Parental Perceptions, Attitudes, and Beliefs Regarding Vaccination of Children Aged 0-5 Years: A Qualitative Study of Hill-tribe Communities, Thailand

"Due to the context-specific nature of vaccine hesitancy in hill tribe parents, healthcare providers as well as policy makers should focus on gaining a better understanding of vaccine hesitancy in order to develop interventions that are appropriate for this context..."



Vaccine-preventable diseases are a major cause of morbidity and mortality in Thailand's sub-populations, such as the migrant population, ethnic minorities, and hill-tribe populations, because of limited health infrastructure, decreased accessibility to services, language barriers, low level of awareness, and limited funding. This study aimed to elicit an understanding of hill tribe parental perceptions, attitudes, and beliefs about vaccination for children aged 0-5 years to identify potential areas for intervention and improvement.



Working from August 2019 to February 2020 in 3 villages, Theng, Mae Suay, and Mae Fah Luang, the researchers conducted a qualitative study employing semi-structured interviews of 74 hill-tribe parents (14 Akha, 11 Hmong, 12 Lahu, 13 Lisu, 12 Karen, and 12 Yao). In order to operationalise empathic neutrality within the interviews, the researchers attempted to understand (not prove preexisting) reasons for deciding not to (or to partially) vaccinate children. There was a non-judgmental stance toward whatever content emerged during the interviews, which the researchers believe facilitated trust with participants and led to positive feedback loops within their social networks, facilitating positive responses from subsequent participants.



Some parents believed that the vaccine was unnecessary for their children and valued natural treatments, such as breast milk, good care, and hygiene, which they felt were more effective in building the child's immune system. Many parents fear that vaccinations could lead to long-term health problems, such as seizures, or other severe side effects. Others are concerned that the vaccines may not be effective, that children under 5 years are vulnerable and too fragile to handle immunisation, and/or that the benefits of immunisation do not outweigh the risks. Some parents have religious or cultural beliefs that prevent them from vaccinating their children.



Specifically, from the interviews conducted, 4 themes emerged:

• Traditional beliefs and practices - 22 participants reported they refused going for vaccinations because they believed that their family ancestors did not allow young children to leave their homes. Outside the home, the ancestor has no power to protect the child. Certain hill tribe groups may also refuse a vaccine due to the beliefs that it contains a toxin intended to function as a chemical weapon by the Thai government to eliminate the hill tribe people.
• Traumatic experiences - 18 parents who refused vaccination for their children expressed feelings that vaccines are unsafe, harmful, and unpleasant for their children; 14 participants expressed mistrust in healthcare providers due to language barriers, stigmatisation, and socioeconomic status.
• Lack of information and effective communication - Lack of knowledge about the importance of vaccinating children is a common problem in the hill tribe communities. Some parents are influenced by misinformation about vaccines or may not be aware of how to access accurate information. More than 10 participants with no formal education stated they could not use "the pink book" (the maternal and child health book). Instead, they asked their neighbours about the next appointments for their children.
• Trust and support from the community - Many participants indicated they mainly sought information related to vaccine benefits and harms from sources such as healthcare providers and community leaders, as well as village health volunteers (VHVs). Most of the parents indicated that the community leader could be helpful in reminding parents about the vaccine list and schedule in their specific language (e.g., Akha, Lahu, Hmong) during community meetings.

These findings highlight that it is crucial to build trust by providing knowledge, appropriate information, and advice about vaccinations in order to improve vaccine coverage in children under 5 years of age in the hill-tribe context. Providing effective communication and education, as well as raising public awareness through campaigns by trusted healthcare providers and community leaders, could reduce the vaccine hesitancy of hill tribe parents at the community level, helping limit the spread of rumours and distrust. In this study, to improve access, the study participants also supported initiatives such as leveraging direct personal contact or door-to-door campaigns, using VHVs to promote immunisation in children, or broadcasting vaccine information in specific languages. Further training of healthcare providers to ensure they can provide culturally appropriate, non-stigmatising care to hill-tribe people could also be an important intervention.



In conclusion: "Providing clear information and advice about vaccinations to parents in language that parents can understand is crucial for building relationships and trust with parents and improving the vaccine coverage rate in hill tribe children aged under five years."