Addressing Vaccine Hesitancy in China: A Scoping Review of Chinese Scholarship

"Globally, most strategies to deal with vaccination hesitancy focus on the users of vaccination. However, in the Chinese context, scholars stress the importance of improving the vaccination program itself."

Well-publicised incidents such as the hepatitis B vaccine incident (2014), the Shandong vaccine crisis (2016), and the Changsheng vaccine crisis (2018) have eroded people's confidence in China's National Immunization Program (NIP) and, according to some researchers, have fuelled vaccine hesitancy in this country. Drawn from 4 Chinese databases, this scoping review of Chinese literature (2007-2019) maps relevant information and presents a systemic account of the proposed determinants and responses to vaccine hesitancy in China.

The researchers identified 77 relevant studies during this time period, noting that vaccine hesitancy in China was not studied extensively before 2012. It became a major problem only after the aforementioned series of vaccine safety scandals and incidents in the last decade. The review revealed 4 approaches to vaccine hesitancy:

• Vaccine safety (n = 35): Scholars have pointed to illegal corporate production, supervision model deficits, state-business collusion, and bureaucratic production system as routes for understanding the presence of unsafe vaccines.
• Vaccine incident response (n = 17): Several social policy researchers have noted that public distrust can be attributed to failed crisis management efforts on the part of the state and experts. It has been suggested that the lack of public participation and lack of information transparency in risk assessment, as well as suspicions about state-expert conspiracy, have reduced the credibility of expert risk assessment. Journalists have argued that because local officials are concerned about accountability, they tend to restrain the dissemination of negative information when crises occur. In addition, there are no special personnel and specific policies and strategies to support systematic communication between the state and public, leading to increased distrust of the state. In short, it has been argued that risk communication, instead of being a democratic dialogue, is dominated by experts who communicate top-down and regard the public as ignorant and irrational.
• Professional conduct (n = 12): Researchers have noted, for example, that doctors are impatient and not very responsive to questions during vaccination, which causes the public to be dissatisfied with medical services.
• Parental concerns (n = 13): Some have argued that media reports have stimulated parental distrust with words such as "toxic vaccine". Researchers have also highlighted the prevalence of vaccination hesitancy among medical staff, which leads to negative publicity about vaccines.

In line with the different ways in which Chinese academics have defined the problem of vaccination hesitancy, studies have focused on different strategies to deal with the problem. For example, some scholars have focused on implementing regular training and annual assessments for doctors to improve their communication skills with parents during vaccination. Others have argued for a so-called participatory turn during incident response, suggesting that risk assessment procedures should allow stakeholder participation and that discussion should be conducted with these stakeholders to ensure the fairness of risk assessment.

Some Chinese studies on vaccination hesitancy have put forth new policies to reduce the public's distrust in vaccination. One public policy expert observed that the system of accountability is very complex: The local government, health bureau, court, social supervision committee, and medical ethics committee govern political accountability, administrative accountability, legal accountability, social accountability, and professional accountability, respectively. Due to a lack of collaboration between these bodies, medical staff are confused as to whom they are accountable to and what they are accountable for.

In short, the review found that Chinese literature ties vaccine hesitancy primarily to vaccine safety and medical conduct. Compared to international research, parental concerns are underrepresented. Along similar lines, to reduce vaccine hesitancy and to increase public trust, most studies Chinese have pointed to improvements to the governance and supervision systems of vaccines in China. Even the few studies that do deal with parental beliefs and cognitions consider the beliefs of parents in the context of severe vaccination incidents.

The analysis suggests that strategies to mitigate public distrust in vaccination programmes in China should not only be limited to education of, communication with, and information dissemination to parents, but should also emphasise vaccine safety control, social participation, and transparency in vaccination governance, as well as efforts to raise the standards of medical professionals engaged in vaccination.

In conclusion, the Chinese context of vaccination scandals notably frames the discussion of vaccination hesitancy and potential solutions, which stresses the importance of considering vaccination hesitancy in specific social and political contexts.