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A substantial amount of study has been undertaken on vaccine hesitancy and the various elements influencing an individuals decision to accept or not accept a vaccine. SAGE developed three categories based on experience in various countries and comprehensive literature reviews to analyze these issues, referred to as the 3Cs model: complacency (not considering diseases as high-risk and vaccination as crucial), convenience (practical obstacles), and confidence (a lack of trust in vaccine safety and effectiveness) [2, 5]. This model was later revised in 2018, emphasizing the importance of more than just the concept of confidence, and emerged as the 5Cs model (Table1): confidence, complacency, constraints (modification of the term convenience to now include both structural and psychological barriers), calculation (individuals engagement in extensive information searching), and collective responsibility (communal orientation to protect others) [18, 19].

In 2016, Thomson et al. introduced a different taxonomy to explain vaccine uptake determining factors, known as the 5As. They identified five categories regarded as access (the ability of an individual to reach or be reached by vaccination), affordability (the capacity of an individual to afford vaccines either financially or non-financially), awareness (personal knowledge about the importance of vaccination as well as its objectives and risks), acceptance (the degree to accept or refuse vaccination), and activation (motivation/encouragement to receive vaccination) [20].

In the Indonesian context, there have been no studies specifically dedicated to assessing or exploring hesitancy regarding routine vaccination using the 5Cs approach. However, a recent study conducted by Sujarwoto et al. [21], which investigated COVID-19 vaccine hesitancy in a district in Indonesia, revealed that respondents held low levels of confidence and complacency beliefs about the vaccine. Furthermore, the study identified more general sources of mistrust within the community, particularly concerning health providers and vaccine developers. However, these factors may vary depending on individual, cultural, and societal contexts. By comprehending these elements, healthcare providers and public health officials can formulate precise strategies to tackle vaccine hesitancy and enhance vaccine acceptance and utilization, as presented in Table 1.

Misinformation and conspiracy theories are widely recognized as critical drivers of vaccine hesitancy. False information about the safety and efficacy of vaccines can spread quickly and easily through social media and other channels, which leading to fear and skepticism about vaccination [22, 23]. One prominent example of vaccine misinformation is the claim that the measles, mumps, and rubella (MMR) vaccine causes autism. As a result, some parents have refused to have their children vaccinated, which in the long term, could lead to outbreaks of measles in specific populations [24, 25].

During the COVID-19 pandemic in Indonesia, misinformation and hoaxes have contributed to vaccine hesitancy among parents and caregivers, especially concerning vaccines that require multiple injections as part of routine immunization [26, 27]. The proportion of children who received their primary measles and rubella immunizations experienced a decline from 95% in 2019 to 87% in 2021. Moreover, there has been a substantial increase in the percentage of children who were not administered the diphtheria, pertussis, and tetanus (DPT) immunizations, rising from 10% in 2019 to 26% in 2021 [27]. This situation poses a significant risk to children, as it increases their susceptibility to a range of preventable diseases.

Beside misinformation and conspiration theories, lack of trust in government and healthcare institutions could impact the vaccine hesitancy. For instance, the case of Tuskegee Syphilis Study, which was conducted by unethically on African American men, has resulted in Black communities [28] enduring mistrust of government and healthcare institutions. Similarly, in Indonesia, the lack of trust in the government has been triggered by various factors, including past conflicts in certain provinces [29] and the governments response to the COVID-19 situation [30]. This lack of trust is exacerbated by existing disparities in healthcare access and delivery, which could lead people to be hesitant about getting the vaccine due to concerns about unequal distribution and difficulty of access [31, 32].

Next, vaccine safety and adverse effects is commonly stimulating vaccine hesitancy [33]. People may be unwilling to get immunized out because they are worried about adverse reactions, especially if they have a history of allergies or prior medical disorders [19, 33]. In the past, there have been questions about the safety of the HPV vaccine due to claims made by certain people that it can result in chronic discomfort, seizures, and even death [34]. The vaccine is safe and effective, but scientific evidence has shown that these allegations are mainly baseless [34, 35].

Similarly, concerns about the safety of the COVID-19 vaccine have been expressed, particularly in light of its rapid development and emergency use authorization [36]. Clinical studies and real-world data have consistently shown that these vaccines are highly effective with minimal risk of severe side effects [37]. However, a national survey on COVID-19 vaccine acceptance conducted by the Ministry of Health of Indonesia, which included 112,888 participants, revealed some concerning results. It showed that 64.8% were willing to take the vaccine, 7.6% were unwilling to take it, and 26.6% were unsure about whether to get vaccinated. Furthermore, participants in the survey expressed various concerns about COVID-19 vaccines. Specifically, 30% were uncertain about the vaccines safety, 22% had reservations about its effectiveness, 12% expressed fears of potential side effects, 8% cited religious or belief-related reasons, and 15% cited other factors [38].

In the social context, previous studies showed that cultural and religious beliefs may also play a role in vaccine hesitancy [39]. Some individuals may be hesitant to get vaccinated due to religious or cultural beliefs that conflict with vaccination, such as the belief that illness is Gods punishment or that alternative remedies are more effective than modern medicine [40].

Concerns about the use of fetal cells in vaccine development and the belief that illnesses are divine punishment have contributed to vaccine reluctance in some Orthodox Jewish communities, for instance [41, 42]. Correspondingly, in Indonesia, a country where approximately 87% of the population is Muslim, concerns have arisen over the use of non-halal components obtained from pork in vaccine formulations. These concerns have the potential to increase vaccine hesitancy in the country [43].

In addition, vaccine hesitancy may be influenced by socioeconomic variables such as low income, educational attainment, and limited healthcare accessibility [44]. Individuals residing in financially disadvantaged conditions may encounter obstacles in accessing vaccinations, such as financial constraints or scheduling conflicts that prevent them from receiving the vaccine promptly, or they may opt not to receive it [44, 45]. Individuals with lower education levels may have a restricted understanding of vaccines and their advantages, rendering them more vulnerable to misinformation [46]. In addition, inadequate healthcare accessibility may impede individuals from obtaining vaccinations on time, while restricted access to precise health information may result in misconceptions or skepticism regarding vaccines [47].

Behavioural scientists have investigated how heuristics, including vaccination, might influence judgement and decision making. Heuristics, a mental shortcut that enables people to solve problems quickly and make intuitive decisions, can be helpful when initiated by the correct variables [48, 49]. However, the influence of wrong circumstances such as misinformation and disinformation, and anti-vaccine movement, can lead to systemic errors or cognitive biases. For example, omission bias occurs when people tend to view harms from the act commission (actions) as more excellent than harms from omission (inactions); confirmation bias refers to the finding that strong initial beliefs are resistant to change because they influence how subsequent information is interpreted; and the Dunning Krueger effect, in which people who lack expertise fail to accurately assess their knowledge in comparison to experts on the subject [49].

Notwithstanding the unwillingness of specific individuals to receive vaccines, it is important to acknowledge the existence and impact of the anti-vaccine movement. They engage in campaigns against vaccines, frequently disseminating inaccurate information and instilling apprehension regarding their safety and efficacy [50]. The current campaign has the potential to generate vaccine hesitancy among individuals who had previously placed their trust in the healthcare system and vaccination initiatives. The outcome is an escalating count of individuals who hesitate or deliberately decline vaccination, resulting in decreased vaccination rates and heightened susceptibility to diseases that vaccines can prevent [50, 51]. Consequently, it is fundamental to acknowledge the apprehensions of individuals who are hesitant towards vaccines and furnish precise information to refute the misinformation propagated by the anti-vaccine movement.

Vaccine hesitancy has been found to be associated with a range of socio-economic and demographic variables. The prevalence of concerns regarding the safety and effectiveness of vaccines is observed to be higher in high-income countries (HICs), as opposed to low- and middle-income countries (LMICs), where factors such as cultural and religious convictions, unfavorable past encounters with foreign medical interventions and vaccination initiatives, and challenges within healthcare systems are more prevalent [52]. Common factors between the two categories encompass a lack of trust in medical institutions and governmental bodies, the spreading of conspiracy theories, and the dissemination of misinformation through social media [19, 52].

Parents who declined to vaccinate their children or held a pessimistic outlook towards vaccination were found to be more susceptible to demonstrating such apprehensions [53]. The primary rationale cited by parents in India, Nigeria, and Pakistan for abstaining from vaccinating their children was the perceived risk of adverse effects associated with immunization. The apprehension regarding severe adverse effects may stem from prior encounters with unfavorable incidents after immunization, which may be attributed to the vaccination process [54,55,56]. This, together with the belief that vaccines may cause harm, has led to the perception that vaccinations result in adverse reactions such as fever. Furthermore, a commonly reported conjecture was that the polio vaccine administration was linked to adult sterility, leading to a significant number of parents declining to immunize their children with the vaccine [56].

In the Indonesian context, vaccine hesitancy can be attributed to various factors, given the countrys middle-income status. The complexity of the issue presents a significant challenge [26]. Vaccine hesitancy in Indonesia is a multifaceted problem that requires tailored and collaborative efforts across various sectors. Despite the governments initiatives to improve vaccination rates, there remains a substantial gap in our understanding of the factors influencing vaccine acceptance and hesitancy [26, 57].

Furthermore, it is critical to highlight the significant disparities in vaccine coverage observed across Indonesias nationwide measles and rubella (MR) immunization program. Coverage rates vary widely among districts, ranging from as low as 2% to as high as 100%. Notably, more than one-third of districts report coverage rates below the established threshold of 70%. The link between the discontinuation of vaccination programs due to hesitancy and the subsequent decline in coverage rates is well-established [26].

Moreover, the hesitancy to receive the COVID-19 vaccine in Indonesia has been found to be highly correlated with various socio-demographic characteristics, including age, residential location, educational attainment, employment status, and family economic situation. Participants from Indonesia, Myanmar, Thailand, and Vietnam exhibited a higher degree of hesitancy towards receiving COVID-19 vaccines compared to their counterparts from the Philippines [58].

Additionally, concerns about vaccine safety have played a substantial role in shaping public discourse. Negative perceptions of vaccine safety, including anxieties about the rapid pace of vaccine development, have been identified as a primary driver of hesitancy. In low- and middle-income countries (LMICs) like Indonesia, where documented COVID-19 cases and fatalities have been relatively lower, individuals may perceive the disease as less severe, leading to reduced willingness to accept any potential risks associated with vaccination [59].

Finally, it is worth emphasizing that confidence in routine vaccinations has declined amid the ongoing COVID-19 pandemic. This trend has been observed in numerous countries, with some experiencing a significant decrease of up to 44 percentage points. The diminishing confidence level, coupled with the unique challenges faced by LMICs, has further exacerbated vaccine hesitancy in Indonesia [60].

In high-income countries, vaccine hesitancy could originate from complacency, as vaccine-preventable diseases have declined in these regions. In 2019, there were more than 1200 reported measles cases across 31 states in the United States [61]. This trend can be partially attributed to vaccine hesitancy [62]. Certain parents resisted vaccinating their children because of concerns regarding vaccines safety and probable negative consequences. Meanwhile, a few others declined vaccination due to their religious or philosophical convictions. The epidemic underscored the necessity for enhanced instruction and consciousness regarding the importance of immunizations, alongside endeavors to counteract the dissemination of false information concerning immunizations and enhance immunization availability. In Europe, there have been recent outbreaks of vaccine-preventable diseases such as measles and mumps [27, 63], which have been attributed to vaccine hesitancy. Vaccine hesitancy in certain nations is linked to a dearth of confidence in governmental and healthcare establishments, alongside a conviction that vaccines are superfluous owing to advancements in sanitation and hygiene. These outbreaks have led to demands for heightened vaccination rates and initiatives aimed at addressing vaccine hesitancy through public awareness drives and improved availability of vaccines.

Moreover, a contentious issue exists regarding the administration of the human papillomavirus (HPV) vaccine, which further exacerbates hesitancy [34]. Although the vaccine has demonstrated effectiveness in preventing cervical cancer and other diseases associated with HPV, some parents in developed countries are unwilling to immunize their children due to worries regarding the vaccines safety and potential negative consequences. The safety concerns surrounding the HPV vaccine were subject to investigation in Denmark [64]. The media initiated coverage of purported unfavorable occurrences concerning Danish females, encompassing a documentary that portrayed a cohort of girls exhibiting diverse incapacitating symptoms that were presumed to have been induced by HPV vaccination. The findings indicate a rapid decline in the utilization of HPV vaccination in the specified nation during the period spanning from 2009 to 2014 [64]. In certain instances, the reluctance has been intensified by inaccurate information propagated through social media and other communication platforms. As a result, the vaccination rates for HPV in certain high-income nations have persisted below the recommended levels set by public health authorities, leading to a continued susceptibility to HPV-associated illnesses among those who have not received the vaccine.

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