Impacts of Health System Factors and Socioeconomic Factors on Acceptability of Non-National Immunization Program Vaccine in Chongqing: A Qualitative Study

Abstract

Background: Childhood vaccines are highly cost-effective, preventing an estimated 2–3 million deaths globally each year and playing a crucial role in disease prevention. In China, the government fully funds and provides National Immunization Program (NIP) vaccines, achieving very high coverage rates. However, non-NIP vaccines, which are self-financed and voluntary, have lower coverage, particularly in rural and economically disadvantaged areas. This study aims to investigate how the health system and socioeconomic factors affect the acceptability of non-NIP vaccines in Chongqing, China, and provide policy recommendations to improve coverage.Methods: This study employed a qualitative research design grounded in the Knowledge, Attitude, and Practice (KAP) theory, which posits that health behaviors, such as vaccine acceptance, are shaped by a sequential process of knowledge acquisition, attitude formation, and behavior adoption. The conceptual framework incorporates (1) health system factors: policies, governance, healthcare provider practices, and (2) socioeconomic factors, including caregiver demographics and financial conditions.Data collection was conducted in May 2024. In Dazu District, Chongqing, two community health centers were selected according to local socioeconomic development levels, and a purposive sampling method was applied. Key informant interviews were conducted with local health authorities to explore their perspectives on the coverage and promotion of non-NIP vaccines. Individual interviews were conducted with primary healthcare providers to understand their experiences and attitudes toward providing immunization services. Additionally, focus group discussions (FGD) were organized with mothers of children under six months to investigate their perceptions and decision-making processes regarding the administration of non-NIP vaccines. In total, seventeen interviews were conducted, and a thematic analysis approach was applied to identify key themes related to vaccine acceptability.Results: Key findings revealed that insufficient maternal knowledge and hesitant attitudes significantly impacted maternal acceptability of non-NIP vaccines. In seeking information about non-NIP vaccines, most mothers preferred online platforms and guidance from friends and healthcare providers. However, many lacked detailed knowledge about these vaccines, including the diseases they prevent, the number of doses required, and the vaccination schedule. Some mothers were also uncertain about the accuracy of their understanding, primarily depending on healthcare providers for reminders about vaccination timing. This reliance, combined with negative news and inconsistent or unclear communication from friends and healthcare providers, contributed to vaccine hesitancy. In particular, many mothers were worried that administering too many vaccines at an early age could harm their infants’ health, as NIP vaccines are mandatory, and additional non-NIP vaccines might be perceived as an extra burden.Policy reviews and qualitative interviews highlighted several challenges faced by healthcare providers when introducing non-NIP vaccines to caregivers. First, according to the interviews, the Chongqing Non-Immunization Program Vaccine Vaccination Plan (2020 Edition) highlighted an “informed” principle, requiring healthcare providers to inform caregivers about non-NIP vaccines. Given that non-NIP vaccines are a voluntary choice and require out-of-pocket payment, healthcare providers usually inform caregivers about them but would not actively recommend them. Second, the number of children vaccinated fluctuated daily. This variability was due, in part, to busier periods which limited the healthcare providers’ availability to discuss non-NIP vaccines with caregivers in detail. Third, the promotion of non-NIP vaccines was sometimes perceived by caregivers as a sales tactic, resulting in complaints being filed with local Health Commissions. These complaints resulted in healthcare providers having to submit explanatory documents, increasing their workload further. Fourth, the immunization rate of non-NIP vaccines was not linked to performance-based incentives, reducing healthcare providers’ motivation to introduce them. Collectively, these challenges hindered the effective communication and acceptability of non-NIP vaccines.Conclusion: The findings found that maternal knowledge and attitudes toward non-NIP vaccines were largely influenced by online sources and information from healthcare providers. Insufficient knowledge, hesitant attitudes, and limited communication impacted maternal acceptability of non-NIP vaccines. Healthcare providers faced challenges such as heavy workloads, tension with caregivers, and lack of incentives, all of which hindered effective communication with mothers. Policy recommendations include implementing performance-based incentives to encourage healthcare providers to actively introduce non-NIP vaccines and strengthening communication between healthcare providers and caregivers through both digital and offline platforms.