Childhood vaccine refusal in Türkiye: a dual perspective qualitative study of parents and healthcare workers.

Background: Childhood vaccine refusal is a growing public health challenge worldwide. In Türkiye, formal refusal, defined as a parental decision to decline one or more scheduled vaccines that is documented in primary care immunization records, rose from 183 families in 2011 to more than 12,000 in 2016, yet the structural, cultural, and ethical dimensions of parental decision-making remain poorly understood. This study explored these tensions from the perspectives of both vaccine-refusing parents and vaccine-administering healthcare workers. Methods: Semi-structured interviews were conducted between February and August 2017, before the COVID-19 pandemic, with 19 vaccine-refusing parents and 21 healthcare workers (physicians, nurses, and midwives) in Türkiye. Participants were recruited through criterion-based purposive sampling combined with snowball sampling, an approach appropriate for a hard-to-reach group. Data were analyzed using hybrid inductive-deductive thematic analysis, combining a deductive framework derived from the interview guides with inductively generated codes. Themes were then interpreted through principlism, relational autonomy, and the best interest of the child standard. Results: Four interconnected ethical tensions were identified: (1) the gap between informed refusal and uninformed choice, shaped by information asymmetry and structural constraints within the performance-based healthcare system; (2) a crisis of trust in healthcare institutions, which participants associated with financial incentives in the payment model and with distrust of the pharmaceutical industry; (3) conflict between religious and medical authority over vaccine permissibility; and (4) contested parental autonomy within patriarchal family structures where mothers' voices were frequently marginalized. Conclusion: Vaccine refusal in Türkiye is embedded in structural, cultural, and relational conditions that information provision alone cannot address. Participants in both groups described the performance-based payment model, which ties part of physicians' pay to preventive service targets, as favouring documentation over dialogue. Effective strategies may therefore require reform of this model, religious literacy training, gender-sensitive clinical approaches, and collaboration with trusted community leaders. These pre-COVID-19 findings provide a baseline for understanding the persistent roots of vaccine hesitancy.