Rapidly Urbanizing Communities in Middle-Income Countries Could Be Sources of Vaccine Hesitancy

Where you live is an indicator of many public health factors, including whether you decide to accept vaccinations for yourself and your children.

This might not be surprising to a resident of the US, a country now famously polarized into so-called blue and red communities.

But it seems to be true in many other parts of the world, too. And the trends we have observed in Shanghai, China¹—a rapidly urbanizing, middle-income country—seem to cut against the US trend of more urban communities tending toward vaccine acceptance.

Measuring parental attitudes toward vaccines is complicated. We used the well-known Parental Attitudes toward Childhood Vaccines (PACV) scale—developed in the US²—to measure vaccine hesitancy in Shanghai, China, focusing on a comparison of hesitancy between Shanghai locals and more recent migrants into the city.

Among 1,021 Shanghai residents, 42.5% mentioned delaying a vaccine and 11.5% mentioned not getting a vaccine for reasons other than illness or allergy. A majority of parents expressed concerns about vaccine side effects (73.8%), vaccine safety (63.9%), and vaccine effectiveness (52.4%). Other questions with commonly expressed hesitant views included parents delaying vaccination (42.5%), preferring child to not be co-administered multiple vaccines (42.0%), concerns about the number of vaccinations (31.7%), and an overall rating of vaccine hesitancy (20.8% identified as hesitant).

Migrants from rural areas were also more concerned about side effects (86.7%) and that the vaccine might not prevent disease (62.9%) compared with their local resident counterparts (71.0% and 49.3%, respectively).

Rapid urbanization in China and other middle-income countries has created a group of migrants whose experiences and backgrounds are different from locals and may differentially impact their confidence in vaccines and their vaccine uptake.

In our study in Shanghai, China, parents expressed hesitancy largely in terms of perceived vaccine safety and efficacy, and with regard to the expanding schedule of recommended vaccines. Generally, those holding a non-local (recent migrants) residency were found to be more hesitant than local residents, which could lead to clustering of under-vaccinated children and lead to reduced coverage in populated urban areas.

Especially when it comes to seeing children through recommended vaccination schedules, vaccine hesitancy leads to reductions in vaccination coverage and outbreaks of vaccine-preventable disease.

In many urban settings around the world, hesitancy trends should be followed closely in hopes of maintaining vaccination coverage for millions of residents, including children.

Notes

1. Wagner A, Huang Z, Ren J, Laffoon M, Ji M, et al. “Vaccine Hesitancy and Concerns About Vaccine Safety and Effectiveness in Shanghai, China.” American Journal of Preventive Medicine 60/supp 1 (Jan 2021):S77-86.

2. Opel DJ, Taylor JA, Mangione-Smith R, Solomon C, Zhao C, Catz S, Martin D. “Validity and Reliability of a Survey to Identify Vaccine-Hesitant Parents.” Vaccine 29/38 (Sept 2011):6598–6605.

About the Authors

Mengdi Ji completed MPH and MHI degrees from the University of Michigan in 2021 and will begin doctoral work in epidemiology at the University of Michigan School of Public Health in fall 2022. Her research interests include vaccine hesitancy, vaccination disparity, and vaccination in low- and middle-income countries. She also studies predictors that influence parental vaccine decision-making for their children.

Abram Wagner is research assistant professor of Epidemiology in the School of Public Health. He studies predictors of vaccine-preventable disease incidence, with a particular focus on vaccine hesitancy. Wagner’s research is targeted toward evidence-based programs and policies that work toward the control of a broad range of vaccine-preventable diseases.