{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T07:44:00Z","timestamp":1782805440955,"version":"3.54.5"},"reference-count":23,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:00:00Z","timestamp":1782777600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Health Commission of Chongqing municipality, China","award":["2024MSXM021"],"award-info":[{"award-number":["2024MSXM021"]}]},{"name":"Chongqing Middle-aged High-end Medical Talent","award":["2024GDRC014"],"award-info":[{"award-number":["2024GDRC014"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Background: Vaccine hesitancy remains a major global public health challenge despite high immunization coverage. While concerns about adverse events following immunization (AEFI) are widely recognized, limited attention has been paid to caregivers\u2019 ability to distinguish vaccine-related adverse reactions from coincidental illnesses, as well as to the associations of compensation awareness and institutional trust with vaccination decisions. Methods: A cross-sectional survey was conducted between January and March 2025 among 3497 caregivers of children aged 0\u20136 years using multistage random sampling. Data were collected on AEFI knowledge (including understanding of coincidental illnesses), compensation mechanism awareness, institutional trust, and vaccination behaviors. Vaccine hesitancy was assessed using a self-reported measure and the WHO SAGE Vaccine Hesitancy Scale (VHS). Multivariable linear regression models were used to estimate factors associated with hesitancy scores. Results: The prevalence of vaccine hesitancy was 8.6%, with a mean VHS score of 23.2 \u00b1 4.2. Although general awareness of AEFI reached 90.0%, correct understanding of coincidental illnesses was only 25.7%. Higher AEFI knowledge and compensation awareness were associated with lower hesitancy scores, whereas distrust in compensation mechanisms and perceived vaccine unsafety were associated with higher hesitancy. Coverage of national immunization program (NIP) vaccines exceeded 90%, while uptake of self-paid vaccines varied from 46.7% to 89.7%. Conclusions: Vaccine hesitancy among caregivers was associated with cognitive understanding, economic considerations, and institutional trust. Limited understanding of coincidental illnesses may be associated with increased concerns about vaccine safety, while compensation awareness and institutional trust were associated with lower levels of vaccine hesitancy. Strengthening communication on AEFI causality and improving transparency of compensation policies may help reduce vaccine hesitancy and support immunization programs in settings with mixed public\u2013private financing systems.<\/jats:p>","DOI":"10.3390\/vaccines14070577","type":"journal-article","created":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T05:58:04Z","timestamp":1782799084000},"page":"577","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Vaccine Hesitancy Among Caregivers in China: Associations of Misinterpreted AEFI, Compensation Awareness, and Institutional Trust"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2468-063X","authenticated-orcid":false,"given":"Binyue","family":"Xu","sequence":"first","affiliation":[{"name":"Chongqing Center of Disease Control and Prevention (Chongqing Academy of Preventive Medicine), Chongqing 400016, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qing","family":"Wang","sequence":"additional","affiliation":[{"name":"Chongqing Center of Disease Control and Prevention (Chongqing Academy of Preventive Medicine), Chongqing 400016, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1492-7571","authenticated-orcid":false,"given":"Jiawei","family":"Xu","sequence":"additional","affiliation":[{"name":"Chongqing Center of Disease Control and Prevention (Chongqing Academy of Preventive Medicine), Chongqing 400016, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ningpei","family":"Bai","sequence":"additional","affiliation":[{"name":"Chongqing Center of Disease Control and Prevention (Chongqing Academy of Preventive Medicine), Chongqing 400016, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chunbei","family":"Zhou","sequence":"additional","affiliation":[{"name":"Chongqing Center of Disease Control and Prevention (Chongqing Academy of Preventive Medicine), Chongqing 400016, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1016\/S0140-6736(20)32657-X","article-title":"Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income countries from 2000 to 2030: A modelling study","volume":"397","author":"Li","year":"2021","journal-title":"Lancet"},{"key":"ref_2","unstructured":"World Health Organization (2023). Immunization Coverage, WHO. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/immunization-coverage."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.ebiom.2016.08.042","article-title":"The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey","volume":"12","author":"Larson","year":"2016","journal-title":"EBioMedicine"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e1064","DOI":"10.1016\/S2468-2667(22)00171-2","article-title":"Developing an effective and sustainable national immunisation programme in China: Issues and challenges","volume":"7","author":"Chen","year":"2022","journal-title":"Lancet Public Health"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1146\/annurev-publhealth-090419-102240","article-title":"Vaccine Hesitancy, Acceptance, and Anti-Vaccination: Trends and Future Prospects for Public Health","volume":"42","author":"Ward","year":"2021","journal-title":"Annu. Rev. Public Health"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e1117","DOI":"10.1542\/peds.2014-1279","article-title":"Parental financial incentives for increasing preschool vaccination uptake: Systematic review","volume":"134","author":"Wigham","year":"2014","journal-title":"Pediatrics"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"126422","DOI":"10.1016\/j.vaccine.2024.126422","article-title":"Association between parental vaccine hesitancy and geographical coverage for childhood vaccination: A cross-sectional study","volume":"42","author":"Gera","year":"2024","journal-title":"Vaccine"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"4165","DOI":"10.1016\/j.vaccine.2015.04.037","article-title":"Measuring vaccine hesitancy: The development of a survey tool","volume":"8","author":"Larson","year":"2015","journal-title":"Vaccine"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1016\/j.vaccine.2017.12.043","article-title":"The vaccine hesitancy scale: Psychometric properties and validation","volume":"36","author":"Shapiro","year":"2018","journal-title":"Vaccine"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Ren, J., Wagner, L.A., Zheng, A., Sun, X., Boulton, M.L., Huang, Z., and Zikmund-Fisher, B.J. (2018). The demographics of vaccine hesitancy in Shanghai, China. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0209117"},{"key":"ref_11","first-page":"441","article-title":"Current Status and Factors of Vaccine Hesitancy in Tetanus Vaccination Among Traumatic Patients\u2014China, 2024","volume":"7","author":"Chen","year":"2025","journal-title":"China CDC Wkly."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1177\/1529100618760521","article-title":"Increasing Vaccination: Putting Psychological Science Into Action","volume":"18","author":"Brewer","year":"2017","journal-title":"Psychol. Sci. Public Interest"},{"key":"ref_13","unstructured":"World Health Organization (2019). Causality Assessment of an Adverse Event Following Immunization (AEFI): User Manual for the Revised WHO Classification [Internet], WHO. Available online: https:\/\/www.who.int\/publications\/i\/item\/9789241516990."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Zhang, F., Ren, J., Garon, C., Huang, Z., Kubale, J., and Wagner, A.L. (2024). Complex interplay of science reasoning and vaccine hesitancy among parents in Shanghai, China. BMC Public Health, 24.","DOI":"10.1186\/s12889-024-17990-4"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"128184","DOI":"10.1016\/j.vaccine.2025.128184","article-title":"Parental perceptions of adverse events associated with the whole-cell pertussis vaccine in Brazil","volume":"74","author":"Ribeiro","year":"2026","journal-title":"Vaccine"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1599","DOI":"10.1080\/21645515.2018.1459252","article-title":"Measuring trust in vaccination: A systematic review","volume":"14","author":"Larson","year":"2018","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2301793","DOI":"10.1080\/21645515.2024.2301793","article-title":"The impact of risk perception and institutional trust on COVID-19 vaccine hesitancy in China","volume":"20","author":"Chen","year":"2024","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Wong, J., Gill, C., Abdo, A., and Eisa, A. (2025). The Influence of Financial Incentives on Vaccination Hesitancy: A Narrative Review of Recent Research. Vaccines, 13.","DOI":"10.3390\/vaccines13030256"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2454076","DOI":"10.1080\/21645515.2025.2454076","article-title":"Willingness to pay for vaccines in China: A systematic review and single-arm Bayesian meta-analysis","volume":"21","author":"Li","year":"2025","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"4161","DOI":"10.1016\/j.vaccine.2015.04.036","article-title":"Vaccine hesitancy: Definition, scope and determinants","volume":"33","author":"MacDonald","year":"2015","journal-title":"Vaccine"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1177\/14034948211004323","article-title":"Why do parents refuse childhood vaccination? Reasons reported in Finland","volume":"50","author":"Nurmi","year":"2022","journal-title":"Scand. J. Public Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"ckaf161.724","DOI":"10.1093\/eurpub\/ckaf161.724","article-title":"Addressing childhood vaccine hesitancy using an online decision aid: A longitudinal evaluation","volume":"35","author":"Vandeberg","year":"2025","journal-title":"Eur. J. Public Health"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Dong, B., Xu, H., Qi, Y., and Li, Y. (2025). Understanding vaccine hesitancy through the lens of trust and the 3C model: Evidence from Chinese General Social Survey 2021. Front. Public Health, 13, Erratum in Front. Public Health 2025, 13, 1730651.","DOI":"10.3389\/fpubh.2025.1671457"}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/7\/577\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T06:47:55Z","timestamp":1782802075000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/7\/577"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,30]]},"references-count":23,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["vaccines14070577"],"URL":"https:\/\/doi.org\/10.3390\/vaccines14070577","relation":{},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,30]]}}}