Vaccine hesitancy in paediatric public health: A comprehensive narrative review

INTRODUCTION

The monumental success of immunisation in reducing the global burden of infectious disease is one of public health’s crowning achievements. Unlike most medical interventions, vaccines confer protection that extends beyond the immunised individual to the broader community through the establishment of herd immunity, a phenomenon critical for protecting vulnerable populations such as newborns, the immunocompromised, and those with contraindications to vaccination. However, this collective defence is fragile, contingent on maintaining high and equitable vaccination coverage. In recent decades, the persistent and, in some regions, growing phenomenon of vaccine hesitancy has emerged as a primary barrier to achieving these coverage goals. The strategic advisory group of experts (SAGE) on immunisation formally recognised the severe impact of vaccine hesitancy and, in 2012, established a dedicated Working Group to define, diagnose, and address this complex challenge.^[1]

Vaccine hesitancy is a context-specific, dynamic behaviour influenced by a spectrum of factors. As defined by SAGE, it resides on a continuum between full acceptance and outright refusal of all vaccines, with hesitant individuals potentially accepting some vaccines but delaying or refusing others.^[1,2] This nuanced understanding is crucial, as it moves beyond labelling parents as simply ‘anti-vaccine’ and instead acknowledges the legitimate questions, logistical barriers, and information gaps that can lead to suboptimal vaccine uptake. In paediatric populations, parental decision-making directly determines a child’s risk of contracting vaccine-preventable diseases (VPDs) such as measles, pertussis, and diphtheria. These diseases carry disproportionately high morbidity and mortality in young children.

This review aims to provide a comprehensive narrative synthesis of vaccine hesitancy within paediatric public health, with a specific lens on India, which accounts for a substantial proportion of the world’s birth cohort and faces a dual burden of infectious disease and entrenched health inequities. Drawing on the foundational SAGE working group report^[1] and contemporary research, we will explore the global and Indian prevalence of hesitancy, deconstruct its multifactorial causes using established behavioural models, and evaluate the evidence for interventions tailored to diverse settings. The objective is to consolidate current knowledge to inform public health strategy, clinical practice, and future research directions aimed at preserving the vital gains of immunisation programmes.

PREVALENCE OF VACCINE HESITANCY: GLOBAL PATTERNS AND THE INDIAN SCENARIO

Globally, vaccine hesitancy is not uniformly distributed but exhibits significant geographical and demographic variability. A systematic review and meta-analysis focusing on parents of children aged 0–6 years estimated a pooled hesitancy rate for routine childhood vaccines of 21.1% (95% confidence interval [CI]: 17.5–24.7%).^[3] This substantial figure underscores hesitancy as a widespread, normative concern rather than a fringe issue. Regional and national studies reveal stark contrasts: hesitancy for routine childhood vaccines in the United States was estimated at 6.1% (95% CI: 5.0–7.3%),^[3] while specific concerns, such as those surrounding the human papillomavirus (HPV) vaccine, can drive refusal rates higher in certain communities.^[4] The COVID-19 pandemic introduced a new dimension, with parental hesitancy for paediatric COVID-19 vaccines^[4,5] reported at 28.9% (95% CI: 25.5–32.5%),^[6-10] often exceeding rates observed for established routine immunisations. Selected studies on vaccine hesitancy prevalence in India are summarised in Table 1.

In India, the context is shaped by its vast population, cultural diversity, and significant urban-rural divides. National immunisation coverage has improved markedly through programmes such as the Universal Immunisation Programme, yet pockets of low coverage and persistent hesitancy remain a critical concern. Studies from disparate regions paint a concerning picture. In the urban slums of Siliguri, West Bengal, a study found that a striking 83% of families exhibited vaccine hesitancy, a behaviour that persisted despite 73.2% of caregivers acknowledging vaccines’ protective role.^[11] Similarly, a facility-based study in Coastal South India identified substantial hesitancy among mothers, strongly associated with informal sources of information and community narratives.^[12] The pandemic exacerbated these trends; one study noted that 38% of Indian mothers reported increased hesitancy towards routine childhood immunisations, primarily driven by fear of exposure to Severe Acute Respiratory Syndrome Coronavirus 2 at health facilities.^[13]

The public health consequences are dire. It is estimated that VPDs contribute to approximately 500,000 child deaths annually in India, with nearly 8.9 million children at risk due to incomplete vaccination. These figures highlight that vaccine hesitancy is not merely an abstract belief system but a tangible driver of mortality and morbidity, reinforcing the urgent need for targeted, localised interventions.

THE DETERMINANTS OF VACCINE HESITANCY: APPLYING THE 3CS MODEL

Understanding vaccine hesitancy requires moving beyond a simple list of reasons to a structured model of behavioural influence. The SAGE Working Group endorsed the ‘3Cs’ model – Complacency, Convenience and Confidence – as a useful heuristic framework for categorising determinants.^[1]

Complacency exists where the perceived risk of VPDs is low. In regions where immunisation has successfully suppressed diseases such as polio or measles for years, younger generations of parents may have never witnessed their devastating effects, leading to a diminished sense of urgency. Complacency is often cited as a significant factor in high-income settings, but it is also relevant in successful sub-national regions within India.

Convenience encompasses factors related to the physical availability, affordability, and accessibility of vaccination services, as well as the quality of the service experience. Barriers include long travel distances to health centres, inconvenient operating hours, long wait times, vaccine or supply stock-outs, and perceived or real disrespect from healthcare providers (HCPs). For daily wage labourers or caregivers with multiple children, the opportunity cost of attending a clinic can be prohibitive, effectively rendering vaccination ‘inconvenient’.

Intervention strategies aligned with the 3Cs model are shown in Table 2. Confidence is multifaceted, encompassing trust in: (a) the safety and efficacy of vaccines (product confidence), (b) the healthcare system that delivers them (provider confidence), and (c) the motives of policymakers who recommend them (policy confidence). Safety fears – whether about immediate side effects (fever, swelling) or long-debunked myths linking vaccines to autism or infertility – are primary confidence issues.^[4,15] In India, confidence is intricately linked to socio-cultural and religious beliefs. Misinformation spreads rapidly through social media and WhatsApp. At the same time, historical contexts such as the controversial HPV vaccine trials and legacy suspicions from earlier public health campaigns can erode trust in government programmes.^[16]

These ‘3Cs’ do not operate in isolation. The SAGE report further organises influences into a Determinants Matrix, categorising factors as individual/group factors (e.g., personal experience, beliefs), vaccine/vaccination-specific issues (e.g., mode of administration, cost), and contextual factors (e.g., media environment, health system governance).^[1] In the Indian context, this matrix is activated by powerful forces: religious and community leaders wield significant influence;^[16] gender dynamics and low maternal education can limit a mother’s autonomy in healthcare decisions;^[12,14] and the digital divide can either be a conduit for misinformation or a barrier to accessing reliable health information.

EVIDENCE-BASED INTERVENTIONS TO MITIGATE HESITANCY

Addressing vaccine hesitancy requires a multi-pronged, evidence-based approach tailored to the specific determinants at play. A systematic review of strategies concluded that there is no universal ‘silver bullet’; interventions must be context-appropriate and often combined for greater effect.^[17]

DISCUSSION AND FUTURE DIRECTIONS

This review underscores that vaccine hesitancy in India is a complex, multi-layered public health crisis fuelled by an interplay of global behavioural patterns and unique local realities. The application of the 3Cs model and the determinants matrix provides a valuable diagnostic lens for public health practitioners to dissect the root causes of low coverage in specific communities. For instance, hesitancy in an urban slum may stem primarily from convenience barriers and confidence issues related to misinformation. In contrast, in a rural tribal area, complacency due to unfamiliarity with disease and contextual factors, such as geographical isolation, may predominate.

CONCLUSION

Vaccine hesitancy represents a formidable and evolving threat to the monumental gains of paediatric immunisation, both globally and in India. It is a nuanced behaviour rooted in a complex web of psychological, social, and practical factors, elegantly captured by models of complacency, convenience, and confidence. In India, these factors are amplified by the nation’s scale, diversity, and persistent inequities, leading to dangerous gaps in immunity and preventable child mortality. Combating this threat requires moving beyond one-size-fits-all information campaigns. Success hinges on diagnostic precision – understanding the local drivers of hesitancy – and on the strategic implementation of multi-component interventions that combine empathetic HCP communication, proactive community partnerships, and relentless health system strengthening to make vaccination accessible, understandable, and trustworthy. The path forward demands a sustained, collaborative effort from government, healthcare professionals, researchers, media, and community leaders to protect every child’s right to a life free from Vaccine-preventable diseases.