Vaccination is one of the most effective public health interventions, significantly reducing childhood morbidity and mortality from vaccine-preventable diseases (VPDs) such as measles, polio, and diphtheria (1). Despite the availability of free immunization programs in many low- and middle-income countries, including India, gaps in vaccine coverage remain, particularly in semi-urban and peri-urban areas (2). One of the emerging barriers to immunization uptake is vaccine hesitancy, defined by the World Health Organization as a "delay in acceptance or refusal of vaccines despite availability of vaccination services" (3). It is a complex phenomenon influenced by factors such as complacency, convenience, and confidence in the health system.

India’s Universal Immunization Programme (UIP) aims to achieve high vaccine coverage among children under five. However, studies have shown that even in areas where vaccine supply is adequate, a considerable proportion of parents are reluctant or delay vaccinating their children due to fear of adverse effects, misinformation, religious or cultural beliefs, and lack of trust in healthcare providers (4,5). In semi-urban areas, where traditional beliefs intersect with modern healthcare services, such hesitancy is often more nuanced and context-dependent (6).

Understanding the determinants of vaccine hesitancy in these settings is essential for developing targeted strategies to improve vaccine acceptance and reduce the burden of VPDs. While several quantitative studies have addressed vaccine uptake, few have integrated qualitative insights to explore the underlying psychosocial and cultural drivers behind parental decision-making. Therefore, this study aims to assess the prevalence and predictors of vaccine hesitancy among parents of under-five children in semi-urban areas using a mixed-methods approach.

Study Design and Setting:

A community-based, cross-sectional study with a mixed-methods design was conducted over a period of six months (January–June 2024) in selected semi-urban areas served by primary health centers. The mixed-methods approach included both quantitative and qualitative components to gain a comprehensive understanding of vaccine hesitancy and its determinants.

Study Population:

The study included parents or primary caregivers of children aged under five years who were residents of the selected semi-urban areas for at least six months. Participants who were not willing to provide informed consent or had children with contraindications for vaccination were excluded.

Sample Size and Sampling Technique:

A sample size of 400 participants was calculated using a 95% confidence level, 5% margin of error, and assuming a 50% prevalence of vaccine hesitancy to ensure maximum sample representation. A multistage sampling technique was employed. Initially, three semi-urban health centers were selected randomly. From each health center, households with eligible participants were identified using systematic random sampling.

Data Collection Tools and Procedure:

For the quantitative component, data were collected using a pre-tested, structured questionnaire developed based on the WHO’s Vaccine Hesitancy Scale and adapted for local context. The questionnaire captured socio-demographic details, immunization status of the child, awareness, attitudes toward vaccines, and sources of vaccine-related information.

For the qualitative component, in-depth interviews were conducted with 30 purposively selected parents identified as vaccine-hesitant during the survey. A semi-structured interview guide was used to explore their beliefs, fears, social influences, and interactions with health services. Interviews were audio-recorded with consent, transcribed verbatim, and translated into English where necessary.

Data Analysis:

Quantitative data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to summarize the data. Bivariate analysis using chi-square tests identified associations between vaccine hesitancy and independent variables. Variables with p<0.05 were entered into a multivariable logistic regression model to determine adjusted odds ratios and 95% confidence intervals.

Qualitative data were analyzed using thematic content analysis. Transcripts were read repeatedly, coded manually, and emerging themes were identified to explain the psychosocial and contextual factors contributing to vaccine hesitancy. Triangulation was performed to integrate findings from both quantitative and qualitative strands.

A total of 400 parents of under-five children participated in the study. The mean age of respondents was 29.8 ± 4.7 years, with the majority being mothers (74%). Among the participants, 27.5% (n=110) exhibited vaccine hesitancy.

Socio-Demographic Characteristics and Vaccine Hesitancy

Table 1 presents the socio-demographic distribution of the participants and its association with vaccine hesitancy. Vaccine hesitancy was more prevalent among parents with lower educational levels, particularly those with education below high school (38.7%), compared to those with higher education (18.2%). Unemployed mothers showed a significantly higher hesitancy rate (35.1%) compared to employed mothers (20.8%) (p<0.05).

Table 1. Socio-Demographic Characteristics and Vaccine Hesitancy (n=400)

Knowledge and Attitude Factors

Table 2 summarizes the knowledge, attitudes, and sources of information. Participants who believed vaccines might cause serious side effects were significantly more hesitant (52.8%) than those who disagreed with that notion (15.3%).

Parents primarily dependent on social media for vaccine-related information showed a hesitancy rate of 44.2%, significantly higher than those consulting health workers (18.9%).

Table 2. Knowledge, Attitude, and Information Source (n=400)

Multivariable Logistic Regression

Factors significantly associated with vaccine hesitancy were included in the logistic regression model (Table 3).

Low maternal education (Adjusted Odds Ratio [AOR]: 2.4; 95% CI: 1.5–4.0), belief in serious vaccine side effects (AOR: 3.1; 95% CI: 1.9–5.2), and social media as the main source of information (AOR: 2.2; 95% CI: 1.3–3.7) remained independent predictors of hesitancy.

Table 3. Multivariable Logistic Regression for Predictors of Vaccine Hesitancy

These findings demonstrate that vaccine hesitancy is influenced by a combination of socio-economic, cognitive, and informational factors in semi-urban populations.

This mixed-methods study highlights a concerning level of vaccine hesitancy (27.5%) among parents of under-five children in semi-urban regions. This prevalence is consistent with findings from other Indian studies that report hesitancy rates ranging from 20% to 30%, particularly in communities with limited access to accurate vaccine-related information and healthcare counseling (1,2).

Parental education emerged as a significant determinant of vaccine acceptance. Participants with lower educational attainment were more likely to hesitate or delay vaccinations, corroborating previous findings that link low literacy levels to poor health-seeking behavior and increased susceptibility to misinformation (3,4). Educated parents are more likely to understand vaccine benefits and access verified sources of information, which can mitigate fear-driven behaviors (5).

A key factor contributing to hesitancy in this study was concern about potential side effects, especially adverse reactions perceived as severe or permanent. This fear has been well documented globally, particularly in regions where awareness campaigns are inconsistent or poorly executed (6,7). Similar patterns were observed in studies from rural Bangladesh and Pakistan, where vaccine refusal was often driven by anecdotal reports of post-vaccination illness, often amplified by local gossip or social media (8,9).

The influence of information sources was also evident. Parents who relied on social media for vaccine-related knowledge had significantly higher odds of hesitancy. This aligns with studies indicating that misinformation—particularly anti-vaccine narratives and conspiracy theories—spread rapidly on digital platforms and erode public trust in vaccines (10,11). In contrast, trust in healthcare professionals and personal interaction with health workers has been shown to enhance vaccine acceptance (12). Strengthening frontline health worker communication skills could therefore be a key strategy to combat hesitancy (13).

Cultural beliefs and traditional health practices were another important influence, with several respondents expressing confidence in herbal remedies or spiritual healing in lieu of biomedical interventions. These findings align with literature from Sub-Saharan Africa and South Asia, where cultural norms and local beliefs play a strong role in shaping health decisions, often competing with modern medical advice (14,15).

The qualitative findings complemented the quantitative data, revealing a complex interplay of fear, social influence, and systemic mistrust. Several hesitant parents cited prior negative experiences, such as poor post-vaccination support or perceived negligence by healthcare providers. These experiences can perpetuate skepticism and foster community-wide mistrust in immunization programs.

To address vaccine hesitancy effectively, interventions must be multifaceted. Targeted health education tailored to specific literacy levels, proactive misinformation management, and culturally sensitive communication strategies are essential. Involving community influencers such as religious leaders and local health volunteers may also bridge the gap between scientific messaging and traditional belief systems.

Vaccine hesitancy among parents of under-five children in semi-urban areas remains a significant public health concern, driven by low education levels, fear of side effects, misinformation, and cultural beliefs. Strengthening health education, promoting trust in healthcare providers, and countering misinformation—especially on social media—are essential strategies to improve vaccine acceptance and achieve higher immunization coverage in these vulnerable populations.

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