Integrating vaccine hesitancy into the health belief model: additive effects on parental decision-making for child RSV vaccination

Respiratory syncytial virus (RSV) is a major cause of respiratory infections in young children. With pediatric RSV vaccines in late-stage clinical evaluation, understanding how parental perceptions and vaccine hesitancy (VH) shape vaccination intentions is critical for achieving high vaccination coverage and maximizing public health benefits. This study applied the Health Belief Model (HBM) to identify factors influencing vaccination intentions and examined VH as a distinct outcome alongside vaccination intention within the HBM framework. A survey of 402 parents of children aged ≤ 5 years in South Korea assessed RSV knowledge, HBM constructs, and VH. Structural equation modeling (SEM) was used to test two models: (1) an HBM-only model examining pathways from knowledge to vaccination intention mediated by HBM constructs and (2) an extended HBM–VH model specifying both vaccination intention and VH as parallel outcomes. Overall, 17% of parents reported no intention to vaccinate their children against RSV. At the bivariate level, RSV knowledge, HBM constructs, and VH were all significantly associated with vaccination intention. In the HBM-only SEM, perceived susceptibility and cues to action mediated the relationship between RSV knowledge and intention. In the extended HBM–VH model, RSV knowledge was indirectly associated with vaccination intention through HBM constructs (β = 0.15, p < 0.001). Vaccination intention was most strongly associated with cues to action (β = 0.31, p < 0.001), whereas VH was most strongly associated with perceived barriers (β = 0.73, p < 0.001). Incorporating VH improved the model’s stability and explanatory power. VH represents a distinct construct within the HBM, and its inclusion enhances understanding of parental decision regarding vaccination. Strengthening provider training to address hesitancy and improving parent–provider communication may further promote vaccine acceptance.