Vaccine Hesitancy Among Caregivers in China: Associations of Misinterpreted AEFI, Compensation Awareness, and Institutional Trust

Background: Vaccine hesitancy remains a major global public health challenge despite high immunization coverage. While concerns about adverse events following immunization (AEFI) are widely recognized, limited attention has been paid to caregivers’ ability to distinguish vaccine-related adverse reactions from coincidental illnesses, as well as to the associations of compensation awareness and institutional trust with vaccination decisions. Methods: A cross-sectional survey was conducted between January and March 2025 among 3497 caregivers of children aged 0–6 years using multistage random sampling. Data were collected on AEFI knowledge (including understanding of coincidental illnesses), compensation mechanism awareness, institutional trust, and vaccination behaviors. Vaccine hesitancy was assessed using a self-reported measure and the WHO SAGE Vaccine Hesitancy Scale (VHS). Multivariable linear regression models were used to estimate factors associated with hesitancy scores. Results: The prevalence of vaccine hesitancy was 8.6%, with a mean VHS score of 23.2 ± 4.2. Although general awareness of AEFI reached 90.0%, correct understanding of coincidental illnesses was only 25.7%. Higher AEFI knowledge and compensation awareness were associated with lower hesitancy scores, whereas distrust in compensation mechanisms and perceived vaccine unsafety were associated with higher hesitancy. Coverage of national immunization program (NIP) vaccines exceeded 90%, while uptake of self-paid vaccines varied from 46.7% to 89.7%. Conclusions: Vaccine hesitancy among caregivers was associated with cognitive understanding, economic considerations, and institutional trust. Limited understanding of coincidental illnesses may be associated with increased concerns about vaccine safety, while compensation awareness and institutional trust were associated with lower levels of vaccine hesitancy. Strengthening communication on AEFI causality and improving transparency of compensation policies may help reduce vaccine hesitancy and support immunization programs in settings with mixed public–private financing systems.