Parent and caregiver perceptions about the safety and effectiveness of foreign and domestic vaccines in Shanghai, China
Parent and caregiver perceptions about the safety and effectiveness of foreign and domestic vaccines in Shanghai, China
Zhuoying Huang 0 1 2
Xiaodong Sun 0 1 2
Abram L. Wagner 0 2
Jia Ren 0 1 2
Matthew L. Boulton 0 2
Lisa A. Prosser 0 2
Brian J. Zikmund-Fisher 0 2
0 Funding: This research was funded by the University of Michigan Office of Global Public Health (https://sph.umich.edu/global/), by a University of Michigan Rackham International Research Award ( , USA
1 Department of Immunization Program, Shanghai Municipal Centers for Disease Control & Prevention , Shanghai , China , 2 Department of Epidemiology, School of Public Health, University of Michigan , Ann Arbor, MI , United States of America, 3 Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School , Ann Arbor, MI , United States of America, 4 Child Health Evaluation and Research Unit, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School , Ann Arbor, MI , United States of America, 5 Department of Health Behavior & Health Education, School of Public Health, University of Michigan , Ann Arbor, MI , United States of America, 6 Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School , Ann Arbor, MI , United States of America
2 Editor: Chaojie Liu, La Trobe University , AUSTRALIA
Chinese parents have access to domestic and foreign vaccines for their children. Their
vaccine preferences are unclear, especially given recent pharmaceutical quality scandals and
widely held beliefs deriving from Traditional Chinese Medicine (TCM). This study
characterized parental beliefs about the safety and effectiveness of Chinese and foreign vaccines.
In May 2014, caregivers of young children at public immunization clinics in Shanghai, China,
responded to a survey on vaccine perceptions. The two outcomes (differential belief in the
effectiveness and safety of foreign vs domestic vaccines) were separately regressed onto
demographic predictors in multinomial logistic regression models.
Among 618 caregivers, 56% thought the effectiveness of domestic and foreign vaccines
were comparable; 33% thought domestic were more effective and 11% foreign. Two-thirds
thought foreign and domestic vaccines had similar safety; 11% thought domestic were safer
and 21% thought foreign were safer. Compared to college graduates, those with a high
school education or less had greater odds of believing domestic vaccines were more
effective, and also had greater odds of believing imported vaccines were safer. Greater trust in
TCM was not associated with differential beliefs in the effectiveness or safety of domestic vs
15GWZK0101). ALW's salary was funded through
a Health Outcomes Post Doctoral Fellowship from
the PhRMA Foundation (http://www.
phrmafoundation.org/). The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Although there is no evidence that foreign and domestic vaccines differ in either
effectiveness or safety, less educated caregivers in China (but not those with greater trust in TCM)
appear to believe such differences exist. Further exploration of the causes of these beliefs
may be necessary in order to optimize vaccine communications in China.
Vaccination are an important part of infectious disease control efforts in China [
has a two-tiered vaccination program. The government provides category 1 vaccines for free
to citizens throughout the country at immunization clinics and category 2 vaccines are
available for a cost at these same clinics. The China Experts Advisory Committee on Immunization
Program decides which vaccines are category 1 vaccines within the Expanded Program on
Immunization (EPI) . The EPI in China started in 1978 with Bacillus Calmette-GueÂrin
vaccine, oral polio vaccine, measles vaccine, and diphtheria-tetanus-pertussis vaccine, and it has
since expanded to include hepatitis B vaccine in 2002, as well as hepatitis A, rubella, mumps,
meningococcal meningitis, and Japanese encephalitis in 2007 [
Both domestic, Chinese vaccines and foreign, imported vaccines are available in China.
Category 1 vaccines are produced by Chinese manufacturers [
], but EPI vaccines produced
by foreign manufacturers are also available for sale at immunization clinics and are considered
category 2 vaccines. After a clinical trial, and subsequent approval from the China Food and
Drug Administration, other vaccines can be sold and administered at immunization clinics as
category 2 vaccines [
]. Category 2 vaccines include those produced by both domestic and
foreign manufacturers (pneumococcal polysaccharide vaccine, influenza vaccine, and
Haemophilus influenzae type b vaccine), by only domestic manufacturers (enterovirus 71 vaccine,
rotavirus vaccine and cholera vaccine), and by only foreign manufacturers (pneumococcal
conjugate vaccine and human papillomavirus vaccine). Because of their cost and because they
are not required for school entry, category 2 vaccines have lower coverage than category 1
vaccines; these vaccines are also often administered to infants and children who are older [
past the age at which infants may be most vulnerable to serious disease. Nonetheless, in
Shanghai, category 2 vaccines are a substantial proportion of all doses administered± 46.3% in 2017
(Personal Communication, Xiang Guo, Shanghai CDC, 6 April 2018).
Studies that have directly compared domestic and imported vaccines in China have found
similar immunogenicity and safety profiles. In a study of a domestically produced and
imported measles-mumps-rubella vaccine (MMR), the proportion of individuals seropositive
after vaccination with either vaccine was within three percentage points for measles and
rubella (a larger spread of seven percentage points was seen for mumps), and the rate of
adverse events following immunization was similar for the two vaccines (3.92/100,000 doses
administered for the domestic vaccine and 1.39/100,000 for the imported vaccine) [
Little information is available on differential parental perceptions of vaccines from China vs
other countries. Beliefs about safety and effectiveness could be influenced by concern about
the quality of pharmaceutical products originating within China. Recent news articles have
highlighted how counterfeit products have been linked to serious illness in children and
hospital patients [8±10].
An additional but competing influence on vaccine decision-making in China could be
concepts from Traditional Chinese Medicine (TCM). Currently, 12% of licensed doctors in China
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are TCM practitioners [
], and the Chinese government has officially supported the
promotion and development of TCM [
]. TCM includes concepts like body constitution, which
describes an individual's susceptibility to certain diseases and can better facilitate personalizing
health prevention and promotion activities [
]. Therefore, beliefs about pediatric vaccines
could be influenced by a family's consideration of quality of Chinese vs foreign-made
products, as well as the suitability for products made in China vs other countries for the body of a
Chinese child according to TCM considerations. Qualitative [
] and quantitative [
of parents in Australia have found a relationship between greater beliefs in TCM and
vaccination skepticism; although similar studies have not been conducted in China, beliefs about
TCM could plausibly affect beliefs about vaccines, in general, and in imported vaccines, in
We conducted a study to characterize caregivers' differential beliefs about the safety and
effectiveness of Chinese vs imported vaccines in Shanghai, China. Secondarily, we wanted to
assess the relationship between trust in TCM and Western medicine and differential beliefs
about Chinese vs imported vaccines. These relationships can be used to better understand how
parents in China develop beliefs about vaccines and can be a starting point for thinking about
how best to develop vaccine messaging that targets parents' attitudes, assumptions, and
This cross-sectional study enrolled caregivers (i.e., mothers, fathers, or other) of children aged
8 months to 7 years in May and June of 2014. We employed a two-stage cluster sampling, with
township immunization clinics as the clusters. Townships were selected by a probability
proportionate to size systematic selection procedure based on the population listed in the China
2010 Census. Within each clinic, we selected a convenience sample of 20 caregivers. The
sample size calculation was based on the aims of another project (comparing measles vaccination
timeliness of 81% in non-locals and 91% in locals, which required a total simple random
sample size of 416). We assumed an intracluster correlation coefficient of 0.024 based on a
previous study . With 20 people sampled per cluster, the design effect was 1.456, and the
effective sample size was 606.
The questionnaire collected information on caregiver perceptions of pediatric vaccines. Many
questions were on a 5-point Likert scale from 1 to 5. Perceptions of vaccine effectiveness was
measured by the question ªHow effective are [foreign-made | Chinese-made] vaccines in
Chinese children? (selected from ª(1) Not at all effectiveº to ª(5) Extremely effectiveº). Perceived
vaccine safety corresponded to the question ªHow safe are [foreign-made | Chinese-made]
vaccines in Chinese children? (ª(1) Not at all safeº to ª(5) Extremely safeº). We also measured
perceptions of different medicine systems (beyond vaccinations) through the question ªHow
trustworthy is [TCM | Western medicine] to cure infectious disease?º (ª(1) Not at all
trustworthyº to ª(5) Extremely trustworthyº). Participants were also asked: ªHow trustworthy are
recommendations from your doctors at the immunization clinic?º on the same scale. The
questionnaire is available as part of a previous publication [
Both outcomes (differential belief in effectiveness of domestic vs imported vaccines and
differential belief in safety of domestic vs imported vaccines) were created by placing participants
into one of three categories: those who believed that foreign and domestic vaccines had the
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same safety (or effectiveness), those who believed that foreign vaccines were safer (or more
effective), and those who believed that domestic vaccines were safer (or more effective).
The distribution of the main variables of interest are described with proportions or means and
standard errors (SE). The correlations among beliefs were assessed with Spearman's
Both outcomes were separately regressed onto demographic predictors using a multinomial
logistic regression model, where the referent category was belief that imported and domestic
vaccines had the same effectiveness or safety. Significance was assessed at an α level of 0.05,
and precision of results evaluated through 95% confidence intervals (CI). Survey procedures
were used in the analysis, including clustering at the township level and using sampling
weights. All analyses were conducted in SAS version 9.4 (SAS Institute, Cary, NC, USA).
This study was approved by the University of Michigan Health Sciences and Behavioral
Sciences Institutional Review Board (#HUM00087564) and the Shanghai CDC Ethical Review
Committee (#2014±10). Verbal informed consent was obtained from all individual
participants included in the study prior to data collection.
Of 734 caregivers of children approached at immunization clinics, 618 (84%) agreed to
participate in the survey. Most participants (65%) were mothers, the remainder were fathers (28%) or
other family members (8%), usually grandmothers (Table 1). The participants were balanced
between local (44%) vs non-local (56%) residents.
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A majority of respondents (357, 56%) thought the effectiveness of domestic and imported
vaccines were comparable, whereas 182 (33%) thought domestic were more effective and 76
(11%) foreign. Two-thirds (415, 67%) thought foreign and domestic vaccines had similar
safety, whereas 11% (75) thought domestic were safer and 21% (124) foreign. Trustworthiness
of Western medicine to treat infectious disease was 3.76, compared to 3.28 for TCM. About
half (319, 54%) thought Western medicine and TCM were similarly trustworthy; 35 (6%)
thought TCM more trustworthy and 261 (40%) thought Western medicine more trustworthy.
Participants average rating of trust in doctors was 4.11 (Table 2). Correlations between
variables are shown in Table 1. Beliefs about the effectiveness and safety of imported and domestic
vaccines were highly correlated; although the correlations were higher between the two
questions about imported vaccines and the two questions about domestic vaccines than they were
between the domestic vaccines and imported vaccines. Beliefs about the trustworthiness of
Western medicine and TCM were also significantly, positively correlated.
Table 3 lists the regression results. Income and education were significantly related to
beliefs about vaccine safety and effectiveness. Compared to college graduates, individuals with
a high school education or less had 2.63 times higher odds of believing domestic vaccines were
more effective (95% CI: 1.25, 5.52), and also had 3.69 times higher odds of believing that
imported vaccines were safer (95% CI: 1.64, 8.30). For income, compared to individuals in
families with the highest income levels, individuals whose families made 6 to <10,000 RMB
per month had 0.52 times the odds of believing imported vaccines were safer (95% CI: 0.29,
0.93). As individuals expressed greater trust in doctors, the odds of believing imported
vaccines were safer increased 1.28 times (95% CI: 1.03, 1.59). Higher levels of trust in Western
medicine or TCM was not associated with differential beliefs in the effectiveness or safety of
domestic vs imported vaccines.
Individuals who hold positive beliefs about vaccine safety and effectiveness are more likely to
get vaccinated [
], and so understanding the origination of these beliefs in both Western and
non-Western settings is important to preventing or minimizing vaccine hesitancy [
]. In this
survey from Shanghai, China, most caregivers of young children rated domestic and foreign
vaccines as having similar effectiveness and safety. Of those who expressed a difference
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between the two types of vaccines, slightly more believed that domestic vaccines were more
effective than imported vaccines, but that foreign vaccines were safer than domestic vaccines.
This contrast that is seen in beliefs about effectiveness vs safety could be tied to Chinese
caregivers' confidence in domestic scientific enterprise vs regulatory agencies. Beliefs about
effectiveness could be tied to beliefs about scientific capability (e.g., the clinical trials behind
vaccine development): more Chinese individuals may have growing confidence that scientific
enterprise in China is roughly equivalent in quality to that from abroad. Beliefs about safety
might be more tied to the regulatory environment and the presence of recent food and medical
scandals [8±10]. However, more research is needed on how beliefs about effectiveness and
safety of medical interventions are formed.
Education was a strong factor that was related to differential beliefs in the effectiveness and
safety of domestic vs imported vaccines. Interestingly, those with less education believed
domestic vaccines more effective, but imported vaccines safer. It is unclear how these beliefs
were formed, especially in low education groups. Most vaccine educational materials are
tailored to a rational, analytical approach [
], and may be less effective in lower educational
groups. Additionally, beliefs in both vaccine safety and effectiveness could undoubtedly be
influenced by the vaccine scandal from spring 2016, when it was discovered that expired
vaccines were improperly transported, possibly leading to a few deaths, and leading to many more
children receiving ineffective vaccines [
]. Few studies have actually compared different
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vaccines. One study comparing an imported vs domestically-produced
measles-mumpsrubella vaccine found immunogenicity was slightly higher in the Chinese-made vaccine (e.g.,
86.76% seroconversion for mumps vs 79.17% for the foreign-made vaccine), and the rate of
adverse events was relatively similar (3.92 per 100,000 population vs 1.39 per 100,000
population for the foreign-made vaccine) [
We found a moderate, but significant, positive correlation between trust in TCM and
Western medicine. This could point to a distinction within the Chinese population among those
with greater trust in health authorities (Traditional Chinese or Western) vs those with less
trust in either. Beliefs about the effectiveness and safety of vaccines±both domestic and
imported±more strongly correlated to trust in Western medicine than in TCM, although
neither was related to a differential belief in the effectiveness or safety of domestic vs imported
vaccines. Obviously the development of vaccines in China is an outgrowth of Western
medicine, not TCM, so the correlations among beliefs about domestic vaccine safety, vaccine
effectiveness, and Western medicine suggest that Chinese caregivers' considerations of a ªbody
constitution,º is more of a vague consideration of physical differences between Westerners
and Chinese children, and not differences explicitly delineated by TCM. That greater trust in
doctors was related to belief that imported vaccines were safer could point to the role of
doctors in servicing as trusted sources of information. The important role of doctors in promoting
vaccines has been extensively explored in the Western literature [
], and is particularly
important in settings where caregivers and patients face complicated health care choices.
Public health implications
There are a number of practical implications to our findings, beyond the emphasis that doctors
serve as an important and highly trusted source of health information. Most vaccine messaging
developed today is analytical and focused on facts [
]. However, health decision making is
often based on heuristics and emotions that have little basis in evidence-based science; these
heuristics or unconscious associations may be related to differential beliefs about imported vs.
Chinese vaccines. For parents with a larger distrust of vaccines, generating narratives and
providing consistent pro-vaccination messaging over time can sway opinions [
]. There is not
any reason for vaccination providers to promote domestic or imported vaccines over the
other, and high coverage of either can prevent the spread of infectious disease. However,
certain vaccines, such as pneumococcal conjugate vaccine or human papillomavirus vaccine, will
only be produced by foreign manufactures in the short term. Any attempts to promote
coverage of these vaccines will require public health officials and vaccination providers to recognize
that parents may have different beliefs and perceptions about domestic vs imported vaccines.
Because caregivers tended to think domestic vaccines were more effective, but less safe than
imported vaccines, vaccination providers could emphasize safety when promoting domestic
vaccines and effectiveness when promoting imported vaccines.
Strengths and limitations
There are several limitations. We examined the prevalence of certain beliefs, but cannot
definitively establish causality, or even temporality. In addition, we are limited to the population of
caregivers in Shanghai, and our study may not be generalizable to other locations in China
whose populations differ by education and income. Because we sampled individuals from
immunization clinics, there could be selection bias in that our study population may be more
receptive to receiving immunization services than the general population. However, by
sampling clinics throughout the city of Shanghai, we have a reasonable approximation of the
diversity of beliefs within this city.
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Beliefs of caregivers of young children in China about vaccine safety and effectiveness were
relatively positive in this cross-sectional survey, and most caregivers thought Chinese-made and
imported vaccines had similar effectiveness and safety. As caregivers face choices about giving
their children different vaccines, they are likely influenced by their educational background,
and their understanding of different material, often presented to them by doctors. Trust in
TCM was not associated with differential beliefs in vaccine safety or effectiveness of domestic
vs imported vaccines. Further exploration of the causes of these beliefs may be necessary in
order to optimize vaccine communications in China.
We appreciate the local Centers for Disease Control and Prevention staff and immunization
clinic staff who coordinated site visits and interviews.
Conceptualization: Zhuoying Huang, Abram L. Wagner, Brian J. Zikmund-Fisher.
Formal analysis: Abram L. Wagner.
Funding acquisition: Abram L. Wagner.
Investigation: Zhuoying Huang.
Methodology: Lisa A. Prosser, Brian J. Zikmund-Fisher.
Project administration: Zhuoying Huang, Xiaodong Sun, Jia Ren.
Resources: Xiaodong Sun.
Supervision: Zhuoying Huang, Xiaodong Sun, Jia Ren, Matthew L. Boulton.
Writing ± original draft: Abram L. Wagner.
Writing ± review & editing: Zhuoying Huang, Xiaodong Sun, Jia Ren, Matthew L. Boulton,
Lisa A. Prosser, Brian J. Zikmund-Fisher.
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