Managing vaccination hesitancy under performance-based accountability: a qualitative study of primary care in Türkiye

Vaccine hesitancy is often framed as a consequence of individual beliefs or misinformation. However, growing evidence suggests that vaccination decisions are shaped by broader social and institutional contexts. In Türkiye, childhood vaccination is delivered through a primary healthcare system operating under a performance-based accountability framework. This study aimed to explore how vaccine hesitancy is experienced, negotiated, and managed at the primary healthcare settings. A qualitative study was conducted in a district of Istanbul, Türkiye using semi-structured in-depth interviews with vaccine-hesitant parents, and focus groups with family physicians, and community-level health managers working within the primary healthcare system. Interviews and focus groups explored perceptions of vaccination, experiences of vaccine hesitancy, and strategies used to address hesitancy in clinical practice. Data were analysed thematically to identify patterns across participant groups and to examine how vaccination decisions and encounters were shaped by institutional and social contexts. Four interconnected themes were identified. First, parents frequently expressed uncertainty about the necessity and efficacy of vaccination for diseases not personally encountered, alongside a pattern of confirmatory information seeking. Second, performance-based accountability mechanisms unintentionally undermined trust by leading some parents to interpret physicians’ vaccination recommendations as financially motivated, creating tensions within vaccination encounters. Third, clinical encounters were increasingly characterised by epistemic contestation, as parents drew on alternative sources of authority while physicians reported persuasion fatigue. Finally, vaccine hesitancy and refusal were embedded within social networks and broader processes of institutional trust, which were further reinforced by the COVID-19 pandemic. Family physicians and community-level health managers expressed largely convergent views regarding the challenges of managing vaccine hesitancy within the current primary healthcare framework. Vaccination decision-making reflects interactions between policy frameworks, institutional trust, and socially mediated interpretations of risk and professional authority. Sustaining vaccination programmes requires health systems that not only achieve high coverage but also preserve the trust on which preventive care depends.