Table 3 Distribution of different themes arising from in-depth interviews about vaccine attitudes, Shanghai, 2016

Mandatory and free vaccines

Children should only get mandatory vaccines and no optional vaccines.

5/34

“We are basically doing our vaccines according to the card. […] If it says something is due, we will just do it. Nothing more.” (Participant 20)

For-fee vaccines are a conflict of interest for immunization clinics.

3/34

“I think that for all of the for-fee vaccines there must be some conflict of interest. And the quality of vaccines is vital to children… Like the vaccine scandal last time, right? And the free vaccines […] are implemented nationwide for all children. They shouldn’t have any big problems. Moreover, there shouldn’t be any conflict of interest involved.” (Participant 24)

Vaccine scheduling

Co-administering multiple vaccines in one visit causes too much pain for the child.

8/34

“Of course I will do one shot at a time! Doing five shots at once is too terrible! […] If you do multiple shots, that would be too much pain, right? She will cry every time, and will not get settled afterward.” (Participant 7)

Combination vaccines are convenient by limiting the number of times families must come to clinic.

4/34

“For example the pentavalent vaccine we got today. It saves many office visits and shots for my child.” (Participant 32)

Severity

Mild diseases do not require vaccination

4/34

“For example, diseases that only need a few days resting at home, I think, we may or may not get those vaccines.” (Participant 3)

Diseases impacting development or brain function should be targets of vaccination.

9/34

“For diseases that need hospitalization, or will lead to severe outcome like disability, we definitely will get vaccines.” (Participant 13)

“Many vaccines in this country are […] mandatory. This maybe is due to fact that the disease is fatal, or it will have severe impact on, for example, your ear development or anything. So those are necessary. And I wouldn’t necessarily consider [vaccines] for a disease like the pneumonia or something like that.” (Participant 11)

Severity is the most important disease attribute to consider when making a decision to get a vaccine.

11/34

“It is the severity, not the prevalence, but the severe outcome which is more important. So I will normally consider getting a vaccine for a severe disease.” (Participant 16)

Susceptibility

Prevalence is the most important disease attribute to consider when making a decision to get a vaccine.

7/34

“Like chicken pox, this is necessary. Because the prevalence is quite high. Even if it is a voluntary vaccine, I will still get it for this price.” (Participant 17)

Children should receive vaccines to protect against diseases easily transmitted.

6/34

“Because you will never know where you might encounter disease. Moreover, nowadays, many parents are bringing their kids to rural areas where insect-borne disease are possible. Respiratory infection, insect-borne diseases could all be encountered. So I will get my children vaccinated, regardless of the chance. I have to prevent that.” (Participant 2)

Contagiousness is the most important disease attribute to consider when making a decision to get a vaccine.

5/34

“Maybe diseases that are highly contagious also need to be vaccinated. Not only does it harm the kid, but others as well.” (Participant 3)

Immune system and physical constitution

Immunizations are needed when or if the immune system is not adequately developed.

3/34

“I took my son to get a flu shot when he was one year old. Because I think my kid at one year old does not have a well-developed immune system. [..] Then we also got that when he is two. But when he turned three years old, we stopped. I think his immune system will be better since he has had exposure to more diseases.” (Participant 6)

The immune system works fine by itself, and so some immunizations may be unnecessary.

7/34

“Because for pneumonia you only need to take the [intravenous] drip to get better. There is not a large consequences [for disease]. And for the kid, getting sick once in a while isn’t that bad of a thing, as long as the child can recover from it and be treated for it.” (Participant 11)

Contracting a disease is mediated by an individual’s physical constitution.

10/34

“For me I sometimes think it is not necessary to vaccine on purpose. In fact, for meningitis or any inflammation, it is caused by low levels of immunity in the child and low quality nutrition. In general, changes in the physical constitution will cause these inflammations.” (Participant 24)

“I have two children in the family who developed [pneumonia]—my brother and sisters’ kids. So I felt this vaccine is necessary! Very terrible. But later, based on my child’s physical constitution, and his history in resisting flu or other viruses, we decided not to get this shot.” (Participant 18)

“We chose not to get the Hib vaccine because I think my child’s immunity is okay. Nor did we get the pneumonia vaccine.” (Participant 6)

Too many vaccines are harmful to an individual’s immune system (particularly for those with a certain physical constitution).

6/34

“If a child has an allergic physical constitution, I mean, generally speaking, allergies don’t bother people too much. But other people have a physical constitution with an extreme sensitivity to allergies. Then if they get too many vaccines at once, I am just concerning that they can’t handle them physically.” (Participant 21)

Location of vaccine manufacturer

Chinese-made vaccines are more appropriate.

12/34

“When comparing Chinese vaccines to foreign vaccines, how do you know if the imported ones are more suitable to the physical constitution of Chinese babies?” (Participant 3)

“So if [the vaccines] are produced by the country, there shouldn’t be any problem. But it is not necessarily the case when it comes to for-fee vaccines. […] I will not get imported vaccines, or other imported products like baby formula, because the physical constitution of foreign children are different than ours.” (Participant 24)

Foreign-made vaccines are more appropriate.

16/34

“I had a problem when my daughter got the vaccine, who had a big reaction after getting the country-provided vaccine, but who has had very little reaction after getting the imported ones. […] My daughter got the domestic vaccine once, and she vomited right after the shot, right here. […] So I always chose the imported vaccines after that.” (Participant 10)