Why Do Some Korean Parents Hesitate to Vaccinate Their Children?

"VH research...to date has mainly focused on Western countries and Japan, and status investigations or research in Korea have been insufficient."

The proportion of required child vaccinations is known to be high in Korea, and vaccine hesitancy (VH) studies are rarely conducted. Although the concept and classifications of VH are unfamiliar in that country, "ANAKI" (Korean abbreviation of "raising children without medication") became a societal issue in 2017. In that context, the researchers surveyed parents in Korean alternative education facilities to examine their reasons for VH based on the Health Belief Model (HBM).

The subjects were recruited from 12 alternative education preschools and 2 elementary schools (Southern Gyeonggi, South Korea) in which there would presumedly be VH parents. Conducted between August and November 2018, the surverys included HBM questions covering the following topics: perceived susceptibility and severity, which are individual perceptions; personal factors and cues to action, which are modifying factors; and perceived benefits and barriers, which refer to the possibility of behaviour.

Among the 129 subjects, 43 vaccinated without hesitancy, 20 vaccinated on time with hesitancy, 32 vaccinated with a deliberate delay of one month or longer, and 34 did not vaccinate. Apart from HBM questions, all 4 of these VH groups were asked about the perception of the necessity and safety of vaccinations. The result showed statistical tendencies of lower VH being associated with a higher level of perception of necessity (p<0.001) and safety (p<0.001).

The most common reasons for hesitancy by group were as follows: For the group who vaccinated on time with hesitancy, the reasons were in the order of concerns and experiences of adverse reactions, distrust of safety management, and distrust of government policies. For the delay group, the reasons were in the order of concerns and experiences of adverse reactions, distrust of government policies, and distrust of safety management. For the refusal group, the reasons were in the order of concerns and experiences of adverse reactions, distrust of safety management, and the meaninglessness of vaccinations.

The persons who affected VH were as follows: For the group who vaccinated on time with hesitancy, the order was online anti-vaccination activists, decision by oneself, and acquaintances. For the delay group, the order was decision by oneself, anti-vaccination activists, acquaintances, and family. For the refusal group, the order was decision by oneself, anti-vaccination activists, acquaintances, activists in membership organisations, and experts of Korean traditional or alternative medicine.

Vaccination increased with an increase in the awareness that severe outcomes can occur when unvaccinated. Explanations by doctors, text messages and emails from institutions, and concerns about disadvantages caused by not complying with government policies also increased vaccination.

HBM analysis showed that the group with lower VH had more concerns about infectious diseases when not vaccinated, which affected the perceived threat and led to vaccination acceptance. In contrast, the more hesitant group thought highly of the possibility of natural recovery even when exposed to infections, which lowered the perceived threat and led to vaccination refusal. Furthermore, lower hesitancy was associated with the perception of benefits that vaccination can prevent infections, having a positive effect to accept vaccination. In contrast, concerns about the adverse reactions from vaccination or not being provided with sufficient information about vaccination appeared to be higher in the hesitant groups and affected refusal. However, insufficient information exceeded 50% in the vaccination groups as well. Cues to action were direct/indirect experiences of adverse reactions. If the level of this factor increased, the perceived threat decreased and affected refusal. The self-efficacy item, which was the belief that recovery can sufficiently be made from adverse reactions through medical treatment, was higher in level for groups closer to vaccination without hesitancy; thus, it had a positive impact on vaccination. All factors showed statistical significance in the univariate analyses, so the HBM-VH decision model was valid.

In the researchers' analysis, these results showed the importance of awareness-raising and communication. In addition, when considering distrust in the vaccination safety management and government policies, understanding of the vaccination policies and management systems along with information about adverse reactions is important for communication. Being provided with sufficient information and communicating with experts are the rights of the parents who decide about vaccination and are important factors.

There are various overseas studies examining which approach to VH is effective, and the results vary due to differences in the social systems and cultures of each country. Korea has characteristics such as an official system for traditional medicine, an incomplete primary healthcare system, short physician-patient consultations, and disadvantages faced by unvaccinated children. The researchers call for future VH research that considers Korea's historical, social, and cultural background.

One thing seems clear: Considering the research results showing low trust in the healthcare system, "caution must be taken in instituting regulation-based policies. A resolution in which social agreement is possible must be found through comprehensive trust-building communication with VH parents."