Parental perceptions, attitudes, and beliefs regarding vaccination of children aged 0–5 years: A qualitative study of hill-tribe communities, Thailand

ABSTRACT

The widespread availability and use of vaccines have tremendously reduced morbidity and deaths related to infectious diseases globally. However, in hill-tribe communities in Northern Thailand, vaccination rates remain low, and there is limited literature on parental perceptions, attitudes, and beliefs about vaccination for children under five years of age. We conducted a qualitative study employing semi-structured interviews to understand parents’ perceptions, attitudes, and beliefs about vaccinations. A purposive sample was used to recruit participants. Data were analyzed using thematic analysis. 74 hill-tribe parents (14 Akha, 11 Hmong, 12 Lahu, 13 Lisu, 12 Karen, and 12 Yao) were interviewed. Four themes emerged from the interviews: 1) traditional beliefs, and practices 2) traumatic experiences, 3) lack of information and effective communication, and 4) trust and support from the community. 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 five years of age in the hill-tribe context.

Introduction

Vaccines are among the most effective public health interventions to prevent communicable diseases^1–3 preventing an estimated 2–3 million deaths each year globally.^4–6 In Thailand, the Ministry of Public Health (MoPH) launched the Expanded Program on Immunization (EPI) in 1977 in public health services nationwide.⁷ Currently, the MoPH provides 12 basic vaccines free of charge for children from birth to 12 years of age (e.g. tuberculosis vaccine (BCG), Hepatitis B (HB), Diphtheria-Tetanus-Pertussis-Polio (OPV/IPV), Haemophilus influenza type B (Hib), measles-mumps-rubella (MMR), Japanese Encephalitis (JE), Rotavirus, and Human papillomavirus (HPV) vaccine.^8,9

Compared to countries within Southeast Asia, Thailand has drastically increased its vaccine coverage rate and has limited diseases such as polio and measles. Since 2005 the EPI has achieved immunization coverage of around 96–99% among Thai children.¹⁰ However, vaccine-preventable diseases are still a major cause of morbidity and mortality in sub-populations,¹¹ 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.^12–14 A recent report in 2018 showed vaccine uptake in hill-tribe children aged 0–5 years of DTP/OPV3 was 70.0%, MMR was 30%, JE3 was 68.22%, and DTP/OPV5 was 4.8%, which is considered much lower than the specified target (and compares poorly with Thai children, for instance, who have a vaccination rate for MMR of over 90%) and reflects a problem in this public health intervention.^15,16

According to recent data, it has been estimated that more than 5 million people belonging to various ethnicities lived in Thailand in the year 2020, which accounts for 7.2% of the total population. The Department of Social Development and Welfare, the total officially recognized “hill tribe” population number 925,825¹⁷ and 30% live in Chiang Rai province (350,000) which has the largest population of hill tribe people in the country.¹⁵ Of this population, approximately 100,000 are children. Most hill tribe people live in remote or mountain top areas along the Thailand – Myanmar–Laos border and under both the national poverty line and national education level.^18,19 Hill tribe people face many barriers in accessing healthcare services including vaccination for their children and these barriers can indeed have serious consequences. Without proper vaccinations, hill tribe children are more vulnerable to diseases such as measles, mumps, rubella, and other preventable infections. These diseases can cause severe complications, long-term health issues, and even death.¹¹

According to a report by the Thai Department of Disease Control from 2014–2019, the yearly number of new measles infections was approximately 5,000 nationwide, and more than 10% were found in the ethnic minority population.²⁰ In addition, in 2020, 6.73 per 100,000 hill tribe children were reported to have measles, and 24.8 were under 5 years of age. The unpublished provincial Health Office report from Chiang-Rai, Thailand’s northernmost province, highlights some common health problems among hill tribe children. The reported incidences of measles, tetanus, and outbreaks of diphtheria in remote areas further underscore the vulnerability of hill tribe children to these preventable diseases.^21,22

Decreased rates of immunization among hill tribe children may be due to the many barriers they face in accessing healthcare services.^13–15 Previous studies, both in the domestic and international literature, found that the lower vaccination coverage rate in children was caused by many factors, such as knowledge, economic status, language barriers, and access to healthcare services.^23–28 However, there are no existing studies exploring immunization among the hill tribe population in Thailand, all of whom have different cultures, languages, and beliefs particularly related to healthcare practices. 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.²⁹ 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.

Methods

Study design

A qualitative approach with in-depth, semi-structured interviews was used to gain insight into the ethnic hill tribe parents’ perceptions, attitudes, and beliefs toward vaccination for children aged 0–5 years in rural areas in Thailand. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to structurally report the methods and results of this study.³⁰

Setting and participants

Participants were recruited from three hill tribe villages, Theng, Mae Suay, and Mae Fah Luang, whose population are made up of Akha, Lisu, Lahu, Hmong, Yao, and Karen people. Prior to recruitment, the research team met with each nurse practitioner or public health officer in the area to explain the study in detail. Information sheets about the project were provided to each sub-district health promotion hospital (SDHPH). Inclusion criteria included 1) hill tribe parents with at least one child (aged 0–5 years); 2) able to speak Thai fluently.

A total of 1,576 parents were invited to participate in the study, with 475 of those belonging to the Akha ethnic group, 102 from the Lisu group, 518 from the Lahu, 245 from the Hmong, 91 from the Yao, and 145 from the Karen. Of those, 74 parents who met the inclusion criteria and chose to volunteer for this study were approached by the principal investigator (PI) during an appointment at the SDHPH for health services in non-emergency situations such as developmental screening, dental visit, and vaccination. These discussions were conducted by the PI in accordance with the study protocols. The parents who were approached were provided with detailed information about the study and were asked to provide written informed consent. This study was approved by the Institutional Review Board of the Provincial office, and informed consent was obtained by all participants. (IRB No. CRPPHO NO.3/2562)

Data collection

In-person interviews were conducted from August 2019 to February 2020 in meeting room at SDHPH or at participants home, according to their preference. The researchers on this project worked at a university and came from various backgrounds with extensive experience with the ethnic minority population in these areas and qualitative method expertise. The primary investigator set up a three-day research workshop for team members to mentor and train junior qualitative researchers in critical and reflexive engagement with the data and other team members, such as trained research assistants, in overcoming language problems during interviews.

A semi-structured interview guide was developed during the literature review and through consultation with the hill tribe village leaders. The questions were assessed for appropriateness, including validity, by the research team and three experts working in the field (one hill tribe researcher expert, a public health officer and a nurse practitioner who worked in primary care settings in the hill tribe communities). Questions were open-ended and included questions such as “Could you please tell me about the vaccination experience for your child?,” “Did your child or children experience any adverse effects after vaccination?,” and “Has your child(ren) missed or delayed a vaccine? and could you please tell me the reason.”

In order to operationalize 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 and within our analytical and publication processes. We firmly believe that our empathic neutrality facilitated trust with our participants and led to positive feedback loops within their social networks, facilitating positive responses from subsequent participants.

The interviews were carried out by KM and KP, who were qualitative experts with 10 years of experience, and initiated with a broad, open-ended question that provided a flexible framework for the interviews where participants were encouraged to discuss any issue they deemed relevant to the topic of childhood vaccination. As participants narrated their stories, probing questions were designed to provide an opportunity for parents to discuss their perceptions and experiences when their child had vaccinations or did not get vaccinated. The interviews lasted between 45 to 65 minutes and were conducted in Thai. Interviews were audio-recorded and transcribed verbatim. To ensure a comprehensive evaluation of the data, the investigator took into account the perspectives provided by both parents. A total of 60 interviews were conducted with the mothers and an additional 14 with both parents. The investigator also looked for common threads and discrepancies between the responses of both parents, exploring whether one parent had a greater understanding of the issue at hand. After examining the data, the investigator drew conclusions based on both parents’ responses. After conducting a series of interviews, saturation was reached in that no new data, themes, or ideas were emerging from the interviews, and themes were being repeated.³¹ Following the interview, participants responded to a demographic questionnaire.

Data analysis

The transcriptions of interviews and field notes were analyzed using thematic analysis and inductive methodology, including the six phases of thematic analysis as described by Braun and Clarke³¹ assisted by the qualitative software program NVivo version 12. Two of the authors transcribed and familiarized themselves with the data. Following that, the researchers began to identify preliminary codes, which are features of the raw data that appear to be interesting and meaningful. There were 28 codes or key issues obtained from the data. The codes were grouped into major and sub-themes regarding parents’ perceptions of vaccination.

Following this phase, data were compared to identify recurring themes and to review relationships between the main theme and sub-themes, which make a logical argument and may contribute to the overall narrative of the data. Consistent and close readings of the transcripts allowed for fidelity to the thematic analysis method and the data. We were careful to preserve the essence of the participants’ voices, using their narratives to develop thematic titles; hence, our results include rich individual quotes (with assigned codes and numbers) as well as combinations of quotes from multiple participants to form a cohesive narrative. Finally, the authors agreed on the final key themes. These themes were repeatedly checked against the transcripts in order to identify patterns. Interpretation of themes was informed by the literature, objectives of the study, and additional discussions with two other authors with ample working experience in hill tribe healthcare practice. Afterward, the results were revised and critiqued by the research team before a conclusion was developed.³¹

Results

Participants’ characteristics

Seventy-four semi-structured interviews were conducted with the 74 participants from six ethnic minority groups. Among the participants, 18.92% were Akha, followed by Lisu (17.57%), Lahu (16.22%), Karen (16.22%), Yao (16.22%), and Hmong (14.86%). The majority of participants were women. Their ages varied between 16–62 years. Of these participants, 24.30% had not enrolled in formal education, 31.10% had completed primary school, whereas and 44.6 had graduated from college or higher education and characteristics are provided in Table 1.

Table 1.

Participants characteristics.

Characteristics	(n = 74)	(%)
Gender
Women	60	81.1
Men	14	18.9
Ethnicity
Akha	14	18.9
Hmong	11	14.9
Lahu	12	16.2
Lisu	13	17.6
Karen	12	16.2
Yao	12	16.2
Age (year)
15–24	13	17.6
25–34	24	32.4
35–44	21	28.4
≥45 (mean age for women ± SD = 33.37 12.57) (mean age for men ± SD = 31.14 ± 10.62)	16	21.6
Education
No Formal Education	18	24.3
Primary School	23	31.1
Junior High School	24	32.4
Senior High School	6	8.1
Collage	3	4.1

M ± SD = mean ± standard deviation.

Themes

Parents described their negative perceptions, unpleasant feelings, and personal beliefs regarding the vaccination of children aged 0–5 years within the hill tribe community context.

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 or that the benefits of immunization do not outweigh the risks. Some parents have religious or cultural beliefs that prevent them from vaccinating their children. From the interviews conducted, four themes that emerged in the analysis comprised: 1) traditional beliefs, and practices 2) traumatic experiences, 3) lack of information and effective communication, and 4) trust and support from the community. The excerpts from the interviews selected to illustrate each theme are authentic and succinct, remaining faithful to the participants’ overall sentiments and providing explicit examples of each respective theme.

Traditional beliefs and practices

Traditional beliefs, including ancestor worship was one of the most common forms of traditional belief practiced by hill tribe communities. There is a deep-rooted fear that often arose from a lack of understanding regarding the science behind vaccinations and their benefits, or from superstitious beliefs that vaccinations might have a negative impact on their spiritual wellbeing. Twenty-two participants reported that 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. For example, one mother stated:

My grandparents said we would violate the ancestor rules … a child younger than one year old must stay at home and the ancestor will protect my son because he lives close to the ancestor spirits.

Apparently, my parents believe my child is being watched over by an ancestor spirit. Introducing something foreign into their bodies could violate this protection, so it’s important to respect parents’ wishes. (Mother, P5.7)

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. Eleven parents interviewed expressed this view, as exemplified below:

It is not safe. My nephew had a vaccination one time … After two or three days passed, he had a seizure and was in a coma. The doctor said his brain was damaged … we think because of the vaccine. It contains harmful substances, such as mercury and fetal cells… toxic chemicals… that kill the child’s brain cells … and I try not to bring my child for vaccination. (Father, P1.8)

Traumatic experiences

Traumatic vaccination experiences, vaccine side effects or adverse events, and negative interactions with healthcare providers were common reasons for denying vaccination. Eighteen parents who refused vaccination for their children expressed feelings that vaccines are unsafe, harmful, and unpleasant for their children. For example,

After having a vaccine at two months old, my child had a high fever, swelling, and redness … I brought her to the hospital … The doctor said she was allergic to vaccines … That was the last vaccination … Now she is two years old and healthy. (Father, P4.12)

As I waited for my child to receive their vaccination, I saw a hill tribe woman next to me being scolded by a nurse. She had skipped her child’s vaccination schedule. I could feel the great pain and trauma that she was experiencing. (Mother, P1.2)

Fourteen participants expressed mistrust in healthcare providers due to language barriers, stigmatization, and socioeconomic status.

It may be that they do not listen to me … because they are not familiar with the hill tribe people, who are dirty, impoverished, and different from them … Hence, I believe this is the reason why we do not wish to visit the hospital. (Father, P3.6)

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. In this study, a small majority of participants agreed that vaccinations for children are mandatory, but they did not possess any knowledge related to immunizations. Some participants, particularly those without formal education, stated that they did not understand how vaccines worked, what was inside the needle, or why young children need more vaccinations than adolescents or adults. This was exemplified by a participant who explained:

No one informed me about the vaccine. I did not ask because I am sure if the nurse explained it to me … I still would not understand … .it is because I have no education. (Father, P5.5)

Lack of information and communication were reflected in parents’ decision to vaccinate their children. Lack of information and ineffective communication included language used, inappropriate information delivery, and communication methods between parents and healthcare providers.

I could not bring my child to the hospital by myself because I could not read. Even though I can speak Thai, when the nurse advised me to do something … I needed my husband to help me gain understanding. If my husband has to work … we have to skip the vaccine schedule. (Mother, P4.5)

More than 10 participants with no formal education stated that they could not use “the pink book” (the maternal and child health book). Instead, they asked their neighbors about the next appointments for their children. For example,

As an ethnic person, I am unable to read the Pinkbook and it is useless. (Mother, P1.5)

Trust and support from the community

Support from the community was another consideration mentioned by the participants. Many participants indicated that 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).

VHVs are the link between people, the community, and the hospital, but they don’t know about vaccines. They know nothing about mosquito control, disabled people, or assessing basic needs. I think VHVs could help by contacting parents directly or delivering door-to-door reminders before an appointment. (Mother, P4.2)

Most of the parents who had previously missed the child’s vaccination indicated that beyond providing information, the community leader could be responsible for the child’s vaccination by reminding parents about the vaccine list and schedule in their specific language (e.g., Akha, Lahu, Hmong) during community meetings. This approach could be effective for raising parents’ awareness, especially for those who live far from the vaccination facility and have low literacy levels. For example,

My children were fully vaccinated, even though I could not understand Thai. This is because the community leader reminded them about the vaccine schedule and children on the list. (Father, P4.3)

Participants agreed that community health systems are imperative for providing trustworthy and accurate information, since many parents believe vaccines are necessary for their children.

In the past, the community leader reminded us through local broadcasting. We were doing well with vaccination, but now we have a newly elected leader, and there is no broadcasting at all. Therefore, we are falling behind. (Mother, P5.4)

Discussion

The purpose of this study was to explore parental perceptions, attitudes, and beliefs toward vaccination for children aged 0–5 years in a hill tribe community context.^32–34 The findings of this study align with studies on ethnic minority populations globally that have demonstrated that the major reason people do not receive vaccines is limited understanding and lack of trust in the effectiveness of the vaccine. A study by Wijayanti et al. (2021) demonstrated that parents who had doubts or insufficient information about vaccines can lead to the individual having an inadequate understanding of the information presented to them.³⁵ The finding also highlights the importance of ensuring that parents have access to accurate information about the safety and efficacy of vaccines so that they can make informed decisions.

Some parents believed that the vaccine was unnecessary for their children and valued natural treatment, such as breast milk, good care, and hygiene, which they felt were more effective in building the child’s immune system. Moreover, the low vaccine uptake by hill tribe children under five years old was also related to parental beliefs that these children are vulnerable and too fragile to handle immunization.^36,37 When studying parents’ views on vaccination, Burghourts et al. (2017) similarly observed a fear of adverse effects and the beliefs that vaccines could harm their child, that their child was too young (under five years old), and that their child had a low risk of catching diseases, which led parents to refuse vaccination.³⁸ Some parents needed reassurance from a trustworthy person and knowledgeable healthcare provider that the vaccine was safe. Studies on vaccine coverage in ethnic children have shown that a lack of trust in vaccine effectiveness and fear of side effects leads to a low rate of vaccine uptake and a high rate of vaccine refusal.^39,40

In this study, one of the main findings was that some parents declined vaccines due to significant negative experiences when dealing with healthcare providers, largely due to their hill tribe background. These experiences created a mistrust of the healthcare system, leading to a refusal of vaccines. Moreover, in some parents, vaccines are seen as a product containing toxins and vaccinations are considered to be a violation of ancestral worship rules. Deep-rooted personal beliefs can make it difficult for healthcare providers to solve the problems of parents’ vaccine hesitancy.^41–43 Providing effective communication and education, as well as raising public awareness through campaigns by trusted healthcare providers and community leaders, would reduce the vaccine hesitancy of hill tribe parents at the community level, helping limit the spread of rumors and distrust.⁴⁴

In this study, the participants did not vaccinate their children for a wide range of reasons, such as adverse effects following vaccinations, poverty, and geographic difficulties. However, some hill tribe parents are very interested in vaccinations. Providing information to tribal communities in an easy-to-understand format that is tailored to their specific culture is essential to ensuring that the message being communicated is successful and that parents are able to make informed decisions and could improve vaccination rates among hill tribe children.^45–47 In this study, to improve access, the study participants also supported initiatives such as direct personal contact or door-to-door campaigns, using VHVs to promote immunization in children, broadcasting vaccine information within specific languages. Improving vaccine accessibility in hard-to-reach areas should increase service provision and thereby improve the initial low vaccine uptake.^48,49

Limitations

This study has several limitations. The major one is that it used purposive sampling method within six hill-tribe groups who were mostly women with low education levels, which may not be generalizable to other hill tribe populations.³¹ Another limitation is that we may be limited by our positionality as outsiders ourselves. Nonetheless, the researchers in our group have a long history of health research in hill tribe populations. The researchers tried to be reflexive, open-minded, and build trust with this community.

Recommendations

As a result of these findings, strategies to increase the vaccination rate of children have been suggested, including the use of VHVs and local radio broadcasts, which are culturally appropriate for hill tribes. In considering possible interventions, we hypothesized that community-based interventions such as vaccination programs in school, provider reminders, and use of a language intervention would support hill tribe parents in childhood vaccination. Ultimately, these findings address collaboration with community leaders or key stakeholders to provide information support and door-to-door interventions led by VHVs to address the vaccination gap, improve trust between parents and healthcare providers, and provide the parents with a sense of safety when vaccinating their children. Further training of healthcare providers to ensure that they can provide culturally appropriate care which is non-stigmatizing to hill tribe people would also be an important intervention.

Conclusion

The results of this study show the parental perception toward vaccination for children aged under five years in the hill tribe community context. Parental beliefs, lack of knowledge, lack of information, difficult previous experiences and poor communication resulted in vaccine hesitancy and lack of trust among hill tribe parents, which explains at least in part why they choose to forgo vaccination for their children, along with challenges related to hill tribe geography. These findings can help us to imagine multiple strategies and interventions, targeting both hill tribe parents and health professionals, which would help reduce parental hesitancy. 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.

Funding Statement

The work was supported by the The Center of Excellence for the Hill Tribe Health Research [CEHR No. 37/2561].

Abbreviations

EPI

Expanded Program on Immunization

SDHPH

Sub-District Health Promotion Hospital

VHVs

Village Health Volunteers

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The audio recordings and transcripts analyzed in this study are not publicity available as it is possible to sufficient deidentify them to maintain participant privacy and confidentiality. Addition deidentify information can be obtained from the corresponding author upon reasonable request (email: katemanee.moo@mfu.ac.th).