https://orcid.org/0000-0002-6707-5600
ABSTRACT
Vaccination programs are cost-effective for preventing communicable diseases, yet vaccine events caused vaccine crises among parents nationwide, which has created challenges for current and future vaccination programs. This study aimed to investigate parents’ emotional reactions (i.e., anger and anxiety) toward the 2018 vaccine event in China and explore the associations between parental emotional reactions and vaccine decision-making. A cross-sectional survey was conducted among 1,135 parents in 2018. Five-point Likert scales were provided for respondents to rank their anger and anxiety toward the event, and their vaccine-related trust and intentions before and after the event. Multiple logistic regression analyses were employed to explore the associations. Regarding the vaccine event, 576 (50.8%) and 402 (35.4%) respondents felt very angry and angry, and 310 (27.4%) and 516 (45.5%) respondents felt very anxious and anxious, respectively. Altogether, 797 (70.3%) respondents reported a lower trust in domestically produced vaccines after the event, and 704 (62.3%) respondents reported declines in intention to choose domestically produced vaccines for their children. Multiple logistic regression analyses revealed that anxiety was a predictor of lower trust and intention after the event (p < .001), anger was a predictor of lower trust (p = .005), and both were risk factors for declines in trust and intention (p < .01). This study confirmed that negative emotional reactions toward a vaccine event were important contributors for parental vaccine decisions. Health authorities and facilities are encouraged to act in a timely manner to reduce the public’s negative emotions by providing rapid crisis responses.
Introduction
Vaccination is one of the greatest achievements of public health, but in recent years, concerns over it have emerged around the world,Citation1 which have contributed greatly to increasing vaccine hesitancy.Citation2 Vaccine hesitancy, “the delay in acceptance or refusal of vaccines despite availability of vaccination services”, as defined by the World Health Organization (WHO),Citation3 was listed as one of the ten threats to global health in 2019.Citation4 Increases in vaccine hesitancy have caused delays in achieving global polio eradication goalsCitation5,Citation6 and have led to a well-documented worldwide resurgence of vaccine-preventable diseases such as measles.Citation7 This dangerous trend is on the rise in many countries, including China.
In China, vaccines are divided into two categories under the Regulations on Vaccine Circulation and Vaccination Management.Citation8 Category 1 vaccines are mandatory and included in school entry requirements. Category 1 vaccines include hepatitis B, polio, DPT (Diphtheria, Pertussis, and Tetanus) vaccines, etc. The government provides all domestically produced Category 1 vaccines free of charge, and at the same time, parents can choose imported Category 1 vaccines, but must pay out of pocket. Category 2 vaccines are non-mandatory, and both domestically produced and imported Category 2 vaccines require out-of-pocket immunization fees. These vaccines include rabies, influenza, hepatitis A vaccines, etc.
Four major vaccine events involving children’s health have occurred in China over the past decade, causing vaccine crises and panic among parents nationwide. In 2010, false reports were widely circulated in the media that nearly a hundred children died or became disabled after they were vaccinated with vaccines manufactured in Shanxi Province that were exposed to high temperatures.Citation9 In 2013, false reports in the media claimed that eighteen neonates died after receiving hepatitis B vaccinations in southern China.Citation10 Although investigations provided clarifications to the two vaccine events, vaccine hesitancy was observed among parents.Citation11 In 2016, a family in Shandong Province illegally purchased 25 different kinds of vaccines worth 88 USD million, improperly refrigerated them, and illegally resold these invalid vaccines to clinics and hospitals in 18 provinces across China.Citation12 According to the Chinese Center for Disease Control and Prevention, 50% parents refused to vaccinate their children with Category 2 vaccines after this event, and the situation lasted for several months.Citation11 One year later, in 2017, the China Food and Drug Administration (CFDA) found that a total of 252,600 and 400,520 substandard DPT vaccines that had been manufactured by Changsheng Biotechnology and Wuhan Institute of Biological Products were sold to Shandong, Chongqing, and Hebei Provinces,Citation13 which had not elicited widespread concerns among the public until fraud in the rabies vaccine production records of Changsheng Biotechnology was discovered by CFDA in 2018.Citation14 Changsheng Biotechnology was subsequently fined ¥9.1 billion ($1.3 billion) and 18 people from the company were arrested.Citation15
During such crises, the public might experience various emotions such as anger, sadness, fright, and anxiety.Citation16 For instance, most parents reported feeling angry after hearing of these unexpected adverse events or rumors.Citation17,Citation18 According to Dillard and Peck,Citation19 the public’s emotional reactions often predict their behaviors. Previous research has reported that negative emotional experiences (e.g., anger and anxiety) can influence people’s health behaviors or decisions both during a public health crisis and in daily life, either having positive or negative effects.Citation20 For positive effects, for example, during the H1N1 flu pandemic, highly anxious people tended to comply more rigorously with recommended health protective behaviors;Citation21 in this condition, the anxiety might stem from concerns of experiencing the negative consequences of not engaging in health protective behaviors, which motivated these individuals to behave in a more health-conscious manner. For negative effects, several studies have observed that high levels of anxiety might stop people from receiving vaccination;Citation22,Citation23 the anxiety might be induced by preventative approaches/procedures, which stopped them from getting necessary medical interventions. However, despite these inconsistencies, it is not clear how people’s negative emotional reactions toward vaccine crises are related to vaccine hesitancy.
According to the WHO Strategic Advisory Group of Expert (SAGE) Working Group on Vaccine Hesitancy, trust to vaccine is hypothesized as a major component in measuring vaccine hesitancy.Citation24 Intention to take vaccines is also an important variable, which is widely employed to measure the public’s vaccine hesitancy.Citation25 Previous studies often measured public trustCitation26,Citation27 and intention to vaccinationCitation28 after vaccine events to evaluate the influences exerted by the events, and proposed possible solutions accordingly. Consequently, we employed trust and intention to measure vaccine hesitancy in this study.
To address the research gap, we conducted this study right after the 2018 Changsheng Biotechnology vaccine event (hereafter “2018 vaccine event”) to 1) investigate parents’ emotional reactions (i.e., anger and anxiety) toward the 2018 vaccine event and 2) explore the associations between parental emotional reactions and their vaccine hesitancy status (i.e., trust and intention).
Methods
Study design and setting
This study was conducted between July 31st and August 3rd in 2018, two weeks after the vaccine event. A one-shot cross-sectional survey was conducted in Zhejiang Province, which has a population of over 60 million and whose GDP ranks 4th among Chinese provinces. Six cities were purposively selected in Zhejiang, representing high (Hangzhou and Ningbo), medium (Wuyi and Yongkang), and low (Jiangshan and Kaihua) levels of economic development. Convenience sampling was utilized to select maternal and child health hospitals in each city. These hospitals were selected as they cover a high proportion of documented pregnant women in the cities we studied. The target population for this study was future parents of young children, as most vaccinations are conducted during the first three years after birth and hepatitis B vaccine is administered within 24 hours of birth.Citation29 A cluster sampling method was employed to recruit available and eligible respondents at each hospital. The questionnaire in this study was adapted from two previous studies conducted for the 2013 and 2016 vaccine events,Citation10,Citation28 and it was pre-tested among 22 parents and revised according to the results of the pre-testing and feedback received from these parents (see Appendix A file 1 for the full survey instrument). Data were collected by well-trained investigators from Zhejiang University.
Data collection and eligibility criteria
Study locations were set up in the antenatal clinic waiting area and maternity inpatient department, respectively, at each selected hospital. All expectant women who came for antenatal examinations, puerpera who had a delivery within one week, and their partners at the study locations were approached. Within couples, only the future primary decision-maker for issues relevant to their baby’s health was invited to fill out the questionnaire. The investigators introduced participants to the content of the study and obtained written consent prior to their inclusion in the study. The questionnaire was self-administered, with investigators explaining the questions when necessary. Returned questionnaires were deemed invalid when having respondents unaware of the vaccine event, assessed by asking “have you heard about the Changsheng problematic vaccine event?”
Variables and measurement
Independent variables
The emotional reactions of the parents were assessed with the following questions: “Do you feel angry about the vaccine event?” and “Do you feel anxious about the vaccine event?” A 5-point Likert scale was provided for participants to rank their anger (“Not angry at all” to “Very angry”) and anxiety level (“Not anxious at all” to “Very anxious”). For this analysis, answers for the two questions were dichotomized into “angry” (very angry, angry) and “not angry” (neutral, not angry, not angry at all), as well as “anxious” (very anxious, anxious) and “not anxious” (neutral, not anxious, not anxious at all), respectively.
Dependent variables
In this study, vaccine hesitancy was measured by two variables, trust in domestically produced vaccines and intention to choose domestically produced vaccines for their children. The questionnaire included four questions with responses graded on a 5-point Likert scale to evaluate parents’ trust in domestically produced vaccines (e.g., “Are you trustful of domestically produced vaccines before/after the vaccine event?”) (“Very distrustful” to “Very trustful”) and their intention to choose domestically produced vaccines (e.g., “Do you intend to choose domestically produced vaccines for your child before/after the vaccine event?”) (“Very unlikely” to “Very likely”). The same grouping methods were employed for parental answers of trust and intention toward domestically produced vaccines, which were dichotomized into “trust” and “distrust,” and “likely” and “unlikely,” respectively. Declines of parental trust/intention were generated by subtracting their responses to the above two questions after the vaccine event from their answers to the above two questions before the vaccine event. Scales of trust/intention that decreased after the vaccine event when compared to before were categorized as “yes,” and the others as “no.” Parents’ trust and intention after the event, and the declines of trust and intention were outcome variables of this study.
Statistical analysis
Data analysis included descriptive and analytic components. For descriptive analysis, frequencies and proportions were calculated. The analytic component compared proportions of respondents’ socio-contextual characteristics and emotional reactions between the respective two dichotomic groups of the four dependent variables via Chi-square tests. Multivariate logistic regressions were performed to explore the influence of emotions on vaccine-related trust/intention and the according trust/intention decline, adjusting for socio-contextual characteristics (i.e., gender, age, parity, education level, income, and residence). Data were analyzed using Stata 16 and a statistical significance level of p < .05 was assumed.
Results
A total of 1,283 questionnaires were collected out of the 1,573 that had been distributed (response rate 81.6%), and another 148 were not eligible for inclusion, leaving 1,135 included in final analysis. As shown in , among the 1,135 respondents, more than half were mothers, had an education level of junior college or higher, lived in rural areas, and had a monthly income of more than 5,000 RMB (707 USD). The average age was 28.8 ± 4.9 years old. Regarding the vaccine event, 978 (86.2%) of the respondents felt angry, and 826 (72.9%) felt anxious.
Table 1. Respondent characteristics and emotions (n = 1,135)
Before the vaccine event, 751 (66.2%) of the parents reported trusting in domestically produced vaccines, while only 131 (11.5%) were trustful after the event (). Altogether, 797 (70.3%) parents reported feeling lower trust after the event, 316 (27.9%) remained the same as before, and 21 (1.9%) reported a higher level of trust. The same trend was observed in intention to choose domestically produced vaccines for their children, where an intention decline was reported by 704 (62.3%) respondents. A high proportion of parents (67.1%) intended to choose domestically produced vaccines for their children before the event, but following it this proportion dropped to 18.5% (). Noticeably, there were 33 (2.9%) parents reporting a higher intention after the event, with 393 (34.8%) remaining the same as before.
Table 2. Parental trust and intention before and after the vaccine event (n = 1,135)
Univariate analysis results are shown in . Chi-square tests revealed that, after the vaccine event, urban residents were less likely to trust and choose domestically produced vaccines than their peers (p < .01). Fathers were more likely to choose domestically produced vaccines than mothers (p < .05). Parents with higher household income showed lower intentions to choose domestically produced vaccine (p < .05). Those who were angry or anxious toward the event were much less likely to trust and choose domestically produced vaccines, and their trust and intention were also more likely to decline after the vaccine event (p < .001).
Table 3. Univariate analysis of parental trust and intention and according declines after the event (n = 1,135)
After controlling for confounding variables, parents’ anxiety toward the vaccine event remained predictors of their trust and intention, and both anger and anxiety remained predictors of the corresponding decline in trust and intention toward domestically produced vaccines (). Feeling angry was significantly associated with a lower likelihood of trust in domestically produced vaccines after the event (OR = 0.48, 95% CI [0.29–0.80]), but was no longer a predictor of intention after the event (OR = 0.69, 95% CI [0.44–1.08]). Anger was also observed to be a risk factor for declines in trust and intention (OR = 1.81, 95% CI [1.21–2.72]; OR = 1.73, 95% CI [1.16–2.58]). The same pattern was found with anxiety; parents who experienced anxiety because of the event were less likely to trust in domestically produced vaccines and choose them for their children (OR = 0.39, 95% CI [0.25–0.61]; OR = 0.51, 95% CI [0.35–0.74]). Anxious parents had a significantly higher likelihood of experiencing decreases in trust and intentions (OR = 1.60, 95% CI [1.16–2.21]; OR = 1.61, 95% CI [1.18–2.19]).
Table 4. Multivariate logistic regression analysis for associations between parental trust and intention and emotions (n = 1,135)
Discussion
This study revealed that most respondents experienced anger or anxiety toward the 2018 vaccine event in China. Furthermore, dramatic declines in trust and intention after the vaccine event were observed, with 70.3% and 62.3% respondents showing a lower level of trust in and intention for domestically produced vaccines, respectively. Multiple logistic regressions indicated that anxious respondents were less likely to trust in and choose domestically produced vaccines after the vaccine event, angry respondents were less likely to trust in domestically produced vaccines, and reactions of anger and anxiety were also identified as significant predictors of decline in parental trust and intention to choose domestically produced vaccines for their children.
This study confirmed that vaccine events exert negative impacts on parental trust in vaccination, which has also been reported in previous studies.Citation27,Citation30 Furthermore, findings of this study add to the literature by supporting the significant role of negative emotions (i.e., anger and anxiety) in parental vaccine decision-making. While several of the existing studies exploring associations between vaccine hesitancy and emotions have demonstrated similar findings that high levels of anxiety might stop people from getting themselvesCitation22,Citation23 or their childrenCitation22 vaccinated, they have mostly focused on the impact of people’s anticipated regret and fears.Citation31,Citation32 Few studies have investigated the public’s emotional reactions following vaccine events and their impacts on vaccine hesitancy.
This study also revealed the impact of anger on parental vaccine hesitancy after a major vaccine event, which has not been widely investigated in health behavior-related studies, especially in response to emergent public health events. Future studies should explore in greater detail the role of anger and experience of other negative emotions in health-related decision-making (e.g., engagement in health protective behaviors).
This study revealed that most respondents presented anger or anxiety toward the vaccine event, which was consistent with a former study that demonstrated that vaccine events led to negative emotions in the public.Citation33 Parental anger toward the event may have also resulted from their dissatisfaction with how this event was handled by the government. Ignorance of morality and social responsibility by Changsheng Biotechnology, one of China’s major vaccine suppliers, could also have been a cause of public outrage, in that emotions such as anger and moral outrage are typically stimulated when people see others as responsible for a transgression.Citation34 Parental anxiety was possibly brought on by worries or fears about the side effects of getting problematic vaccines for their children or worries that their children could contract communicable diseases without immunizations, which could be attributed to the vaccine event.
The emotional reactions of people directly involved in crisis situations are highly valued in developing crisis response and communication strategies, due to the noteworthy impacts of emotions on people’s behaviors.Citation16,Citation35,Citation36 According to Fearn-Banks,Citation37 crisis communication is a “verbal, visual, and/or written interaction between the organization and its stakeholders (often through the media) prior to, during and after a negative occurrence”, and crisis communication is an important module of crisis response.Citation38 When hazard of the event is big and public emotion is outrage, crisis communication could be employed to explain what is happening and deal with emotions,Citation39,Citation40 and government involvement is often required if both anxiety and anger appear among the public during a crisis.Citation16
Findings from this study suggest that health authorities or facilities could develop crisis management strategies with better communication skills to provide quick responses both during and after public health crises. A previous study revealed that the public’s attitude improved significantly during the latter stages of vaccine crises after reporting of effective mitigation efforts by the government, which included the government leaders addressing their concerns to this event and ordering an immediate investigation.Citation27 Adequate, reliable, and sufficient information could be provided to the public during fast communication; for instance, health risks of the event, causes of the problem, and the actions undertaken could be communicated with the public as soon as possible.Citation41
There were some other notable findings in this study. First, univariate analysis suggested that respondents with a lower household income level were more likely to choose domestically produced vaccines after the vaccine event; however, the multivariate logistic regression analysis showed no evidence of any significant impact of income. The results could possibly be explained that domestically produced vaccines are relatively cheaper, and Category 1 domestic vaccines are supplied with no charge by the government; hence, parents with a lower income level were more likely to choose domestically produced vaccines. The multivariate analysis further suggested that negative emotions had a great influence on parental vaccine decision-making. Similarly, univariate analysis showed that rural parents had higher levels of trust and intention toward domestically produced vaccines after the event, while the effects were eliminated in the multivariate analysis. Such results were consistent with a previous study that reported little difference in vaccine hesitancy, delay, or refusal between urban and rural residents after the 2018 vaccine event.Citation42
Limitations
There are several limitations of this study. First, only domestically produced vaccine-related trust and intentions were measured; however, since the problematic vaccines were domestically produced and domestically produced vaccines accounted for over 95% market share of vaccinations in China, we believed this to be a reasonable restriction.Citation43 Second, only anger and anxiety were measured in this study, and further studies are needed to investigate the impact of other negative emotions on vaccine hesitancy. Third, we asked the question “have you heard about the Changsheng problematic vaccine event?” to exclude ineligible respondents, where the term “problematic” was negative and might have elicited negative emotions thus caused bias. However, the event was widely reported and referred to as “the Changsheng problematic vaccine event” by media, so we used this term to avoid confusing the respondents. Moreover, the term “vaccine event” itself was negative, which might be difficult to avoid negative emotions. Fourth, this study revealed that a small proportion of parents had a higher level of trust or/and intention after the event. This is a novel finding, which might either be random responding or genuine situations resulting from successful crisis communication. It requires further investigation for possible reasons behind the phenomenon. Fifth, this study was a cross-sectional study. Since several major vaccine crises have happened in the past decade, a longitudinal study could provide information on changes in the public’s emotions toward different vaccine events and the long-term consequences of vaccine event on vaccination attitudes and behaviors.
Conclusion
In summary, findings from the present study confirmed that negative emotional reactions (i.e., anger and anxiety) toward a vaccine event were important predictors of parental vaccine hesitancy. Health authorities and facilities are encouraged to reduce the public’s negative emotions in a timely manner by providing rapid crisis responses to address people’s concerns about vaccine safety. For example, in such vaccine event, the government could promptly inform the public about the consequences of vaccination with the problematic vaccines (e.g., harmless but ineffective), the causes of this event (e.g., inadequate vaccine oversight), and how they had responded to the challenges (e.g., deliberating over new regulations, punishment for the company, etc.). Developing government vaccine oversight takes time. This study provides a rapid crisis response strategy to manage public concerns and negative emotions in a timely manner, which can possibly mitigate the negative impacts exerted by the event (e.g., a lower level of parental trust and intention toward domestically produced vaccines in this study). This event could also be used as a reminder for the government to develop better vaccine oversight and crisis communication capability. There is also need for more research to develop effective intervention strategies to reduce vaccine hesitancy in response to public health crisis.
Disclaimers
The opinions expressed in this article are the authors’ own and do not reflect the view of the institution or funder.
Disclosure of potential conflicts of interest
The authors declare that there is no conflict of interest.
Ethical approval
The study was reviewed and approved by the Ethics Committee of School of Public Health, Zhejiang University (ZGL201807-3).
Authors’ contributions
Ruyu Sun: data interpretation and writing - original draft preparation and editing; Xiaomin Wang: questionnaire design, data collection, data interpretation, and writing - reviewing and editing; Leesa Lin: questionnaire design and writing - reviewing and editing; Ning Zhang: writing - reviewing and editing; Lu Li: supervision and writing - reviewing and editing; Xudong Zhou: study conceptualization, supervision, and writing - reviewing and editing. All authors approved the final version of the paper and provided consent for their names to be used.
Additional information
Funding
References
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Appendix A
Questionnaire
The following questionnaire shall be filled by the (future) primary decision maker for child vaccination.
Part I. Basic Information
Your sex: ①Male ②Female
Your birthday: year___, month___.
Your domicile: ①Urban ②Rural
Your education level:
①Primary school and below
②Junior high school
③High school or secondary school
④Junior college
⑤Undergraduate
⑥Graduate
(5) Your monthly household income:
①Less than or equal to 3,000 RMB
②3,001–5,000 RMB
③5,001–10,000 RMB
④10,001–20,000 RMB
⑤More than 20,000 RMB
(6) Which number of your children do you come to the hospital to give birth to?
①The first
②The second
③The third or more
(7) Have you heard about the Changsheng problematic vaccine event?
①Yes ②No
Part II. Emotional reactions
(8) Do you feel angry about the vaccine event?
①Not angry at all
②Not angry
③Neutral
④Angry
⑤Very angry
(9) Do you feel anxious about the vaccine event?
①Not anxious at all
②Not anxious
③Neutral
④Anxious
⑤Very anxious
Part III. Information understanding
(10) Do you agree with the following items?
(11) Have you heard of the official information released by CDC concerning this vaccine event?
①Yes ②No
(12) If yes, which level of CDC information were you exposed to? (multiple choice)
①National CDC
②Provincial CDC
③District/County CDC
④Not sure/I forgot
(13) Do you trust the official information that was released by CDC?
①Very disrustful
②Distrustful
③Neutral
④Trustful
⑤Very trustful
(14) Please select the correct answer for the following questions
14.1 The vaccines during this vaccine event are harmful vaccines that can lead to health problems in children.
①Yes ②No ③Don’t know
14.2 The vaccines during this vaccine event are harmless but ineffective.
①Strongly disagree
②Disagree
③Neutral
④Agree
⑤Strongly agree
Part Ⅳ. Vaccination intentions
(15) Do you agree with the statement that vaccine is important for your child(ren) to prevent disease?
①Yes ②No
(16) Do you intend to vaccinate your child before the vaccine event?
①Very unlikely
②Unlikely
③Neutral
④Likely
⑤Very likely
(17) Do you intend to vaccinate your child after the vaccine event?
①Very unlikely (skip to Q19)
②Unlikely (skip to Q19)
③Neutral
④Likely
⑤Very likely
(18) If yes, what is the main reason for your decision? (single choice, skip to Q20 after completing this question)
①Vaccines are beneficial for children to prevent infectious diseases.
②Vaccine is required for school enrollment.
③Children around are all vaccinated.
④If my child is not vaccinated, other parents will refuse my child to go to school or play with their child.
⑤This vaccine event is an unusual case, and other vaccines are safe.
⑥Other reasons:___________________________
(19) If no, what is the main reason for your decision? (single choice)
①Vaccines are useless for children’s health.
②Vaccines are harmful for children’s health.
③Vaccine quality is bad.
④Many of my relatives and friends are not going to get their children vaccinated.
⑤Other reasons:___________________________
(20) Are you trustful of domestically produced vaccines before the vaccine event?
①Very distrustful
②Distrustful
③Neutral
④Trustful
⑤Very trustful
(21) Are you trustful of domestically produced vaccines after the vaccine event?
①Very distrustful
②Distrustful
③Neutral
④Trustful
⑤Very trustful
(22) Do you intend to choose domestically produced vaccines for your child before the vaccine event?
①Very unlikely
②Unlikely
③Neutral
④Likely
⑤Very likely
(23) Do you intend to choose domestically produced vaccines for your child after the vaccine event?
①Very unlikely (skip to end)
②Unlikely (skip to end)
③Neutral (skip to end)
④Likely
⑤Very likely
(24) If yes, what is (are) the reason(s) for your decision? (multiple choice)
①Domestically produced vaccines are much cheaper than imported vaccines.
②No imported vaccine is available as an alternative.
③The quality of domestic vaccines will be guaranteed after this event.
④The Changsheng vaccine event is only an individual case, and there is no problem with other vaccines.
⑤Other reason:___________________________
End of survey
Thank you for completing the questionnaire!