European Journal of Cardiovascular Medicine

Vaccination remains one of the most cost-effective public health interventions, significantly reducing morbidity and mortality associated with vaccine-preventable diseases in children under five years of age (1). Despite the global success of immunization programs, vaccine hesitancy—a delay in acceptance or refusal of vaccines despite availability—has emerged as a major public health challenge (2). The World Health Organization (WHO) has identified vaccine hesitancy as one of the top ten threats to global health (3).

In India, the Universal Immunization Programme (UIP) aims to provide free vaccines to all children; however, full immunization coverage still varies considerably across regions and populations (4). Semi-urban areas, often characterized by a blend of rural traditions and urban influences, represent a unique demographic where vaccine-related attitudes and practices can be complex (5). Studies have shown that caregivers’ decisions regarding childhood vaccinations are influenced by a range of factors including educational status, cultural beliefs, misinformation, and mistrust in health systems (6,7).

Understanding vaccine hesitancy in such contexts is essential for designing targeted interventions that can improve vaccine uptake and address barriers effectively. This study was undertaken to assess the prevalence of vaccine hesitancy among caregivers of children under five years in semi-urban areas and to explore the underlying reasons through a mixed-methods approach

This study employed a mixed-methods design, combining both quantitative and qualitative approaches to gain a comprehensive understanding of vaccine hesitancy among caregivers. The research was carried out over a six-month period in selected semi-urban regions.

Study Population and Sampling
Caregivers of children aged 0–5 years were the target population. A total of 250 participants were recruited using purposive sampling from community health centers, anganwadi centers, and immunization outreach clinics. Inclusion criteria included caregivers who were the primary decision-makers for the child’s healthcare and who consented to participate. Individuals unable to communicate effectively due to language barriers or mental disability were excluded.

Quantitative Data Collection
A structured questionnaire was administered face-to-face by trained interviewers. The questionnaire included items on demographic details, immunization history, knowledge about vaccines, attitudes, and reasons for hesitancy. The tool was pre-tested on a sample of 20 participants to ensure clarity and reliability.

Qualitative Data Collection
To explore deeper insights into vaccine hesitancy, in-depth interviews were conducted with 20 caregivers who expressed reluctance or refusal regarding childhood immunization. A semi-structured interview guide was used, and each interview lasted approximately 30–45 minutes. All interviews were audio-recorded with consent and later transcribed verbatim.

Data Analysis
Quantitative data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics such as frequencies and percentages were used to summarize the data. Chi-square tests were used to assess associations between demographic variables and vaccine hesitancy, with a p-value <0.05 considered statistically significant. Qualitative data were analyzed using thematic analysis. Two independent researchers coded the transcripts, and emerging themes were discussed and finalized through consensus.

A total of 250 caregivers participated in the study. The mean age of caregivers was 29.4 ± 5.6 years. Majority were mothers (82%), followed by fathers (13.6%) and grandparents (4.4%). Most respondents belonged to lower-middle socioeconomic status (56%) and had completed secondary education (48%).

Out of the total participants, 62 caregivers (24.8%) were categorized as vaccine-hesitant. The remaining 188 caregivers (75.2%) had no hesitancy and followed the complete immunization schedule for their children.

Socio-demographic Factors and Vaccine Hesitancy

Table 1 presents the association between socio-demographic variables and vaccine hesitancy. A statistically significant association was found between lower maternal education and vaccine hesitancy (p = 0.003). Similarly, caregivers belonging to lower socioeconomic status were more likely to be hesitant (p = 0.018).

Table 1: Association between Socio-demographic Characteristics and Vaccine Hesitancy

*Significant at p < 0.05

Reasons for Vaccine Hesitancy

As shown in Table 2, the most frequently cited reasons for hesitancy included fear of side effects (42%), mistrust in vaccine efficacy (28%), and lack of proper knowledge or awareness (19%). A small proportion (6%) reported religious or cultural beliefs as barriers, while others mentioned logistical issues such as clinic distance or vaccine availability (5%).

Table 2: Reasons for Vaccine Hesitancy among Respondents (n = 62)

Qualitative Findings

Thematic analysis of in-depth interviews with 20 vaccine-hesitant caregivers revealed three major themes: (1) Concerns about vaccine safety and side effects, (2) Influence of peer and family advice against vaccination, and (3) Perceived inadequacy of counseling by healthcare workers. Several participants reported receiving conflicting information from social media, contributing to fear and confusion regarding childhood immunization.

These findings suggest that improving health education and strengthening interpersonal communication between healthcare providers and caregivers can significantly help mitigate vaccine hesitancy.

This mixed-methods study assessed the prevalence and underlying causes of vaccine hesitancy among caregivers of children under five years in semi-urban areas. The findings revealed that nearly one in four caregivers demonstrated some form of hesitancy toward childhood immunization. This aligns with similar studies conducted in various parts of India and other low- and middle-income countries (1,2).

One of the key findings was the significant association between maternal education and vaccine hesitancy. Caregivers with lower levels of education were more likely to harbor concerns or reject immunization, which has been corroborated in previous studies (3,4). Education level is known to influence awareness and acceptance of health interventions, including vaccinations (5).

Fear of side effects emerged as the most common reason for hesitancy, a finding consistent with reports from both rural and urban populations (6,7). Despite the proven safety of vaccines, misinformation—particularly on social media—continues to fuel anxiety among caregivers (8). Mistrust in vaccine efficacy, also identified in our study, reflects broader challenges related to public confidence in healthcare systems (9). Similar sentiments were reported in global surveys conducted by the WHO’s Strategic Advisory Group of Experts (SAGE) on Vaccine Hesitancy (10).

The influence of community opinions and family beliefs was another critical factor identified through qualitative analysis. Social networks often play a pivotal role in shaping health behaviors, especially in close-knit semi-urban settings (11,12). Religious and cultural barriers, though reported by a smaller fraction of participants, indicate the need for culturally sensitive health communication strategies (13).

The role of healthcare workers also came under scrutiny. Several caregivers in our study reported insufficient counseling and rushed interactions during immunization visits, which is a concern echoed in earlier literature (14). Effective communication from frontline health workers has been shown to enhance vaccine acceptance and reduce doubts (15).

This mixed-methods study assessed the prevalence and underlying causes of vaccine hesitancy among caregivers of children under five years in semi-urban areas. The findings revealed that nearly one in four caregivers demonstrated some form of hesitancy toward childhood immunization. This aligns with similar studies conducted in various parts of India and other low- and middle-income countries (1,2).

One of the key findings was the significant association between maternal education and vaccine hesitancy. Caregivers with lower levels of education were more likely to harbor concerns or reject immunization, which has been corroborated in previous studies (3,4). Education level is known to influence awareness and acceptance of health interventions, including vaccinations (5).

Fear of side effects emerged as the most common reason for hesitancy, a finding consistent with reports from both rural and urban populations (6,7). Despite the proven safety of vaccines, misinformation—particularly on social media—continues to fuel anxiety among caregivers (8). Mistrust in vaccine efficacy, also identified in our study, reflects broader challenges related to public confidence in healthcare systems (9). Similar sentiments were reported in global surveys conducted by the WHO’s Strategic Advisory Group of Experts (SAGE) on Vaccine Hesitancy (10).

The influence of community opinions and family beliefs was another critical factor identified through qualitative analysis. Social networks often play a pivotal role in shaping health behaviors, especially in close-knit semi-urban settings (11,12). Religious and cultural barriers, though reported by a smaller fraction of participants, indicate the need for culturally sensitive health communication strategies (13).

The role of healthcare workers also came under scrutiny. Several caregivers in our study reported insufficient counseling and rushed interactions during immunization visits, which is a concern echoed in earlier literature (14). Effective communication from frontline health workers has been shown to enhance vaccine acceptance and reduce doubts (15).

The findings of this study underscore the complexity of vaccine hesitancy, which cannot be attributed to a single cause. Instead, it results from an interplay of personal beliefs, societal influences, and systemic healthcare gaps. Addressing this issue requires a multifaceted approach involving education, community engagement, and capacity-building of healthcare providers.

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