“If I'm a naturopath, It's because I trust nature above everything else”: Canadian naturopaths' construction of vaccination as a risk object

Abstract

Canadians and Quebecers increasingly consult complementary and alternative medicine (CAM) practitioners in parallel with biomedical providers. The close relationship between vaccine hesitancy and CAM use remains under explored in Western countries. We present the results of a qualitative study conducted among one of Quebec's most used CAM approaches: naturopathy. Using Boholm and Corvellec's relational theory of risk to illustrate naturopaths' construction of vaccination as an “object of risk”, we describe how the health representations of 30 Quebec naturopath interviewees are associated with the ways they perceived the risks of infectious diseases and vaccination. Our findings illustrate how Quebec naturopaths' view the body as “at risk” from the possible harmful effects of vaccines. For these naturopaths, the body is a site, a “terrain”, where homeostasis must continually be preserved, and needs to be protected from risks such as vaccines—which were seen as far riskier than infectious diseases—through natural means. Such views are often perceived as unscientific or even irrational by public health researchers. Our study highlights that naturopaths' attitudes towards vaccination are perfectly aligned with the epistemological tenets of their risk representations and conceptions of health.

Full text

“If I'm a naturopath, It's because I trust nature above everything else”:
Canadian naturopaths' construction of vaccination as a risk object
Benjamin Malo
a
, Samantha B. Meyer
b
, Eric Filice
b
, Janice E. Graham
c
, Noni E. MacDonald
d
,
Julie A. Bettinger
e
, Devon Greyson
f
, Shannon E. MacDonald
g
, S. Michelle Driedger
h
,
Gregory Kawchuk
i
, Fabienne Labb
e
j
, Eve Dub
e
a
,
*
a
D
epartement d'anthropologie, Universit
e Laval, Qu
ebec, Qu
ebec, 2325 Rue de l'Universit
e, G1V 0A6, Canada
b
School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
c
Department of Pediatrics, Dalhousie University, 5849 University Avenue, Halifax, Nova Scotia, B3H 4H7, Canada
d
Department of Pediatrics, Dalhousie University, 5980 University Avenue, Halifax, Nova Scotia, B3K 6R8, Canada
e
Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, British Columbia, V5Z 4H4,
Canada
f
School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia, V6T 1Z3, Canada
g
Faculty of Nursing, University of Alberta, 5-308 Edmonton Clinic Health Academy, Edmonton, Alberta, Canada
h
Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
i
Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
j
Axe Sant
e des populations et pratiques optimales en sant
e, Centre de recherche du CHU de Qu
ebec-Universit
e Laval, Qu
ebec, 1050 Chemin Sainte-Foy, G1S 4L8, Canada
ABSTRACT
Canadians and Quebecers increasingly consult complementary and alternative medicine (CAM) practitioners in parallel with biomedical providers. The close rela-
tionship between vaccine hesitancy and CAM use remains under explored in Western countries. We present the results of a qualitative study conducted among one of
Quebec's most used CAM approaches: naturopathy. Using Boholm and Corvellec's relational theory of risk to illustrate naturopaths' construction of vaccination as an
“object of risk”, we describe how the health representations of 30 Quebec naturopath interviewees are associated with the ways they perceived the risks of infectious
diseases and vaccination. Our findings illustrate how Quebec naturopaths' view the body as “at risk”from the possible harmful effects of vaccines. For these natu-
ropaths, the body is a site, a “terrain”, where homeostasis must continually be preserved, and needs to be protected from risks such as vaccines—which were seen as far
riskier than infectious diseases—through natural means. Such views are often perceived as unscientific or even irrational by public health researchers. Our study
highlights that naturopaths' attitudes towards vaccination are perfectly aligned with the epistemological tenets of their risk representations and conceptions of health.
1. Introduction
Vaccination programs are often considered to be one of the greatest
achievements of public health as they have contributed to an important
decrease of the mortality and morbidity of many infectious diseases
(Dub
e, Vivion, &MacDonald, 2015a,2015b). As highlighted during the
COVID-19 mass vaccination campaigns, many factors influence vaccine
acceptance and uptake, such as structural barriers and inequalities in
access to vaccination services, dis- and misinformation, or the role played
by health care providers (Burstr€
om &Tao, 2020;Dub
e et al., 2022).
Studies have shown associations between “complementary and alterna-
tive medicines”(CAM) use and negative attitudes towards vaccination
(Attwell et al., 2018;Deml, Jafflin, et al., 2019). CAM is an evolving
expression encompassing a wide variety of approaches to health, making
it difficult to define (National Center for Complementary &Integrative
Health, 2021). In this paper, we follow Deml et al. (2019) who defines
CAM as “healing practices and modalities operating outside of, in addi-
tion to, or as accompanying biomedicine and accepted medical curricu-
lum”(Deml, Notter, et al., 2019, p. 2).
CAM use has been frequently associated with being indecisive or
uncertain regarding vaccination and vaccine refusal (Wardle et al.,
2016). However, often CAM use and vaccine hesitancy—described by the
World Health Organization (WHO) as a “delay in acceptance or refusal of
vaccines despite availability of vaccination services”—are presented as
* Corresponding author. D
epartement d'anthropologie, Universit
e Laval, Qu
ebec, Qu
ebec, 2325 Rue de l'Universit
e, G1V 0A6, Canada.
E-mail addresses: benjamin.malo@crchudequebec.ulaval.ca (B. Malo), samantha.meyer@uwaterloo.ca (S.B. Meyer), efilice@uwaterloo.ca (E. Filice), janice.
graham@dal.ca (J.E. Graham), Noni.MacDonald@Dal.Ca (N.E. MacDonald), jbettinger@bcchr.ubc.ca (J.A. Bettinger), devon.greyson@ubc.ca (D. Greyson),
smacdon@ualberta.ca (S.E. MacDonald), Michelle.Driedger@umanitoba.ca (S.M. Driedger), gkawchuk@ualberta.ca (G. Kawchuk), fabiennelabbe@gmail.com
(F. Labb
e), eve.dube@ant.ulaval.ca (E. Dub
e).
Contents lists available at ScienceDirect
SSM - Qualitative Research in Health
journal homepage: www.journals.elsevier.com/ssm-qualitative-research-in-health
https://doi.org/10.1016/j.ssmqr.2022.100203
Received 4 October 2022; Received in revised form 31 October 2022; Accepted 26 November 2022
Available online 8 December 2022
2667-3215/©2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
SSM - Qualitative Research in Health 3 (2023) 100203

discrete and measurable variables without regard to the processes and
pathways leading to CAM use, or to the broader socio-cultural context of
vaccination decisions making (Bryden et al., 2018;MacDonald &Dub
e,
2015). Vaccine refusal often reflects deeper concerns about medicine, the
state and the body, and a growing distrust of health professionals, the
pharmaceutical industry and government (Attwell et al., 2018;Dub
e
et al., 2013;Yaqub et al., 2014). Similarly, distrust of biomedicine and
biomedical healthcare providers is a common driver of CAM use (Dub
e
et al., 2015a,2015b;Hornsey et al., 2020;Wardle et al., 2016).
Naturopathy is a CAM that is increasingly used in Canada (Esmail,
2017) and Quebec is among the few Canadian provinces where natu-
ropathy is unregulated. The aim of this study is to describe Quebec na-
turopaths’views of vaccination in general and how their representations
of health influence the way they construct and present vaccination to
their clients.
1.1. Biomedicine, CAM, and naturopathy
Considered to be the dominant paradigm among Western medical
systems, biomedicine is a sociotechnical system that considers human
bodies to be universally equivalent and largely explains illness through
biological causation (Lock &Nguyen, 2010). In Western societies CAM
therapies have historically been seen to be in opposition with biomedi-
cine (Brosnan et al., 2018). CAM were often considered as “quackery”
and pushed to the fringes in opposition to “scientific”and “evidence--
based”biomedical knowledge (Wahlberg, 2007). The naming process of
CAM itself reflects power relationships with biomedicine since the
“biomedical dominance continues to frame the language with which we
engage with issues of health, illness and healing”(Gale, 2014, p. 806).
These power relationships with biomedicine also frame how CAM are
defined and raise terminological issues. As Gale (2014) highlighted,
trying to define CAM is problematic since definitions are contingent, they
try to capture a large array of therapies and practices that barely resemble
each other, some healing practices may be similar with those of
biomedicine and, finally, there is a growing interest among biomedical
practitioners to collaborate with CAM practitioners (i.e., integrative
medicine), rendering categorizations between CAM and biomedicine
hazardous.
Within this context, providing a clear-cut definition is difficult (Dub
e
et al., 2017). In addition to Deml et al.’s (2019) general definition, we
rely on the classification provided by the National Center for Comple-
mentary and Integrative health (NCCIH), the United States of America
lead agency funding research on CAM. The NCCIH distinguishes five
broad types of CAM: alternative health systems (homeopathy, naturop-
athy, traditional Chinese medicine, Ayurvedic medicine, etc.),
body-spirit approaches (faith healing, First Nations traditions, shamanic
healing, etc.), biologically-based treatments (vitamins, dietary supple-
ments, herbs, etc.), physical approaches (osteopathy, chiropractic, mas-
sage therapy, etc.), and body-energy approaches (Qi Gong, Reiki, Yoga,
etc.) (National Center for Complementary &Integrative Health, 2021).
In North America, patients seek both CAM and biomedical treatments
(Eisenberg et al., 1998;Esmail, 2017). It is estimated that Canadians have
spent about $8,8 billion for CAM treatments in the latter half of 2015 and
the first one of 2016, which is an increase of $8 billion spent in
2005–2006 (Ning, 2018). A 2016 Canadian survey conducted with 2000
participants illustrated that 79% of them used at least one CAM therapy
in 2016 (Esmail, 2017). The survey also pointed out that Canadians tend
to consult CAM providers more and more before seeing a physician. Of
note, many biomedical providers, such as nurses, pharmacists, or phy-
sicians, recommend CAM therapies (Ning, 2013). Despite this growing
interest, biomedicine still defines what “good medicine”is. In North
American, the integration of CAM therapies within health care systems is
asymmetric and depends, among other things, on their adoption of the
evidence-based paradigm, hence a perpetuation of power relationships
(Nelson et al., 2019;Owens, 2015).
Generally characterized by a holistic approach that integrates the
mental and spiritual dimensions in addition to the physical dimension
that is often the focus of biomedicine (Suissa et al., 2016), the Canadian
Association of Naturopathic Doctors (CAND) defines naturopathy as “a
distinct primary health care system that blends modern scientific
knowledge with traditional and natural forms of medicine”(CAND,
2022a). Six umbrella principles guide the practice of naturopaths to
varying degrees (World Naturopathic Federation, 2017)(Table 1).
Naturopaths view disease as the body's response to physical, social,
environmental, and psychological imbalances (Baer, 2001b). They
mobilize a wide variety of treatment practices designed to bring back the
body's balance, including diets and lifestyle counseling, colonic irriga-
tion, and natural remedies (e.g., medicinal plants, supplements) (Gort &
Coburn, 1988). Naturopathy became popular in North America in the
1970s, sharing characteristics such as a more individual approach to
well-being with counterculture New Age and holistic health movements
(Baer, 2001a;2001b). There is no consensus on when the first naturo-
paths began practicing in Canada, but there were at least a few before the
First World War and Canadian naturopathy grew particularly in British
Columbia, where the Canadian Association of Naturopathic Doctors was
founded in 1955 and remains the national professional association rep-
resenting naturopathic doctors (Gort &Coburn, 1988).
1.2. The Canadian health care system
The Canadian health care system is based on the principles of universal
access to care. In practice, however, many necessary health services such
as dentistry, physical therapy, and pharmaceuticals are paid through pri-
vate insurance or out of pocket (Angus, 1998). Unlike in Switzerland,
where CAM is usually provided by physicians trained in CAM therapies
and reimbursed if received by medical doctors, most CAM therapies are
not publicly insured in Canada (Deml, Notter, et al., 2019). Health is the
responsibility of the provincial and territorial governments. Naturopathy
is professionally regulated in five provinces: British Columbia, Manitoba,
Alberta, Saskatchewan and Ontario where Naturopathic Doctors (N.D.)
practice as independent providers (Dub
e et al., 2017). These professional
regulations allow naturopaths protected titles (N.D., naturopathic doctor,
and naturopath) and to perform certain acts, some of which are reserved
for naturopathic doctors while others are shared with different medical
professions. For example, naturopathic doctors in British Columbia can,
with appropriate training prescribe drugs and administer vaccines for in-
dividuals older than five years (CAND, 2022b). Nova Scotian naturopaths
have some level of regulation through title protection for naturopathic
doctors. These regulations are similar to those of 19 states (e.g., Arizona,
Maine, and Maryland) in the US and 8 European countries (e.g., Germany,
Switzerland, and Liechtenstein) where naturopathy is either regulated
through some form of licensing and government certifications, or through
treatment regulations (Trebilcock &Mahadevia Ghimire, 2019;Wiesener
et al., 2012a,2012b,pp.1–20).
Table 1
Fundamental principles of naturopathy, adapted from the world naturopathic
Federation (2017).
Concepts Definitions
Vitalism The “vital force”of clients that naturopaths must stimulate.
Naturism Nature holds a fundamental role in successful healing. Naturopaths
must support, facilitate and enhance this healing power by identifying
and removing obstacles to clients' well-being so the body can heal itself.
Causalism Diseases arise from certain “deep causes”that must be treated rather
than the symptoms in order to achieve good health.
Holism Health is seen as a whole that integrates the physical, mental, spiritual,
emotional, and environmental aspects of the individual in the process
of health preservation.
Humorism Developed by Hippocrates, Naturopaths view the body as composed of
four humours: blood, lymphatic, biliary and nervous.
Teaching Naturopaths' role is to teach clients about the dimensions affecting
their health so that they can make decisions that positively influence
their well-being.
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
2

Two schools in Canada provide the necessary training to obtain the
N.D. accreditation: the Boucher Institute of Naturopathic Medicine in
British Columbia and the Canadian College of Naturopathic Medicine in
Ontario (CAND, 2022c). Admittance requires completion of a 4-year
undergraduate program in a biomedical health-related discipline. The
full-time four-year N.D. program is based on a natural approach to
health—such as nutrition and lifestyle counseling—in addition to the
integration of biomedical science courses similar to medical programs.
Students must also pass the Naturopathic Physicians Licensing Exami-
nations (NPLEX) in order to obtain the N.D. title and be qualified to
practice in Canada (CAND, 2022b). As of 2022, there were over 2900
naturopathic doctors in Canada (CAND, 2022a). In provinces and terri-
tories where naturopathy is not regulated, many schools and organiza-
tions offer naturopathy courses, ranging from minimal training to
programs similar to the two recognized naturopathy schools.
Similarly to the United Kingdom, New Zealand, Australia, and many
European countries (e.g., Norway, Sweden, and Spain), naturopathy is
not regulated in Quebec (Trebilcock &Mahadevia Ghimire, 2019, pp.
1–20; Wiesener, Falkenberg, Hegyi, H€
ok, Roberti di Sarsina, et al., 2012).
Quebec naturopaths have no professional organization, are unable to
diagnose or provide treatment. Their precarious legal status exposes
them to legal action by Quebec College of Physicians for violating the
Medical Act, leading many naturopaths to practice underground (Martel,
2015, pp. 99–107). Naturopathy in Quebec is thus fragmented; close to
ten professional naturopath associations exist in Quebec, but none are
recognized by the state. More than 72 schools give naturopathy courses
in Quebec (RITMA, 2020) but only two, the 
Ecole d'enseignement
sup
erieurs de naturopathie du Qu
ebec and the Institut d'enseignement en
science naturopathique, have programs that align with the Boucher Insti-
tute of Naturopathic Medicine and the Canadian College of Naturopathic
Medicine. The other programs are not standardized, may be completed in
a few days, months, or years. Without regulation, no Quebec naturopathy
program is eligible for NPLEX (CAND, 2022b).
The unregulated state of Quebec naturopathy, coupled with multiple
professional associations and schools, has resulted in a variety of prac-
tices ranging from classic naturopathic such as nutritherapy to unor-
thodox and eclectic ones such as lithotherapy and iridology.
1.3. Vaccine hesitancy, CAM, and naturopathy
Vaccine acceptance and uptake are complex and multidimensional
due to legislation and policies, access to health services access, social and
cultural norms, and other factors. Individual attitudes, knowledge and
perception, and healthcare providers play an important role in influ-
encing decisions (MacDonald et al., 2022).
Studies conducted prior to the COVID-19 pandemic in Spain (Hornsey
et al., 2020), Canada (McMurtry et al., 2015), and Finland (Nurmi &
Harman, 2021) showed that CAM practitioners have held negative atti-
tudes towards vaccination and were generally distrustful of the
biomedical paradigm and its practitioners, especially regarding vacci-
nation. Deml et al.’s (2019) study illustrated that—in the Swiss institu-
tionalized context—CAM practitioners mainly used medical journals,
scientific sources, and Swiss vaccination recommendations as sources of
information on vaccines (Deml, Notter, et al., 2019). Another Swiss study
(Ebi et al., 2022) revealed that vaccine-hesitant parents were more likely
than vaccine confident parents to consult CAM practitioners and find a
greater level of satisfaction with CAM than with biomedical practitioners.
Individuals with more distrust in biomedical sources of information were
more prone to endorse CAM sources and were less willing to get vacci-
nated against COVID-19 (Soveri et al., 2021). Those that value natural-
ness, spirituality, and have holistic views on health (i.e., the integration
of mind, body, and spirit) have a greater tendency to consult CAM pro-
viders and be skeptical of vaccination (Bryden et al., 2018). In Attwell
et al.‘s Australian study (2018), the relationship between vaccine hesi-
tancy and CAM is described as symbiotic: “vaccine hesitancy and CAM
exist and function separately, but when combined, provide each other
with ‘resources’that enable them to thrive together”(Attwell et al., 2018,
p. 111). While there is a demonstrated association between CAM use and
lower vaccine uptake rates (Jones et al., 2010;Lee et al., 2016;Wardle
et al., 2016), few studies have assessed North American CAM practi-
tioners' views about vaccination.
Three Canadian studies demonstrated that most naturopathic stu-
dents were vaccine hesitant (Busse et al., 2008;McMurtry et al., 2015;
Wilson et al., 2004). Two studies of students at the Canadian College of
Naturopathic medicine reported that 74.4% would recommend vacci-
nation, depending on the vaccine, while 12.8% of the students would not
recommend any vaccines. Their findings highlighted a decline in trust in
public health among naturopathy students based on more years in an
N.D. program. A study of Ontario naturopathic students reported that
they distrusted information given by vaccine manufacturers, had con-
cerns about vaccine ingredients and long-term effects, and that they
believed that vaccines could overload infants’immune systems and that
some holistic approaches (e.g., homeopathy) could give a better or
similar protection against infectious diseases (McMurtry et al., 2015).
Few studies have looked at CAM practitioners' perspectives on
vaccination. Fewer studies were aimed specifically at naturopaths, and
none were conducted in Quebec. In a context where CAM and vaccine
hesitancy are often linked (Attwell et al., 2018;Wardle et al., 2016),
there is a need to understand those dynamics better. The same observa-
tion can be made about naturopathy (Filice et al., 2020). This article thus
explores Quebec naturopaths' views about vaccines and aims to answer
the following research question: How does Quebec naturopaths’represen-
tations of health influence the ways they construct infectious diseases and
vaccines as risks? We use Boholm and Corvellec (2011) relational theory
of risk to answer this question as this theory allows to meticulously
highlight how risks are constructed and their underpinning logics in
different sociocultural contexts.
1.4. A relational theory of risk
Two main traditions exist in sociology and anthropology on the study
of risk (Zinn, 2004). The first tradition is usually referred to as the notion
of “risk society”and is based on the idea that modernity is highly re-
flexive and that uncertainties towards the future are constant (Beck,
1992;Giddens, 1994). Risks are everywhere and are the product exper-
tise. The second tradition is qualified as “risk culture”and claims that
risks are constructed in sociocultural contexts (Hilgartner, 1992). This
approach draws on Mary Douglas and Aaron Wildavsky's grid-groups
functionalist analysis that aimed to understand how risks are expressed
in different social groups (Douglas &Wildavsky, 1982). For Douglas, the
role played by risk in contemporary societies is the same as the one
played by sins or taboos in traditional societies. In both cases, they
involve uncertainties about the future linked to a danger (Douglas,
1994). This is closely related to Douglas' notion of “dirt”. In her book
Purity and Danger, she analyzed how dirt takes form in different contexts
and in relation to the idea of the clean/unclean dichotomy (i.e., puri-
ty/impurity) (Douglas, 1984). Dirt could be conceptualized as impure
objects (i.e., a risk) to what is constructed as clean, safe, or natural: the
same way other cultures placed such objects under taboo (Ditlevsen &
Andersen, 2020).
Bohom and Corvellec’(2011) relational theory of risk is aligned with
this sociocultural approach of risk and is useful to study how different
logics of risk vary according to local assemblages of suppositions, con-
ventions, practices, and norms. This theory states that risk is constructed
through “situated cognition that establishes a relationship of risk linking
two objects, a risk object and an object at risk, in a causal and contingent
way so that the risk object is considered, in some way and under certain
circumstances, to threaten the valued object at risk”(Boholm &Corvel-
lec, 2011, p. 176).This theory has three dimensions: i) a risk object, ii) an
object at risk, and iii) a relationship of risk. Risk objects refer to “some-
thing that is identified as dangerous”(Boholm &Corvellec, 2011,p.
179), such as natural phenomena (e.g., tornadoes, tsunamis), or cultural
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
3

representations of something conceived as dangerous (e.g., vaccines,
infectious diseases). Objects at risk are characterized by something at
stake of value, be it life, health, or principles. Relationships of risk are etic
(i.e., a researcher's observations) associations between risk objects and
objects at risk that establish what constitutes the risk object, and how and
why it threatens the object at risk. Of note, relationships of risk always
imply praxis. Individuals act upon what they consider risk objects to
protect what they hold dear (Penkala-Gawecka, 2016). For example, if
mothers have negative representations of vaccines (risk objects) and
believe they could have deleterious effects on their child's health (object
at risk), they might refuse vaccination or adapt a routine vaccine
schedule (risk management strategies) (Burton-Jeangros, 2004). Links
established between these elements by an external researcher correspond
to a relationship of risk.
2. Methods
We gathered empirical qualitative data through individual in-
terviews, applying discourse analysis anchored in a social constructivist
approach (Yazdannik et al., 2017). First, discourse analysis allows one to
critically study how discourses produce categories that must not be
treated as an objective truth and that these categories are socially, his-
torically, and culturally contingent. Second, this type of analysis makes it
possible to highlight the relationships between knowledge and social
process (Burr, 2015). This approach was appropriate for the data
analyzed as it allowed us to explore naturopaths’values, beliefs, and
attitudes about vaccination, highlighting their underpinning logics and
how they fit into the broader sociohistorical context. It also allowed us to
take a relativistic stance on the knowledge that was produced and
mobilized by participants.
2.1. Sampling and recruitment
Purposive sampling of maximum variation was used to obtain broad
representation of the many ways naturopathy is practiced in Quebec. We
recruited diverse participants in terms of age, sex/gender, number of
years and type of practice (e.g., nutritherapy, phytotherapy, lithotherapy,
etc.). These parameters were also used to achieve variation within our
sample. Since no regulations exist in Quebec, we included self-identified
naturopaths, whatever their academic backgrounds or professional af-
filiations. Naturopaths practicing outside of Quebec and those speaking
neither French nor English were excluded. We aimed for 30 participants
(Guest, 2014), but our sample was determined inductively by saturation
of themes after maximum variation (Fossey et al., 2002). Recruitment
was stopped once no new themes were identified during the interviews.
Heads of Quebec naturopaths associations with more than 100
members—determined from the information available on Quebec main
associations websites following Filice et al.’s (2020) environmental
scan—were asked to share our study invitation with their members.
Participants could sign up online for the interview or contact the study
team directly. We also built a list of potential participants to contact from
the information available in Quebec principal naturopathy associations
websites. Our sample was constituted purposively through maximum
variation as we ensured diversity in participants' profiles when building
the list of potential participants to invite and when contacting those who
showed interest online. Participants were first contacted by email, then
by phone. The snowballing technique was also used as participants were
asked to share our study invitation to colleagues, again diversity in
profile was assessed before contacting these participants.
2.2. Data collection
Qualitative data were collected via in-depth semi-structured in-
terviews with naturopaths. Interviews were conducted by [Author 1],
[Author 11], and [Author 12]—anthropologists trained in qualitative
methods—between January 2020 and October 2020. Due to the
pandemic context, interviews were mainly conducted online (Google
Teams, Zoom, and Skype) or by phone. Three interviews were conducted
in-person at the request of participants (participant's home, caf
e,
restaurant). At the time of the interviews, COVID-19 vaccines were still
under development and not yet authorized in Canada. An interview guide
based on CAM and vaccine hesitancy literature explored themes such as
personal practice of naturopathy and the philosophy guiding it, as well as
services given to clients and general health practices recommended.
Participants were questioned about infectious disease prevention and
vaccination in general, including vaccines against COVID-19. We also
asked them about their risk management practices regarding infectious
diseases and vaccines. Interviewers disclosed their positionality prior to
the interviews (i.e., applied public health researchers with positive atti-
tudes about vaccines) but reminded the participants that the aim of the
interview aim was to assess their own views and opinions. Interviewers
did not answer questions or provided information on vaccines during the
interviews. Interviews lasted about 75 min on average and were audio-
recorded. Recordings were transcribed verbatim by research assistants.
The research team validated all transcripts to make sure the content was
accurate.
2.3. Data analysis
[Author 1] and [Author 11] analyzed the data collected by induc-
tively classifying key ideas in participants' discourses in line with the
research main objectives (Paill
e&Mucchielli, 2016). Boholm and Cor-
vellec's (2011) relational theory of risk was also deductively used to focus
the analytic framework by identifying objects of risk and objects at risk.
We analyzed the interviews sequentially to be able to adapt our interview
guide to emerging themes identified in interviews and to deepen new
ideas. Analysis was conducted without assessing the validity of the par-
ticipants' claims about vaccines. However, in reporting the findings,
participants' views that are not aligned with the current scientific
consensus about vaccination are signaled.
To facilitate team collaboration, NVivo 13 was used to code verbatim
and conduct the analysis (Dumont, 2010). To ensure data consistency
and standard application of the codes, members of the research team
regularly discussed the analysis process. A reflexive posture was adopted
during discussions to limit potential bias by personal beliefs, knowledge,
and experiences (de Sardan, 2000). The Consolidated Criteria for
Reporting Qualitative Research (COREQ) is available (Supplementary
File 1; Table 1)(Tong et al., 2007).
The CHU de Qu
ebec-Universit
e Laval Research Ethics Committee
provided ethical approval under project number 2019–4300. All partic-
ipants signed an informed consent form prior to the interview. Pseudo-
nyms were used to ensure participant confidentiality.
3. Results
A total of 113 naturopaths from 8 associations were invited to take
part in the study. Of those, 65 did not reply, 18 declined, and 30 agreed to
participate (Table 2). None withdrew their participation after the inter-
view. All participants spoke French, the official language in Quebec. We
were not able to recruit any English-speaking naturopaths for the study.
As [Author 1], [Author 11], and [Author 12] are French-English bilin-
gual, the interviews were analyzed in French (their mother tongue) and
selected quotes were translated into English. Participants used a variety
of approaches and treatments in their practice (Table 3).
We first present how naturopaths constructed the body as a “terrain”
where the person and environment intertwined. In their opinion, health
was guaranteed if one's can ensure his terrain's homeostasis, generally
through natural means. This terrain must be protected at all costs,
making it an object at risk. Second, we present how this conception of the
body led naturopaths to believe that—if one's terrain is balan-
ced—infectious diseases were not to be feared and that the health
practices they deployed (e.g., use of supplements, good nutrition)
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
4

rendered vaccines unnecessary. Third, in this context, vaccines were
constructed as risk objects because they were not considered natural and
were seen as detrimental to the homeostasis of the terrain. Finally, we
highlighted naturopaths managed risks associated to vaccination by
generally not choosing it, preferring the practices they mobilized to
ensure health. When vaccination was seen as a viable risk management
strategy, naturopaths could manage the inherent risks to vaccines
through practices supporting or purifying the body before or after the
shot.
3.1. Homeostasis and the construction of the “terrain”as an object at risk
3.1.1. What Is the “terrain”and why does it matter?
Regarding both vaccination and infectious diseases, naturopaths
identified the “terrain”as the main object at risk they have to protect, by
any means. The terrain could be seen as a metaphor for the “assemblage”
of person and environment (Guattari &Deleuze, 1987). While the notion
of terrain is virtually absent from English-language naturopathic litera-
ture, it is not the case for French-speaking naturopaths (e.g., naturopathy
websites, reports, etc.) and Quebec participants put it at the forefront of
their discourses on health and diseases. For them, the terrain is a holistic
representation of the body. It is the focal point of environmental,
behavioural, emotional, spiritual, and nutritional dimensions. In a way,
terrain is a convergence of external (e.g., pollution, genetically modified
foods) and internal factors (e.g., emotional well-being, general health,
genetics). Isabella (nutritherapy, 28 years of practice) and some partici-
pants used the analogy of a garden to describe the terrain:
The body is made to be healthy. It has all the tools inside to be healthy
[…]. I use the image of the garden a lot. Here, I live in an apartment,
but I have a yard […]. I removed the bad soil and put in good soil. I
have no water outside, but I have water inside, so I am able to water
my garden. I have all the conditions to have something that grows
well. If I sow my seeds on the asphalt driveway, and I have no soil, and
it is under the car: nothing will grow. When we understand the notion
of terrain and we give what is necessary to be healthy …The notion of
terrain, it is the nutrition. It is organic: pesticides must be avoided at
all costs. It is to breathe the purest air possible, not being next to a
highway; it is the emotional environment at home […]; it is how a
mother experiences her pregnancy. In short, it is the physical activity,
the stress balance, the future stress. (Isabella, nutritherapy, 28 years
of practice).
Isabella sees the terrain as a garden. For something to grow, it must be
planted in a multidimensional fertile environment juxtaposed with
multiple ingredients, such as sun or the quality of the potting soil. For the
human body, terrain meant good health was the result of a combination
of a multitude of factors. Isabella provided examples: air quality,
emotional stability, physical activity, weight, and alimentation. Terrain
connotes a highly permeable layer between the physical body and its
external environment. It is the idea that, more than anything congenitally
acquired, our body's health is determined by what we put inside and
surround it by. Further in the interview, she explained one central aspect
of terrain: to be healthy, it first needed to be “balanced”.
3.1.2. A constant quest for homeostasis
Throughout the interviews, naturopaths discussed the importance of
the terrain's homeostasis; a balanced terrain was synonymous with
health. They considered it within their power to balance some factors
affecting the terrain albeit in a “natural”way. One of the fundamental
concepts of naturopathy, naturism (Table 1) states that nature, as the
backbone of good health, is the key to successful healing. Participants
believed homeostasis of the terrain must be achieved through natural
means: “it is not true that with chemical products we can build health”
(Olivia, nutritherapy and phytotherapy, 4 years of practice). As Olivia put
it, the opposite was also true: naturopaths believe the use of chemicals
Table 2
Socio-professional characteristics of participants.
Characteristics Number of participants
Sex/Gender Men 10
Women 20
Years of practice 1–510
6–10 6
11–15 3
16–20 3
21–25 2
26–30 5
>30 1
Place of study Quebec 27
United States 1
Online 2
Table 3
Types of practice.
Practice
a
Definitions Number of
participants [not
mutually exclusive]
Nutritherapy Preventing or healing diseases
through the use of nutritional
supplements, such as vitamins and
macronutrients, and nutrition as a
whole (Bischoff-Ferrari, 2009).
21
Phytotherapy Therapeutic treatment based on the
use of plants and herbs to obtain or
maintain health (Heinrich et al.,
2017).
12
Aromatherapy Using essential oils to obtain health
and well-being (Cooke &Ernst,
2000).
8
Hydrotherapy The use of water as a means of
treating diseases. Hydrotherapy is
alleged to reduce pain, improve
mental health, and immunity
(Mooventhan &Nivethitha, 2014).
3
Gemmotherapy Gaining health with the use of
macerated and filtered embryonic
vegetal tissues in glycerin, alcohol,
and purified water. The extract is
orally consumed in the form of drops
(Andrianne &Leunis, 2008).
2
Homeopathy A medicine based on the idea that a
substance which causes similar
symptoms of a disease can cure said
disease. Homeopathic remedies are
highly diluted products named
nosodes (Fisher, 2012).
2
Massage therapy Manipulation of soft tissues to
reduce stress and increase relaxation
(Ernst, 2003).
2
Lithotherapy The use of stones to obtain or
maintain health (Riddle, 1970).
2
Psychosomatic
approach
Healing physical symptoms through
psychological support (Alexander,
1965).
2
Energy therapies Based on the premises that the body
possesses energy fields that must be
allowed to flow freely by the
practitioner using practices such as
Reiki or Qigong (Coakley &Barron,
2012).
2
Reflexology A massage therapy based on the
premises that applying pressure on
certain points gives health benefits
to internal organs (Wang et al.,
2008).
1
Iridology Analysis of iris as a source of
information on clients' health (Ernst,
1999).
1
a
Of note, often these practices are used in combination.
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
5

(e.g., drugs, vaccines) is deleterious to health; nutritherapy is a natural
way to reach health through the homeostasis of the terrain. An approach
aimed at preventing or alleviating diseases by improved nutrition,
nutritherapy involves supplements (vitamins) or macronutrients (pro-
teins, fats, carbohydrates). Participants recommended their clients stay
as close as possible to “natural”ingredients (i.e., biological food, not
processed aliments). Maintaining a good terrain so that it is balanced
guarantees health. Ian (nutritherapy, 40 years of practice) suggested that
when a person reaches a state of balance between the multiple factors
composing the terrain, they do not have “pathology in itself”and could
consider themselves healthy. Disease comes from terrain imbalance.
Most participants associated disease with the imbalance of the
terrain, occurring when factors influencing the terrain were not in a state
of homeostasis. If there was no balance between one's external (e.g.,
pollution) or internal factors (e.g., microbiome, emotions), diseases
ensue. An imbalanced terrain increased one's susceptibility of contracting
diseases. This belief refers to germ theory denialism. Whereas germ
theory purports that illness is caused by infection of a host by microor-
ganisms that are normally “external”to it, denialism represents illness as
the result of an imbalance of everyday internal and external forces (i.e.,
imbalances of the terrain). Study participants, however, demonstrated a
softer form of germ theory denial: germs exist and can trigger a disease,
but only if the host was in a weakened state (Benjamin, 2021). That is, if
one's terrain is imbalanced. A balanced terrain meant that germs con-
tracted generally does not result in illness and if so, symptoms would be
mild. While most participants adhered to this conception of terrain and
the origin of diseases, none referred directly to germ theory denialism.
In addition, participants believed that only those whose terrain was
already imbalanced were at risk of infectious diseases. Referring to the
COVID-19 pandemic, many said that those who had a “weak body”and a
“weakened immune system”prior to the pandemic were objects at risk.
Notwithstanding, participants generally trivialized infectious diseases
and believed vaccines were thus not needed.
3.1.3. On the trivialization of infectious diseases and the lack of need for
vaccines
With regards to their views of health and disease risks, most partici-
pants were dismissive of vaccines and those becoming dependent on
vaccines. Most believed that vaccines were not necessary because, 1)
infectious diseases were not seen so serious and, 2) naturopaths had
natural and effective means to prevent them by ensuring homeostasis of
the terrain. During the interviews, naturopaths frequently downplayed
the gravity of infectious diseases and their possible side effects. For
example, William (nutritherapy, 22 years of practice) downplayed the
risks associated with measles: “I'm not afraid of my children getting
measles. Every child in the world has had it in the past. There is a one in
100,000 chance that one will die from it”. Of note, one to three of every
1000 children infected with measles will die from complications
following the contraction of the disease (Centers for Disease Control and
Prevention, 2020).
Many participants also stated that they did not consider themselves to
be at risk of developing complications from COVID-19 or that they were
not concerned about the risks of contracting this disease because they felt
their terrain was balanced. They considered COVID-19 symptoms to be
less severe than seasonal influenza. One participant said he thought he
had contracted COVID-19 in the months prior to the interview. Given
that he had only mild discomfort for a few days, he indicated that COVID-
19 was no more serious than influenza.
Certain participants believed some infectious diseases were more
dangerous than others. They distinguished “necessary”and “unnec-
essary”infectious diseases.
There are two types of infectious diseases. There are infectious dis-
eases that we must do together [catching the disease while young].
We had measles, mumps, rubella, and chicken pox together. These are
diseases, in my opinion, that are necessary to build the immune
system. It’s not something that scares me at all. Whooping cough and
polio are not diseases that are necessary for a child’s development”
(Isabella, nutritherapy, 28 years of practice).
Even if infectious diseases were the result of a “weak terrain”, Isabella
believed some were “necessary”, especially during infancy, by allowing
the immune system to strengthen itself and contribute to maintaining the
body's homeostasis. Her perspective aligned with that of many partici-
pants who believed contracting an infectious disease allowed the im-
mune system to develop, and consequently be able to fight future
diseases. In other words, getting an infectious disease was not necessarily
viewed as something harmful or deleterious, but rather as an opportunity
to help build the immune system and ensure that the body was balanced
in the long-term.
Most participants considered vaccines to be unnecessary. They
believed if the terrain was in homeostasis, signifying high vitality (i.e.,
one's “vital force”,Table 1), there was no need for vaccines: “in a healthy
body, a vaccine is not necessary”(Audrey, nutritherapy, gemmotherapy
and phytotherapy, 2 years of practice). Strengthening the terrain natu-
rally, not vaccination, was necessary to prevent infectious diseases.
It was suggested that naturopathy practices helped consolidate the
terrain's homeostasis so that its immune system was strong enough to
fight infectious diseases. Physical activity (e.g., doing yoga, walking),
taking supplements (e.g., vitamins, probiotics, minerals, different CAM),
or good nutrition (eating fruits and vegetables) were the main practices
to prevent infectious diseases by consolidating and balancing one's
terrain.
These practices were related to the idea of a “healthy”and “natural”
lifestyle, believed to ensure a balanced terrain. This, in turn, ensures one
has sufficiently strong vitality to protect against infectious diseases:
If we take care of our body by the right means, which can be natural
or alternative, well maybe [people] will be healthier. If they stop
eating junk food and McDonald’s every three days, they might live
better in their life. They will have less chance of getting all those nasty
viruses. If they take care of themselves, they might not need the
vaccine (Ariana, nutritherapy, massage therapy and aromatherapy,
15 years of practice).
Participants considered vaccines necessary in two instances: for travel
and for those with a weakened terrain. Some participants suggested they
have to consider the contexts of infectious diseases to decide if vaccines
would be necessary. For example, Christopher (nutritherapy, 27 years of
practice) explained that if he had to go to Africa and an Ebola vaccine was
available and that he “had the chance of catching”Ebola, he would
“probably”get vaccinated. He further explained not having vaccinated
his children—except his oldest who received one vaccine and after
allegedly suffered from eczema and bronchospasm—because he believed
there were no risks of infectious diseases, such as measles, mumps,
rubella, or chicken pox given Quebec's health conditions. Jennifer
(aromatherapy, gemmotherapy, phytotherapy, homeopathy and hydro-
therapy, 11 years of practice) had a similar stance and argued that in
Africa or South America there is a “real risk of infectious diseases”,
exemplifying yellow fever, malaria, and cholera. With these diseases, she
believed vaccines would be necessary. She further explained that
essential oils and plants could also offer some protection in this case.
Other participants considered those with a weakened terrain, especially
the elderly or chronically ill people, to be more at risk of infectious dis-
eases who would benefit from the protection offered from vaccination.
A majority of participants viewed COVID-19 vaccination as unnec-
essary because the practices they follow or recommend created a
balanced terrain. For example, Ariana (nutritherapy, massage therapy
and aromatherapy, 15 years of practice) explained that she had used
CAM for over 30 years and almost never caught influenza or a cold. If she
did, it was very brief. This personal experience led her to believe vaccines
were hardly necessary. Since participants also viewed COVID-19 as not
serious and nothing more than a “bad flu”, they did not see any point in
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
6

getting vaccinated (Emilia, nutritherapy, 11 years of practice). However,
the two naturopaths who believed vaccines were necessary did so
because they saw that infectious diseases presented greater risk than
vaccines. One specified that he trusted vaccines only if “their safety has
been demonstrated over a long period of time”(Ben, nutritherapy, 23
years of practice). For this reason, he mentioned he would not get
vaccinated against COVID-19 until its safety has been proven.
Some participants believed vaccination was a form of abdicating in-
dividual responsibilities. While the chronically ill and elderly were not
necessarily seen as responsible for their misfortune, the same could not
be said about others with weakened terrains due to “unhealthy habits”.
For instance, some naturopaths disagreed with the way the government
and public health positioned vaccination as a collective responsibility.
They believed that if people had more “healthy lifestyles”(i.e., balanced
diet, regular physical activity, etc.), their terrain would be strong enough
to combat infectious diseases and they would not need vaccines, which
were seen as highly risky as unnatural.
3.2. The construction of vaccination as a risk object
While participants trivialized the risks of infectious diseases, they
portrayed vaccines as an important risk object. They believed that vac-
cines triggered strong imbalances of the terrain. They viewed vaccines as
breaking this equilibrium and “corrupt the immune system”as Sarah
([approach confidential respecting participant's request], 27 years of
practice) put it. Once the equilibrium was broken, the terrain could
sustain lasting damages.
3.2.1. On the unnaturalness of vaccines and its repercussions on the terrain
Most participants viewed vaccines as an “unnatural”or “artificial”
means of immune system building, in distinct contrast to immunity
developed after infection. Since naturopaths “trust nature above every-
thing else”, they did not “see any point in putting these chemicals”in
their body (Jordan, nutritherapy, 8 years of practice). Isaac explained
vaccines were unnatural because they were “made in a lab”:
The ingredients are made in a lab, so they are synthetic. The fact that
my body is alive, the fact that I put synthetic in it …living cells don’t
recognize what is synthetic (Isaac, nutritherapy, phytotherapy and
hydrotherapy, 3 years of practice).
While almost all the participants considered vaccines dangerous, they
generally agreed the main issue with vaccines were adjuvants, as Sarah
(27 years of practice) explained, “vaccines might be acceptable, but it is
the sauce, the sauce in which the attenuated virus or bacteria are
bathed”. Adjuvants were presumed to contain unsafe “dangerous sub-
stances”, such as formaldehyde or heavy metals. According to partici-
pants, mercury and aluminum threatened one's health by “reducing the
vitality of the [person] receiving the vaccine”(Isaac, nutritherapy, phy-
totherapy and hydrotherapy, 3 years of practice).
For most, injecting metals into the bloodstream “is not part of a
healthy lifestyle”and created imbalances in the terrain (Olivia, nutri-
therapy and phytotherapy, 4 years of practice). Emilia (nutritherapy, 11
years of practice) argued naturopaths do everything in their power “to
drain those heavy metals out of the organism”and they “do not want to
have them voluntarily injected into the organism and the bloodstream”
as they threatened homeostasis of the terrain. For whole pathogen vac-
cines, one participant (Anna, nutritherapy and phytotherapy, 10 years of
practice) mentioned that “it is not the natural way someone would have
contracted a virus”. Some participants also emphasized the partial nature
of scientific knowledge and asserted that the long-term effects of vaccines
on innate immunity and terrain integrity are not sufficiently known.
Many participants feared vaccines were the cause of many harms,
some of which were recognized as very rare adverse events following
immunization by the medical community (e.g., Guillain-Barr
e Syndrome
or Bell's Palsy) and some that were not recognized as potential adverse
events (Mantadakis et al., 2010). For example, Ariana (nutritherapy,
massage therapy and aromatherapy, 15 years of practice) thought vac-
cines caused serious nerve damage since some of her clients believed they
had those adverse events. She stated that after vaccination, some people,
especially people with autoimmune conditions, were at increased risk to
develop diseases during their life. Some participants stated there was a
relationship between the increasing number of vaccines given to children
and the increase of autoimmune disease diagnosis in recent years. While
they agreed links between vaccines and those long-term diseases were
often disregarded by the scientific community, many reported observing
in their practice that vaccines caused long-term damage. This led par-
ticipants to deploy risk management strategies towards vaccines.
3.2.2. Vaccination risk management strategies
Two types of strategies were used by participants and recommended
to clients to manage perceived vaccine risks. First, if vaccines were
accepted or wanted, practices were deployed to manage risks. If a client
decided to get vaccinated, participants said it was necessary to strengthen
the immune system, that is, “preparing the terrain”before the vaccine to
limit its negative impacts. Strengthening the immune system meant
making sure the terrain did not have any nutritional deficiencies, for
example. If there were deficiencies, supplements were suggested: “If they
ever decide to take the vaccine, for example, I tell them they'll need to
take a lot of vitamin C and D. I give them other choices to offset [the
negative effects of vaccines]”(Ariana, nutritherapy, massage therapy and
aromatherapy, 15 years of practice). Some participants also suggested
practices after the vaccine to purify the body and bring it back to its
homeostatic state. One proposed practice aimed at stimulating the body's
vitality so that the terrain could clean itself and return to its homeostatic
state. To achieve this, some participants suggested taking supplements or
essential oils. Some also suggested that homeopathy could help the body
after the vaccine.
Second, a majority of participants believed the best risk management
strategy regarding vaccines was simply to not take them, because there
were other options more natural to protect oneself against infectious
diseases. Indeed, participants believed the practices they deployed were
efficient against infectious diseases. They saw no point in getting or
suggesting vaccines when the terrain was balanced.
4. Discussion
We used Boholm and Corvellec's (2011) relational theory of risk to
explore how Quebec naturopaths viewed health, vaccination, and in-
fectious diseases. Our findings illustrate naturopaths constructing the
body-environment circuit as a terrain that is an “object at risk”that must
be well-protected. Vaccines were depicted as risk objects that could
highly disrupt the homeostasis of the terrain. Participants suggested
vaccines were a source of multiple tangible harms; some are recognized
as adverse events by the biomedical community as related to certain
vaccines while others are not (DeStefano &Shimabukuro, 2019;Man-
tadakis et al., 2010). Uncertainties surrounding vaccines were also a
source of anxiety among naturopaths who stated that it was impossible to
know the long-term damage of vaccines on the terrain. Many studies
previously highlight how these concerns are positively related with
negative vaccine attitudes (Greyson &Bettinger, 2022;Helps et al., 2019;
Paterson et al., 2018) and lower vaccine uptake rates (Dub
e et al., 2021;
Karafillakis et al., 2021;Kilich et al., 2020).
Our findings illustrate Quebec naturopaths believed that homeostasis
of the terrain, which is thought to protect against infectious diseases,
must be achieved through natural methods, such as nutritherapy, phy-
totherapy or general lifestyle behaviours. The naturopaths interviewed
ascribed intrinsic value to balancing the body through natural means.
Vaccines were seen as a manufactured risk along similar lines as air
pollution, genetic modified organisms, etc. Their lack of safety was
constructed primarily in terms of their “unnaturalness”and “artificial-
ness.”Our findings align with the results of Connor (2004) and Reich
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
7

(2016) who pointed out that vaccine refusal can sometimes be associated
with a dichotomy between the natural and the artificial.
Through 111 semi-structured interviews and focus groups with Aus-
tralians, Conor found symbolic value attached to what is natural (Connor,
2004). The intrinsic value of being natural associated to biomedical
therapies that hold “diffuse forms of disability and malaise that are often
associated with environmental pollution and other threats of modern
life”(Connor, 2004, p. 1699). Her research suggests these therapies act as
a defensive response to a risk society in which manufactured risks and
scientific uncertainties were prominent. Manufactured risks are “created
by the very profession of human development, especially by the pro-
gression of science and technology”(Giddens, 1999, p. 4). In this way,
vaccines are manufactured risks.
Reich and colleagues (2016) did a qualitative study of parents, pe-
diatricians, and CAM providers who oppose vaccines, showing that they
construct children as “naturally perfect”and “in need of protection”
(Reich, 2016, p. 104). Parents saw vaccines as an artificial substance that
entered the body unnaturally through injection, and that immunity ac-
quired naturally from infection was better than immunity derived from
vaccination, which was seen as dangerous (Reich, 2016). Finally, her
participants believed a natural lifestyle was sufficient to protect children
against infectious diseases.
Our results also underline that when vaccines were accepted by their
clients, there was a felt need to manage this risk, so their possible dele-
terious effects were counterbalanced. This finding aligns with Douglas'
conceptualization of purity and danger, where dirt is contingent, as well
as the way to manage it (Douglas, 1984). In our study, participants
considered that vaccines were dirt—in Douglas' sense—that needed to be
avoided at all costs. When this dirt was unavoidable and someone
decided to take the vaccine, study participants suggested ritual practices
before and after the vaccine which were intended to manage its inherent
risks. In a way, eliminating vaccines was not “a negative movement, but a
positive effort to organize the environment”(Douglas, 1984, p. 2). All
health practices deployed by the Quebec naturopaths in our study were
intended to balance their clients’terrain, to “organize the environment”.
While vaccines could be considered dirt, this did not apply to infectious
diseases. Indeed, many participants neither feared infectious diseases nor
think they posed any kind of risk if the terrain was balanced. As Douglas
stated, even if dirt is normally destructive, it can also become creative
(Douglas, 1984). Indeed, while infectious diseases are usually repre-
sented as risky or dangerous (Eicher &Bangerter, 2015), participants in
our study did not think they posed important harm. Some even believed
infectious diseases could help consolidate the terrain and protect against
future diseases. Hence, infectious diseases become a creative dirt.
Our findings suggest that Quebec naturopaths' terrain are closely
linked with neoliberal ideology (Brown, 2019). Some participants dis-
agreed with public health's emphasis on collective responsibility for
vaccination. They believed that everyone should be responsible for their
own terrain and that those with an unbalanced terrain because of their
unhealthy behaviours (eating junk food, not being physically active, etc.)
are irresponsible. We have already highlighted the neoliberal features of
CAM (Ning, 2018) and many scholars describe CAM seeing care through
an individualized approach where individuals can be held responsible for
their own health (Givati, 2015;Ning, 2013;Sered &Agigian, 2008). This
perspective does not value the many other social determinants of health
and the structural inequities in which people can be trapped (Krieger,
2014). In Quebec, where naturopathy is not publicly funded, access is not
possible without financial means.
It is necessary to situate our findings in Quebec naturopathy's specific
sociohistorical context. Quebec naturopathy is heavily fragmented,
whether in terms of schools, educational curriculum, professional asso-
ciations, or practices. Even if some participants were more akin to North
America approaches to naturopathy (i.e., alignment with biomedical
principles such as germ theory), many were not (i.e., a soft denial of germ
theory). As Boon highlighted, there is a clash between naturopaths with
“scientific world views”anchored in evidence-based medicine and those
with “holistic world views”rooted in their own intuition and experiential
knowledge (Boon, 1998). This complex relationship of CAM with
evidence-based medicine has been described by others (Embong et al.,
2015;Pedersen &Baarts, 2010).
Finally, our results reinforce findings of previous studies on the
complex relationships between vaccine hesitancy and CAM and highlight
how sociocultural contexts and discourses shape vaccine hesitancy and
CAM (Bryden et al., 2018;Dub
e et al., 2021). Furthermore, as CAM
evolve in different regulatory settings and different power relationships
with the state or biomedicine, it is necessary to take into account these
political, economic and legal contexts when making statements about
CAM and vaccination (Almeida &Gabe, 2016;Green &Colucci, 2020;
Jansen, 2016;Simchai &Keshet, 2016;Uibu, 2021). Such perspective
gives insights into the underpinning logics of vaccine hesitancy among
CAM practitioners and users and avoid abusive generalizations.
This study is not without limitations. Quebec naturopaths are un-
regulated, unlike those practicing in many Canadian provinces. However,
our results are representative of Quebec naturopathy diversity in terms of
type of practice, training background, and affiliation with professionals'
associations. Our initial intention to conduct an ethnography of naturo-
paths’practice settings was not possible given COVID-19 containment
measures, and many interviews were conducted virtually, again due to
the pandemic. Although this could have impacted the interviewee-
interviewer dynamic, the pandemic has drastically changed how peo-
ple communicate and made virtual interviews much less “unfamiliar”
and “unwieldy”.
5. Conclusion
In line with others (Busse et al., 2008;Filice et al., 2020;McMurtry
et al., 2015), our qualitative study of Quebec naturopaths showed sig-
nificant reluctance or opposition to vaccination. Naturopaths saw the
terrain as an object at risk that must be protected naturally as vaccines
were seen threats due to their artificialness. Although these attitudes
could be viewed as unscientific or even irrational, they make sense when
situated within naturopathic understandings about conceptions of
health, their representations of risks, and their relationship with multiple
kinds of evidence. Future research is needed to study how naturopaths’
attitudes on vaccination guide the way vaccines are discussed during
consultations and whether they introduce or reinforce vaccine hesitancy.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
The authors wish to thank the research assistants who have helped
transcribing the interviews: Ang
ele Larivi
ere, Camille Laflamme, Cath-
erine Pelletier, and Morgan Turgeon. We also want to thank the natu-
ropaths who participated in our study. This work was supported by the
Social Sciences and Humanities Research Council of Canada [grant
number 435-2018-1427, 2018].
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ssmqr.2022.100203.
References
Alexander, F. (1965). Psychosomatic medicine: Its principles and applications. W W Norton &
Co Inc.
Almeida, J., & Gabe, J. (2016). CAM within a field force of countervailing powers: The
case of Portugal. Social Science &Medicine, 155,73–81.
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
8

Andrianne, P., & Leunis, J. C. (2008). Les bases de la prescription en gemmoth
erapie :
Param
etres biologiques s
eriques et phytosociologie. Phytoth
erapie, 6, 301–305.
Angus, D. E. (1998). Health care costs: Canada in perspective. In D. Coburn, C. D'Arcy, &
G. Murray (Eds.), Health and Canadian society: Sociological perspective. Toronto:
University of Toronto Press.
Attwell, K., Ward, P. R., Meyer, S. B., Rokkas, P. J., & Leask, J. (2018). Do-it-yourself”:
Vaccine rejection and complementary and alternative medicine (CAM). Social Science
&Medicine, 196, 106–114.
Baer, H. A. (2001a). Biomedicine and alternative healing systems in America: Issues of class,
race, ethnicity, and gender. United States: University of Wisconsin Press.
Baer, H. A. (2001b). The sociopolitical status of U.S. Naturopathy at the dawn of the 21st
century. Medical Anthropology Quarterty, 15, 329–346.
Beck, U. (1992). Risk society: Towards a new modernity. SAGE Publications.
Benjamin, E. (2021). Germ theory denial, anti-vaccination and COVID-19. Journal of Brain
Research, 4.
Bischoff-Ferrari, H. (2009). Validated treatments and therapeutic perspectives regarding
nutritherapy. JNHA-The Journal of Nutrition, Health and Aging, 13, 737–741.
Boholm, Å., & Corvellec, H. (2011). A relational theory of risk. Journal of Risk Research,
14, 175–190.
Boon, H. (1998). Canadian naturopathic practitioners: Holistic and scientific world views.
Social Science &Medicine, 46, 1213–1225.
Brosnan, C., Vuolanto, P., & Brodin Danell, J.-A. (2018). Introduction: Reconceptualising
complementary and alternative medicine as knowledge production and social
transformation. In C. Brosnan, P. Vuolanto, & J.-A. Brodin Danell (Eds.),
Complementary and alternative medicine : Knowledge production and social
transformation. Palgrave Macmillan.
Brown, W. (2019). In the ruins of neoliberalism. New York: Columbia University Press.
Bryden, G. M., Browne, M., Rockloff, M., & Unsworth, C. (2018). Anti-vaccination and
pro-CAM attitudes both reflect magical beliefs about health. Vaccine, 36, 1227–1234.
Burr, V. (2015). Social constructionism. Routledge.
Burstr€
om, B., & Tao, W. (2020). Social determinants of health and inequalities in COVID-
19. The European Journal of Public Health, 30, 617–618.
Burton-Jeangros, C. (2004). Cultures familiales du risque: Anthropos.
Busse, J. W., Wilson, K., & Campbell, J. B. (2008). Attitudes towards vaccination among
chiropractic and naturopathic students. Vaccine, 26, 6237–6243.
CAND. (2022a). About naturopathic medicine.https://www.cand.ca/about-naturopathic-
medicine/. (Accessed 15 August 2022).
CAND. (2022b). Common questions : Education and regulation.https://www.cand.ca/comm
on-questions-education-and-regulation/. (Accessed 10 September 2022).
CAND. (2022c). History of naturopathic medicine.https://www.cand.ca/history-of-nat
uropathic-medicine/. (Accessed 16 August 2022).
Centers for Disease Control and Prevention. (2020). Complications of measles.http
s://www.cdc.gov/measles/symptoms/complications.html#:~:text¼Measles%20can
%20be%20serious.,complications%20include%20pneumonia%20and%20encephal
itis. (Accessed 20 September 2022).
Coakley, A. B., & Barron, A.-M. (2012). Energy therapies in oncology nursing. Seminars in
Oncology Nursing, 28,55–63.
Connor, L. H. (2004). Relief, risk and renewal: Mixed therapy regimens in an Australian
suburb. Social Science &Medicine, 59, 1695–1705.
Cooke, B., & Ernst, E. (2000). Aromatherapy: A systematic review. British Journal of
General Practice, 50, 493–496.
Deml, M. J., Jafflin, K., Merten, S., Huber, B., Buhl, A., Frau, E., et al. (2019).
Determinants of vaccine hesitancy in Switzerland: Study protocol of a mixed-methods
national research programme. BMJ Open, 9, Article e032218.
Deml, M. J., Notter, J., Kliem, P., Buhl, A., Huber, B. M., Pfeiffer, C., et al. (2019). We
treat humans, not herds!”: A qualitative study of complementary and alternative
medicine (CAM) providers' individualized approaches to vaccination in Switzerland.
Social Science &Medicine, 240,1–10.
DeStefano, F., & Shimabukuro, T. T. (2019). The MMR vaccine and autism. Annual review
of virology, 6, 585.
Ditlevsen, K., & Andersen, S. S. (2020). The purity of dirt: Revisiting mary Douglas in the
light of contemporary consumer interpretations of naturalness, purity and dirt.
Sociology, 55, 179–196.
Douglas, M. (1984). Purity and danger: An analysis of concepts of pollution and taboo.
Douglas, M. (1994). Risk and blame: Essays in cultural theory. Londres: Routledge.
Douglas, M., & Wildavsky, A. (1982). Risk and culture: An essay on the selection of
technological and environmental dangers. University of California Press.
Dub
e, E., Labbe, F., Malo, B., Manca, T., Aylsworth, L., Driedger, S. M., et al. (2022).
I don't think there's a point for me to discuss it with my patients": Exploring health care
providers' views and behaviours regarding COVID-19 vaccination. Hum Vaccin
Immunother, Article 2088970.
Dub
e, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. (2013). Vaccine
hesitancy: An overview. Human Vaccines &Immunotherapeutics, 9, 1763–1773.
Dub
e, E., Sauvageau, C., & Gagnon, D. (2017). Vaccine hesitancy and the use of
complementary and alternative medicine. In P. Bramadat, M. Guay, J. A. Bettinger, &
R. Roy (Eds.), Public health in the age of anxiety: Religious and cultural roots of vaccine
hesitancy in Canada. Toronto: University of Toronto Press.
Dub
e, E., Vivion, M., & MacDonald, N. E. (2015). Vaccine hesitancy, vaccine refusal and
the anti-vaccine movement: Influence, impact and implications. Expert Rev Vaccines,
14,99–117.
Dub
e, E., Vivion, M., & MacDonald, N. E. (2015). Vaccine hesitancy, vaccine refusal and
the anti-vaccine movement: Influence, impact and implications. Expert Review of
Vaccines, 14,99–117.
Dub
e, E., Ward, J. K., Verger, P., & MacDonald, N. E. (2021). Vaccine hesitancy,
acceptance, and anti-vaccination: Trends and future prospects for public health.
Annual Review of Public Health, 42, 175–191.
Dumont, V. (2010). Introduction - du d
ebat sur la place des logiciels dans l’analyse de
donn
ees qualitatives. Recherches qualitatives, 9,1–14.
Ebi, S. J., Deml, M. J., Jafflin, K., Buhl, A., Engel, R., Picker, J., et al. (2022). Parents'
vaccination information seeking, satisfaction with and trust in medical providers in
Switzerland: A mixed-methods study. BMJ Open, 12, Article e053267.
Eicher, V., & Bangerter, A. (2015). Social representations of infectious diseases. In
G. Sammut, E. Andreouli, & G. Gaskell (Eds.), Handbook of social representations.
Cambridge: Cambridge University Press.
Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel, S., Wilkey, S., Rompay, M. V., et al.
(1998). Trends in alternative medicine use in the United States, 1990-1997: Results
of a follow-up national survey. JAMA, 280, 1569–1575.
Embong, N. H., Soh, Y. C., Ming, L. C., & Wong, T. W. (2015). Revisiting reflexology:
Concept, evidence, current practice, and practitioner training. Journal of Traditional
and Complementary Medicine, 5, 197–206.
Ernst, E. (1999). Iridology: A systematic review. Forschende Komplement€
armedizin, 6,7–9.
Ernst, E. (2003). The safety of massage therapy. Rheumatology, 42, 1101–1106.
Esmail, N. (2017). Complementary and alternative medicine: Use and public attitudes 1997,
2006 (Vol. 2016). Fraser Institute.
Filice, E., Dub
e, E., Graham, J. E., MacDonald, N. E., Bettinger, J. A., Greyson, D., et al.
(2020). Vaccination discourses among chiropractors, naturopaths and homeopaths: A
qualitative content analysis of academic literature and Canadian organizational
webpages. PLoS One, 15, Article e0236691.
Fisher, P. (2012). What is homeopathy? An introduction. Frontiers in Bioscience-Elite, 4,
1669–1682.
Fossey, E., Harvey, C., McDermott, F., & Davidson, L. (2002). Understanding and
evaluating qualitative research. Australian and New Zealand Journal of Psychiatry, 36,
717–732.
Gale, N. (2014). The sociology of traditional, complementary and alternative medicine.
Sociology compass, 8, 805–822.
Giddens, A. (1994). Risk, trust, reflexivity. In U. Beck, A. Giddens, & S. Lash (Eds.),
Reflexive modernization: Politics, tradition, and aesthetics is the modern social order (pp.
184–199). Cambridge: Polity Press.
Giddens, A. (1999). Risk and responsibility. The Modern Law Review, 62,1–10.
Givati, A. (2015). Performing ‘pragmatic holism’: Professionalisation and the holistic
discourse of non-medically qualified acupuncturists and homeopaths in the United
Kingdom. Health, 19,34–50.
Gort, E. H., & Coburn, D. (1988). Naturopathy in Canada: Changing relationships to
medicine, chiropractic and the state. Social Science &Medicine, 26, 1061–1072.
Green, B., & Colucci, E. (2020). Traditional healers' and biomedical practitioners'
perceptions of collaborative mental healthcare in low- and middle-income countries:
A systematic review. Transcultural Psychiatry, 57,94–107.
Greyson, D., & Bettinger, J. A. (2022). How do mothers' vaccine attitudes change over
time? SSM—Qualitative Research in Health, 2.
Guattari, F., & Deleuze, G. (1987). A thousand plateaus: Capitalism and schizophrenia.
Minneapolis: University of Minnesota Press.
Guest, G. (2014). Sampling and selecting participants in field research. In R. Bernard, &
C. C. Gravlee (Eds.), Handbook of methods in cultural anthropology. Londres: Rowman
et Littlefield.
Heinrich, M., Williamson, E. M., Gibbons, S., Barnes, J., & Prieto-Garcia, J. (2017).
Fundamentals of pharmacognosy and phytotherapy. Elsevier Health Sciences.
Helps, C., Leask, J., Barclay, L., & Carter, S. (2019). Understanding non-vaccinating
parents' views to inform and improve clinical encounters: A qualitative study in an
Australian community. BMJ Open, 9, Article e026299.
Hilgartner, S. (1992). The social construction of risk objects: Or, how to pry open
networks of risk. In J. Shorts, & L. Clark (Eds.), Organizations, uncertainties, and risk.
Boulder: Westview.
Hornsey, M. J., Lobera, J., & Diaz-Catalan, C. (2020). Vaccine hesitancy is strongly
associated with distrust of conventional medicine, and only weakly associated with
trust in alternative medicine. Social Science &Medicine, 255, Article 113019.
Jansen, E. (2016). Naturopathy in South India : Clinics between professionalization and
empowerment.
Jones, L., Sciamanna, C., & Lehman, E. (2010). Are those who use specific complementary
and alternative medicine therapies less likely to be immunized? Preventive Medicine,
50, 148–154.
Karafillakis, E., Francis, M. R., Paterson, P., & Larson, H. J. (2021). Trust, emotions and
risks: Pregnant women's perceptions, confidence and decision-making practices
around maternal vaccination in France. Vaccine, 39, 4117–4125.
Kilich, E., Dada, S., Francis, M. R., Tazare, J., Chico, R. M., Paterson, P., et al. (2020).
Factors that influence vaccination decision-making among pregnant women: A
systematic review and meta-analysis. PLoS One, 15, Article e0234827.
Krieger, N. (2014). Discrimination and health inequities. International Journal of Health
Services, 44, 643–710.
Lee, C., Whetten, K., Omer, S., Pan, W., & Salmon, D. (2016). Hurdles to herd immunity:
Distrust of government and vaccine refusal in the US, 2002–2003. Vaccine, 34,
3972–3978.
Lock, M., & Nguyen, V. K. (2010). An anthropology of biomedicine. Singapore: Blackwell
Publishing.
MacDonald, N. E., & Dub
e, E. (2015). Unpacking vaccine hesitancy among healthcare
providers. EBioMedicine, 2, 792–793.
MacDonald, N. E., Dub
e, E., & Comeau, J. L. (2022). Have vaccine hesitancy models
oversimplified a complex problem to our detriment? The adapted royal society of
Canada vaccine uptake framework. Vaccine, 40, 3927–3930.
Mantadakis, E., Farmaki, E., & Buchanan, G. R. (2010). Thrombocytopenic purpura after
measles-mumps-rubella vaccination: A systematic review of the literature and
guidance for management. The Journal of Pediatrics, 156, 623–628.
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
9

Martel, P. (2015). Le cadre juridique des m
edecines douces. International Review of
Community Development.
McMurtry, A., Wilson, K., Clarkin, C., Walji, R., Kilian, B. C., Kilian, C. C., et al. (2015).
The development of vaccination perspectives among chiropractic, naturopathic and
medical students: A case study of professional enculturation. Advances in Health
Sciences Education, 20, 1291–1302.
Mooventhan, A., & Nivethitha, L. (2014). Scientific evidence-based effects of
hydrotherapy on various systems of the body. North American Journal of Medical
Sciences, 6, 199–209.
National Center for Complementary, Integrative Health. (2021). Complementary,
alternative, or integrative health: What's in a name?.https://nccih.nih.gov/health/i
ntegrative-health. (Accessed 15 September 2022).
Nelson, D. H., Perchaluk, J. M., Logan, A. C., & Katzman, M. A. (2019). The Bell tolls for
homeopathy: Time for change in the training and practice of North American
naturopathic physicians. Journal of Evidence-Based Integrative Medicine, 24,1–11.
Ning, A. (2013). How ‘alternative’is CAM? Rethinking conventional dichotomies
between biomedicine and complementary/alternative medicine. Health: An
Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 17,
135–158.
Ning, A. (2018). How holistic is complementary and alternative medicine (CAM)?
Examining self-responsibilization in CAM and biomedicine in a neoliberal age.
Medical Research Archives, 6,1–11.
Nurmi, J., & Harman, B. (2021). Why do parents refuse childhood vaccination? Reasons
reported in Finland. Scandinavian Journal of Public Health, 50, 490–496.
Owens, K. (2015). Boundary objects in complementary and alternative medicine:
Acupuncture vs. Christian science. Social Science &Medicine, 128,18–24.
Paill
e, P., & Mucchielli, A. (2016). L'analyse qualitative en sciences humaines et sociales - 4e

ed. Domont: Armand Colin.
Paterson, P., Chantler, T., & Larson, H. J. (2018). Reasons for non-vaccination: Parental
vaccine hesitancy and the childhood influenza vaccination school pilot programme in
England. Vaccine, 36, 5397–5401.
Pedersen, I. K., & Baarts, C. (2010). ‘Fantastic hands’—but no evidence: The construction
of expertise by users of CAM. Social Science &Medicine, 71, 1068–1075.
Penkala-Gawecka, D. (2016). Risky encounters with doctors? Medical diversity and
health-related strategies of the inhabitants of bishkek, Kyrgyzstan. Anthropology &
Medicine, 23, 135–154.
Reich, J. A. (2016). Of natural bodies and antibodies: Parents' vaccine refusal and the
dichotomies of natural and artificial. Social Science &Medicine, 157, 103–110.
Riddle, J. M. (1970). Lithotherapy in the middle ages...: Lapidaries considered as medical
texts. Pharmacy in History, 12,39–50.
RITMA. (2020). Les 
ecoles reconnues.https://www.ritma.ca/les-ecoles-reconnues.php?
Classement¼1&Filtres[ ]¼2. (Accessed 30 March 2021).
de Sardan, J.-P. O. (2000). Le "je" m
ethodologique: Implication et explicitation dans
l'enqu^
ete de terrain. Revue Française de Sociologie, 41, 417.
Sered, S., & Agigian, A. (2008). Holistic sickening: Breast cancer and the discursive
worlds of complementary and alternative practitioners. Sociology of Health &Illness,
30, 616–631.
Simchai, D., & Keshet, Y. (2016). New Age in Israel: Formative ethos, identity blindness,
and implications for healthcare. Health (London), 20, 635–652.
Soveri, A., Karlsson, L. C., Antfolk, J., Lindfelt, M., & Lewandowsky, S. (2021).
Unwillingness to engage in behaviors that protect against COVID-19: The role of
conspiracy beliefs, trust, and endorsement of complementary and alternative
medicine. BMC Public Health, 21, 684.
Suissa, V., Castillo, M. C., & Blanchet, A. (2016). Le recours aux m
edecines
compl
ementaires et alternatives (MCA) face aux incertitudes de la m
edecine
allopathique. Psycho-Oncologie, 10, 272–280.
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative
research (COREQ): A 32-item checklist for interviews and focus groups. International
Journal for Quality in Health Care, 19, 349–357.
Trebilcock, M. J., & Mahadevia Ghimire, K. (2019). Regulating alternative medicines:
Disorder in the borderlands. C.D. HOWE Institute.
Uibu, M. (2021). The emergence of new medical pluralism: The case study of Estonian
medical doctor and spiritual teacher luule Viilma. Anthropology &Medicine, 28,
445–460.
Wahlberg, A. (2007). A quackery with a difference—new medical pluralism and the
problem of ‘dangerous practitioners’in the United Kingdom. Social Science &
Medicine, 65, 2307–2316.
Wang, M. Y., Tsai, P. S., Lee, P. H., Chang, W. Y., & Yang, C. M. (2008). The efficacy of
reflexology: Systematic review. Journal of Advanced Nursing, 62, 512–520.
Wardle, J., Frawley, J., Steel, A., & Sullivan, E. (2016). Complementary medicine and
childhood immunisation: A critical review. Vaccine, 34, 4484–4500.
Wiesener, S., Falkenberg, T., Hegyi, G., H€
ok, J., di Sarsina, P. R., & Fønnebø, V. (2012).
Legal status and regulation of complementary and alternative medicine in Europe.
Complementary Medicine Research, 19,29–36.
Wiesener, S., Falkenberg, T., Hegyi, G., H€
ok, J., Roberti di Sarsina, P., & Fønnebø,V.
(2012). Legal status and regulation of CAM in Europe. Part I—CAM regulations in the
European countries. In V. Fønnebø(Ed.), Final report of CAMbrella work package (Vol.
2, p. 314) (Norway).
Wilson, K., Mills, E., Boon, H., Tomlinson, G., & Ritvo, P. (2004). A survey of attitudes
towards paediatric vaccinations amongst Canadian naturopathic students. Vaccine,
22, 329–334.
World Naturopathic Federation. (2017). WNF white paper: Naturopathic philosophies,
principles and theories. Canada.
Yaqub, O., Castle-Clarke, S., Sevdalis, N., & Chataway, J. (2014). Attitudes to vaccination:
A critical review. Social Science &Medicine, 112,1
–11.
Yazdannik, A., Yousefy, A., & Mohammadi, S. (2017). Discourse analysis: A useful
methodology for health-care system researches. Journal of Education and Health
Promotion, 6.
Zinn, J. O. (2004). Literature review: Sociology and risk. Social Contexts and Responses to
Risk Network (SCARR)—Working Paper, 1,1–25.
B. Malo et al. SSM - Qualitative Research in Health 3 (2023) 100203
10