged. A minority expressed reservations about the scientific justification for vaccination, which focussed on what is not yet known rather than mistrust of current evidence. Most midwives felt that vaccines were safe; a minority were unsure, or believed they were unsafe. The majority of midwives agreed that childhood vaccines are necessary. Among those who expressed doubt, a commonly held opinion was that vaccine preventable diseases such as measles are relatively benign and didn't warrant vaccination against them. Finally, the midwifery model of care was shown to focus on providing individualised care, with parental choice being placed at a premium. The midwifery model care appears to differ in approach from others, possibly due to a difference in the underpinning philosophies. Research is needed to understand how midwives see vaccination, and why there appears to be a spectrum of views on the subject. This information will inform the development of resources tailored to the midwifery model of care, supporting midwives in advocating for childhood vaccination

Introduction: Maternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood. Methods: Women attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR). Results: Between October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value. <.0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake. Conclusion: First time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian public h

Purpose - The purpose of this paper is to develop a theoretical framework for understanding the identity politics associated with parental hesitancy and refusal of vaccines for their children ("vaccine hesitancy or refusal" or "VHR"). Understanding these identity politics helps policymakers to craft appropriate communication interventions that do not make the problem worse. Design/methodology/approach - Social identity theory is a way of understanding how group identities develop around the lifestyle practices that often include refusal to vaccinate, and how this group identity is accentuated by conflict with the pro-vaccinating societal mainstream. This paper critically appraises existing studies of VHR to explore this groupness across many different contexts. Findings - Groupness is evident across many different contexts. There are also key group characteristics: preference for natural birth and breastfeeding, nature as a concept and use of complementary and alternative medicine. Research limitations/implications - The paper is speculative and theoretical, using existing sources. Future studies will need to demonstrate empirically with new data. However, this theoretical approach sets up a new research agenda. Social implications - These findings can help governments and policymakers minimise social conflict that risks further polarising vaccine conversations and wedging parents on the fence. Originality/value - This paper argues that the decision to vaccinate or not is an inherently social one, not a matter of pure individual rationality. This is a novel approach to engaging with what is often characterised and studied as an individual decision.

This commentary provides a framework for thinking about communities and vaccination. The concept of ‘herd’ or ‘community immunity’ – and hence the rationale behind mass vaccination – arises from communal interaction...

Although vaccination uptake is high in most countries, pockets of sub-optimal coverage remain posing a threat to individual and population immunity. Increasingly, the term 'vaccine hesitancy' is being used by experts and commentators to explain sub-optimal vaccination coverage. We contend that using this term to explain all partial or non-immunisation risks generating solutions that are a poor match for the problem in a particular community or population. We propose more precision in the term 'vaccine hesitancy' is needed particularly since much under-vaccination arises from factors related to access or pragmatics. Only with clear terminology can we begin to understand where the problem lies, measure it accurately and develop appropriate interventions. This will ensure that our interventions have the best chance of success to make vaccines available to those who want them and in helping those who are uncertain about their vaccination decision.

In attempting to provide protection to individuals and communities, childhood immunization has benefits that far outweigh disease risks. However, some parents decide not to immunize their children with some or all vaccines for reasons including lack of trust in governments, health professionals, and vaccine manufacturers. This article employs a theoretical analysis of trust and distrust to explore how twenty-seven parents with a history of vaccine rejection in two Australian cities view the expert systems central to vaccination policy and practice. Our data show how perceptions of the profit motive generate distrust in the expert systems pertaining to vaccination. Our participants perceived that pharmaceutical companies had a pernicious influence over the systems driving vaccination: research, health professionals, and government. Accordingly, they saw vaccine recommendations in conflict with the interests of their child and “the system” underscored by malign intent, even if individual representatives of this system were not equally tainted. This perspective was common to parents who declined all vaccines and those who accepted some. We regard the differences between these parents—and indeed the differences between vaccine decliners and those whose Western medical epistemology informs reflexive trust—as arising from the internalization of countering views, which facilitates nuance.

Objective: Some parents are hesitant about vaccines and yet still vaccinate their children. Vaccine behaviours are not fixed and parents who are concerned but nonetheless adherent to standard schedules could switch to an unconventional schedule, delaying or cherry-picking vaccines. There is a need to better understand vaccine hesitancy in specific contexts, acknowledging cultural and geographical variation, to ensure interventions targeting hesitancy are well directed and received. Methods: To identify the behaviours, knowledge and attitudes of 'hesitant compliers' in Perth, Western Australia, nine one-on-one in-depth interviews were conducted with vaccinating parents of children ( < 5 years) who were identified as being hesitant. Interview transcripts were analysed qualitatively and themes developed inductively, following a constructivist paradigm. Results: Parents saw vaccination as important for themselves and their community, despite their limited knowledge of vaccine preventable diseases. Parents reported concerns about potential side effects, and worried about the safety of the measles-mumps-rubella (MMR) and seasonal influenza vaccines. Concerned about the role of anti-vaccination information in the community, some sought to isolate themselves from parents who did not vaccinate, although others were concerned that this could entrench non-vaccinators' behaviours. Parents' views were all underlaid by two pivotal 'vaccine-related events' that had occurred in the community: the severe injury of a baby from seasonal influenza vaccination in 2010, and the death of a baby from whooping cough in 2015. Conclusions: Parents interpreted pivotal vaccine-related events in the community as requiring them to take personal responsibility for vaccine decisions. Their reports of continued vaccine fears (evident in international studies in recent decades) demonstrate that vaccine scares have long lasting effects. With vaccine rates high and stable, current strategies appear

This article advances a non-groupist understanding of the foundation, operation and self-perpetuation of states that scholars have hitherto labelled ethnocracies or ethnic democracies. Such states create and ignite zero-sum internal conflicts between portions of their populations. They do so by demarcating the population into ethnic categories. They apply labels to individuals and hierarchically order the categories to which they are deemed to belong, awarding one cohort more privilege than the other. Existing literature on such states has obscured the processes by which states reify and institutionalise identity, instead presenting it through groupist frames in which ethnicity is a pre-existing variable. Re-conceptualising the doing of ethnicity as a process enables us to study internal dissent against ethnic privilege and consider its transformational capacity in inspiring new nationalist discourses.

This paper presents results of a study determining the efficacy of a values based approach to changing vaccination attitudes. It reports an evaluation survey of the "I Immunise" campaign, conducted in Fremantle, Western Australia, in 2014. "I Immunise" explicitly engaged with values and identity; formulated by locals in a community known for its alternative lifestyles and lower-than-national vaccine coverage rates. Data was collected from 304 online respondents. The campaign polarised attitudes towards vaccination and led some to feel more negatively. However, it had an overall positive response with 77% of participants. Despite the campaign only resonating positively with a third of parents who had refused or doubted vaccines, it demonstrates an important in-road into this hard-to-reach group.

This article explores symbolic boundaries and identity-formation of the ‘ethnonational Us’, using narrative analysis of eleven Israeli-Jewish dissidents. The hegemonic nationalist discourse in Israel – Zionism – constructs the dissidents’ identities as the ‘Virtuous Us’, yet these individuals genuinely try to connect with the ‘Demonized Palestinian Other’. I suggest that the dissidents attempt to use alternative national identity discourses to overcome symbolic boundaries. I highlight inconsistencies within individual dissidents’ narratives and attribute them to the employment of multiple discourses, suggesting that some discourses fail to coherently reconcile ‘national’ history with the well-being of the Other, whilst others repel dissidents by appearing to negate or destroy their identities. The dissidents, therefore, cannot use the available discourses to fully overcome symbolic boundaries. Only the hegemonic nationalist discourse can offer a self-evident and compelling enunciation of the dissidents’ political reality, leading one insightful dissident to conclude that there is ‘no way out’ of his dilemma.