Original Article
Determinants of COVID-19 pediatric vaccine hesitancy
and uptake among parents from Pakistan
Determinantes de la reticencia y aceptación
de los padres, en Pakistán, frente a la vacunación pediátrica contra la
COVID-19
Muhammad Subhan Arshad1,2* ORCID: https://orcid.org/0000-0003-0282-0216
Imran Imran3
ORCID: https://orcid.org/0000-0003-1337-8574
Hamid Saeed4 ORCID: https://orcid.org/0000-0002-1400-4825
Imran Ahmad5
ORCID: https://orcid.org/0000-0001-6509-6742
Muqarrab
Akbar6 ORCID: https://orcid.org/0000-0001-8417-315X
Muhammad Omer Chaudhry7 ORCID: https://orcid.org/0000-0002-1298-7709
Muhammad Fawad Rasool1 ORCID: https://orcid.org/0000-0002-8607-8583
1 Department
of Pharmacy Practice, Faculty of Pharmacy, Bahauddin
Zakariya University, Multan, Pakistan.
2 Department
of Pharmacy, Southern Punjab Institute of Health Sciences, Multan, Pakistan.
3 Department
of Pharmacology, Faculty of Pharmacy, Bahauddin
Zakariya University, Multan, Pakistan.
4 University
College of Pharmacy, Allama Iqbal Campus, University
of Punjab, Lahore, Pakistan.
5 Department
of Pharmaceutical Chemistry, Faculty of Pharmacy, Bahauddin
Zakariya University, Multan, Pakistan.
6 Department
of Political Science, Bahauddin Zakariya University,
Multan, Pakistan.
7 School of
Economics, Bahauddin Zakariya University, Multan, Pakistan.
Corresponding author: fawadrasool@bzu.edu.pk
ABSTRACT
Parental hesitancy to vaccinate their children may be
an obstacle to achieving herd immunity against COVID-19. The current study was
aimed to assess the prevalence of parental vaccine hesitancy, vaccine uptake,
and factors associated with these behaviors. A web-based descriptive study
design was used in this study. A self-administered questionnaire was used to
collect data conveniently from Pakistani parents with children younger than 18
years. The participants self-reported the vaccination status among their
children along with their socio-demographic details and attitudes towards
COVID-19 vaccination in children. The association between different variables
was assessed using the Chi-square test, while logistic regression analysis was
performed to assess the predictors of vaccine hesitancy and uptake. Among the
386 study participants, 30 % were hesitant to be vaccinated, while 70 % got
their children vaccinated against COVID-19. The younger parents, having one
child (<12 years), were more hesitant to vaccinate them. Vaccine uptake was
most commonly reported among participants who agreed with the safety and
effectiveness of the COVID-19 vaccine in children. Health authorities should
start educational campaigns to convince hesitant Pakistani parents about the
benefits and safety of pediatric vaccination in order to promote the
vaccination of children against COVID-19.
Keywords: COVID-19;
children; immunization; parents; vaccine hesitancy.
RESUMEN
La reticencia de los padres a la hora de vacunar a
sus hijos puede ser un obstáculo para lograr la inmunidad contra la COVID-19.
El objetivo del presente estudio fue evaluar la prevalencia de la vacilación de
los padres frente a la vacunación, la aceptación de la vacuna y los factores
asociados a estos comportamientos. En este estudio se utilizó un diseńo de
estudio descriptivo basado en la web. Se utilizó un cuestionario
autoadministrado para recopilar convenientemente datos de padres pakistaníes
con hijos menores de 18 ańos. Los participantes informaron del estado de
vacunación de sus hijos, junto con sus datos sociodemográficos y sus actitudes
hacia la vacunación infantil contra la COVID-19. La asociación entre las
distintas variables se evaluó mediante la prueba de Chi-cuadrado, mientras que el
análisis de regresión logística se realizó para evaluar los factores
predictivos de la reticencia y la aceptación de la vacuna. De los 386
participantes en el estudio, el 30 % dudó vacunarse, mientras que el 70 %
vacunó a sus hijos contra la COVID-19. Los padres más jóvenes, con un solo hijo
(<12 ańos), se mostraron más reticentes a vacunarlos. La aceptación de la
vacuna fue más frecuente entre los participantes que estaban de acuerdo con la
seguridad y eficacia de la vacuna contra COVID-19 en nińos. Las autoridades
sanitarias deberían iniciar campańas educativas para convencer a los padres
pakistaníes indecisos sobre los beneficios y la seguridad de la vacunación
pediátrica con el fin de promover la vacunación de los nińos contra la
COVID-19.
Palabras clave: COVID-19; nińos; inmunización; padres; vacilación a la
vacuna.
Received: July
11, 2024
Accepted: March
11, 2025
Introduction
One of the supreme achievements of modern-day medicines is the development
of vaccines to save lives by preventing the outbreak of infectious diseases.(1) Vaccination programs are considered the most effective public health
strategy against infectious diseases, and are predicted to prevent 5.2 million
deaths annually.(2) The eradication of smallpox and the near eradication of polio are evidence
of the mass vaccination programs’ success.(3) Various epidemiological and clinical studies have demonstrated the
beneficial effects of vaccination, like reduction of incidence by prevention,
and decrease in the severity of infectious diseases. In addition to these
benefits, vaccination also lessens the social and economic impact of diseases.(4)
The development of the COVID-19 vaccine played an essential role in
controlling the pandemic situation.(5) COVID-19 vaccines are safe and effective with a high efficacy (70 % to 95
%) and tolerable adverse effects. Among them, mRNA based vaccines have had the
highest effectiveness (94.29 %) and mostly have some severe adverse effects
like headache, fatigue, and pain.(6) At the beginning, COVID-19 vaccines were approved only for adults. Later,
vaccination of children and adolescents was also recommended, after getting
further safety data.(7) It is necessary to vaccinate children and adolescents against COVID-19 to
protect them from the adverse impact of the disease and to attain herd
immunity.(8) In Pakistan, pediatric COVID-19 vaccination was approved in September 2022
for children above 5 years of age and subsequently parents were advised to
vaccinate their children.(9)
Vaccine hesitancy is defined as “a delay in acceptance or refusal of
vaccination despite the availability of vaccination services. Vaccine hesitancy
is complex and context-specific, varying across time, place, and vaccines. It
is influenced by factors such as complacency, convenience, and confidence.”(10) It is considered one of the top 10 threats to public health and acts as a
significant hurdle in the success of vaccination campaigns.(11,12) The vaccine uptake is defined as the use of a vaccine in an immunization
program.(13) Like other vaccination programs, the COVID-19 vaccination campaign also
faced vaccine hesitancy as a major hurdle to its success which is relatively
more prevalent in a country like Pakistan where conspiracy theories are
commonly believed by the general population as propaganda of Western countries
to suppress the Muslim nations.(14,15,16) The worldwide parental COVID-19 vaccination acceptance rate for their
children was lower than the general public's COVID-19 vaccine acceptance rate.(17,18)
To the best of our knowledge, parental vaccination hesitation in immunizing
their children against COVID-19 had not been thoroughly investigated in
Pakistan until the conduction of the current study, regardless of a previous
study from four districts of Pakistan.(9) To investigate this issue of great importance in detail, the current study
set out to evaluate parental uptake of COVID-19 vaccine and hesitancy to
vaccinate their children, to evaluate parental attitudes towards children's
COVID-19 vaccination and to identify the factors associated with vaccine uptake
and hesitancy.
Materials and
Methods
Study design
This study was conducted in Pakistan using a descriptive web-based
cross-sectional study design. Every parent citizen of Pakistan with children
aged 5-18 years was eligible to participate in this study. The vaccination was
approved for children above 5 years throughout the country in September 2022.(9) The analysis did not include the responders who declined to participate
after reading the study's introduction letter (informed consent). The
eligibility requirements to participate in the study were: to be a Pakistani
citizen and to have at least one child aged 5-18 years.
Sample size
A minimum sample was calculated using Raosoft, an
online sample size estimator to represent the target population. A minimal
sample size of 377 was computed, with a 5 % margin of error, a 95 % confidence
interval, and a 50 % response distribution. As we were not sure about total
population of Pakistani parents, so utilized default setting of sample size
calculator for unknow population.
Study instrument
The first draft of the current study's self-administered questionnaire
(SAQ) was developed using a pre-validated SAQ from a multi-country study in the
Eastern Mediterranean area.(19) There were two sections in the SAQ. The first section of the SAQ comprised
19 mandatory questions to gauge individuals' attitudes regarding COVID-19
immunization for children. Participants responded to these questions using a
Likert scale (Agree, Neutral, and Disagree).(20) In the second section, participants asked questions about sociodemographic
and COVID-19-related information, including their age, gender, marital status,
monthly income, professional affiliation, level of education, residential area,
history of infections, vaccination status, number of children, and ages of
their children.
Validation of SAQ
The SAQ was initially created in English and then translated into Urdu by
local multilingual specialists. Before to final approval, a panel of topic
specialists in Pharmacy Practice and Public Health reviewed the SAQ's content
and face validity. A pilot study with 50 respondents was done to ensure the
validity of the questionnaire in the intended population. The SAQ was also
enhanced in response to comments and questions from pilot research
participants. The internal consistency of the SAQ was assured by using commonly
used statistical test Cronbach alpha, who’s value of 0.8 indicated the
reliability of the SAQ.
Ethical considerations
Before administering the SAQ, informed consent was
electronically collected from each participant. The people who agreed to
participate in the study were only allowed to submit a response against the SAQ
after giving background information about the study. The study did not ask
questions that could expose participants' identities to minimize Hawthorne
bias. The study was approved by the ethical review committee of Department of
Pharmacy Practice, Faculty of Pharmacy, Bahauddin
Zakariya University, Multan, Pakistan and Declaration of Helsinki was followed
in its conduction.
Data collection
A convenient sampling technique was used to collect data from the target
population by uploading the study instrument to Google Form (Google LLC, Menlo
Park, CA, USA). Then, its online link was shared via various platforms like
WhatsApp, Facebook, Email, etc. After that, from 11 January to 22 March 2023,
responses were received through this online link for 10 weeks. The checklist
for reporting results of internet E-surveys (CHERRIES) guidelines was followed.(21)
Data analysis
The statistical package for the social sciences (SPSS), version 21.0 (IBM,
Armonk, NY, USA), was used for data analysis. Descriptive statistics were used
to present the study variables; the categorical variables were presented as
frequencies (n) and percentages (%). For inferential analysis, the Chi-square
test was performed to examine significant differences between categorical
variables. A univariate logistic regression analysis was conducted for each
significant linked demographic variable to assess the predictors of COVID-19
vaccination uptake and vaccine hesitancy. An alpha value of ≤ 0.05 was considered
statistically significant.
Results
A total
of 651 responses were received until the 22nd of March, of which 11 were
excluded as they didn’t consent to participate in the study and 254 responses
that didn’t meet eligibility criteria were excluded from the final analysis.
After this, the remaining 386 responses were included in the final analysis.
Among the 386 study participants, 199 (51.6 %) were male, and 187 (48.4 %) were
female, with a mean age of 32.8 (SD ± 7.5) years; 276 (71.5 %) had a profession
not related to health and 110 (28.5 %) had a health-related profession. Three
hundred and fifty-four (91.7 %) participants had been vaccinated against
COVID-19. The majority of the study participants, 164 (42.5 %), had at least
two children, while 239 (61.9 %) participants had children aged less than 12
years (Table
1).
Table 1. Socio-demographic details of the study
participants (N = 386).
|
Variables |
|
Frequency |
Percentage |
|
Gender |
Male |
199 |
51.6 % |
|
|
Female |
187 |
48.4 % |
|
|
18 to 29 |
131 |
33.9 % |
|
Participant’s age (years) |
30 to 39 |
179 |
46.4 % |
|
|
40 to 49 |
65 |
16.8 % |
|
|
≥ 50 |
11 |
2.8 % |
|
Professional belonging |
Health-related |
110 |
28.5 % |
|
|
Not related to health |
276 |
71.5 % |
|
|
Primary (1-5) |
10 |
2.6 % |
|
|
Secondary (6-10) |
30 |
7.8 % |
|
Education level |
Intermediate (11-12) |
49 |
12.7 % |
|
|
Bachelor (13-16) |
176 |
45.6 % |
|
|
Master or above |
121 |
31.3 % |
|
|
< 20,000 |
48 |
12.4 % |
|
|
20,000 to 40,000 |
71 |
18.4 % |
|
Monthly income (PKR) |
40,001 to 60,000 |
78 |
20.2 % |
|
|
> 60,000 |
85 |
22.0 % |
|
|
No income |
104 |
26.9 % |
|
Residential area |
Rural |
158 |
40.9 % |
|
|
Urban |
228 |
59.1 % |
|
|
Yes |
80 |
20.7 % |
|
Participant’s COVID-19 infection history |
No |
266 |
68.9 % |
|
|
Maybe |
40 |
10.4 % |
|
Participant’s COVID-19 vaccination status |
Yes |
354 |
91.7 % |
|
|
No |
32 |
8.3 % |
|
Number of children |
1 |
110 |
28.5 % |
|
|
2 |
164 |
42.5 % |
|
|
3 or More |
112 |
29. 0% |
|
|
Between 12 to 17 years |
81 |
21.0 % |
|
Children's age |
5 to 12 Years |
239 |
61.9 % |
|
|
Have children in both age groups |
66 |
17.1 % |
The association between the
research participants' socio-demographic factors and their children's COVID-19
vaccination status by using the Chi-square test
is shown in Table 2. This inferential analysis revealed that the age (p =
0.003), monthly income (p = 0.027), and COVID-19 vaccination status of the
study participants (p < 0.001) were significantly associated with their
children's COVID-19 vaccination status. The children-related details of the
study participants, i.e. the number of children (p = 0.016) and children’s age
(p < 0.001) were also found to be significantly associated with the
vaccination status of their children.
Table 2. Association between socio-demographics details
of participants and COVID-19 vaccination status of their children (N = 386).
|
|
|
Children's vaccination |
COVID-19 status |
|
|
Variables |
|
Yes N (%) |
No N (%) |
P-value |
|
Gender |
Male |
137 (68.8 %) |
62 (31.2 %) |
0.552 |
|
|
Female |
133 (71.1 %) |
54 (28.9 %) |
|
|
|
18 to 29 |
82 (62.6 %) |
49 (37.4 %) |
|
|
Participant’s age (years) |
30 to 39 |
121 (67.6 %) |
58 (32.4 %) |
0.003* |
|
|
40 to 49 |
56 (86.2 %) |
9 (13.8 %) |
|
|
|
≥ 50 |
10 (90.9 %) |
1 (9.1%) |
|
|
Professional
belonging |
Health-related |
80 (72.7 %) |
30 (27.3 %) |
0.412 |
|
|
Not related to
health |
190 (68.8 %) |
86 (31.2 %) |
|
|
|
Primary (1-5) |
5 (50.0 %) |
5 (50.0 %) |
|
|
|
Secondary (6-10) |
23 (76.7 %) |
7 (23.3 %) |
|
|
Education level |
Intermediate
(11-12) |
38 (77.6 %) |
11 (22.4 %) |
0.225 |
|
|
Bachelor (13-16) |
126 (71.6 %) |
50 (28.4 %) |
|
|
|
Master or above |
78 (64.5 %) |
43 (35.5 %) |
|
|
|
< 20,000 |
35 (72.9 %) |
13 (27.1 %) |
|
|
|
20,000 to 40,000 |
51 (71.8 %) |
20 (28.2 %) |
|
|
Monthly income (PKR) |
40,001 to 60,000 |
57 (73.1 %) |
21 (26.9 %) |
0.027* |
|
|
> 60,000 |
67 (78.8 %) |
18 (21.2 %) |
|
|
|
No income |
60 (57.7 %) |
44 (42.3 %) |
|
|
Residential area |
Rural |
114 (72.2 %) |
44 (27.8 %) |
0.381 |
|
|
Urban |
156 (68.4 %) |
72 (31.6 %) |
|
|
|
Yes |
60 (75.0 %) |
20 (25.0 %) |
|
|
COVID-19
infection history |
No |
182 (68.4 %) |
84 (31.6 %) |
0.494 |
|
|
Maybe |
28 (70.0 %) |
12 (30.0 %) |
|
|
COVID-19 vaccination status |
Yes |
259 (73.2 %) |
95 (26.8 %) |
< 0.001* |
|
|
No |
11 (34.4 %) |
21 (65.6 %) |
|
|
Number of
children |
1 |
65 (59.1 %) |
45 (40.9 %) |
|
|
|
2 |
122 (74.4 %) |
42 (25.6 %) |
0.016* |
|
|
3 or more |
83 (74.1 %) |
29 (25.9 %) |
|
|
|
12 to 17 years |
70 (86.4 %) |
11 (13.6 %) |
|
|
Children's age (years) |
< 12 years |
138 (57.7 %) |
101 (42.3 %) |
< 0.001* |
|
|
Have children in
both age groups |
62 (93.9 %) |
4 (6.1 %) |
|
Statistically significant findings (p ≤ 0.05).
The association of the study participants’responses to
the attitude statements regarding COVID-19 vaccination with vaccination status
of their children when using the Chi-square test is presented in Table 3.
Various attitude statements were found to be significantly associated with the
children’s COVID-19 vaccination status: vaccination protects children from
COVID-19 infection (p < 0.001), COVID-19 vaccines are safe (p < 0.001),
encouragement of vaccination against COVID-19 (p < 0.001), and vaccination
against COVID-19 will end this pandemic (p = 0.001).
Table 3. Association between participants' responses to attitude statements
regarding COVID-19 vaccination for children and the vaccination status of their
children (N = 386).
|
|
Total (N=386) |
Children's COVID-19 |
vaccination
status |
|
|
Variables |
Yes |
No |
P-value |
|
|
|
N (%) |
N (%) |
N (%) |
|
|
COVID-19
vaccines protect children from COVID-19 infection |
|
|
|
|
|
Agree |
307 (79.5 %) |
230 (74.9 %) |
77 (25.1 %) |
|
|
Neutral |
57 (14.8 %) |
32 (56.1 %) |
25 (43.9 %) |
<0.001* |
|
Disagree |
22 (5.7 %) |
08 (36.4 %) |
14 (63.6 %) |
|
|
COVID-19
vaccines are safe for children |
|
|
|
|
|
Agree |
275 (71.2 %) |
211 (76.7 %) |
64 (23.3 %) |
|
|
Neutral |
79 (20.5 %) |
48 (60.8 %) |
31 (39.2 %) |
<0.001* |
|
Disagree |
32 (8.3 %) |
11 (34.4 %) |
21 (65.6 %) |
|
|
I encourage
children’s vaccination against COVID-19 |
|
|
|
|
|
Agree |
279 (72.3 %) |
213 (76.3 %) |
66 (23.7 %) |
|
|
Neutral |
70 (18.1 %) |
40 (57.1 %) |
30 (42.9 %) |
<0.001* |
|
Disagree |
37 (9.6 %) |
17 (45.9 %) |
20 (54.1 %) |
|
|
COVID-19
infection can occur even after vaccination |
|
|
|
|
|
Agree |
212 (54.9 %) |
144 (67.9 %) |
68 (32.1 %) |
|
|
Neutral |
109 (28.2 %) |
78 (71.6 %) |
31 (28.4 %) |
0.601 |
|
Disagree |
65 (16.8 %) |
48 (73.8 %) |
17 (26.2 %) |
|
|
Children who
were infected with COVID-19 do not need to get vaccinated |
|
|
|
|
|
Agree |
92 (23.8 %) |
61 (66.3 %) |
31 (33.7 %) |
|
|
Neutral |
81 (21.0 %) |
54 (66.7 %) |
27 (33.3%) |
0.406 |
|
Disagree |
213 (55.2 %) |
155 (72.8 %) |
58 (27.2 %) |
|
|
Natural immunity
is better than the vaccine |
|
|
|
|
|
Agree |
206 (53.4 %) |
132 (64.1 %) |
74 (35.9 %) |
|
|
Neutral |
91 (23.6 %) |
67 (73.6 %) |
24 (26.4 %) |
0.018* |
|
Disagree |
89 (23.1 %) |
71 (79.8 %) |
18 (20.2 %) |
|
|
Healthy children
do not need a vaccine against COVID-19 |
|
|
|
|
|
Agree |
85 (22.0 %) |
62 (72.9 %) |
23 (27.1 %) |
|
|
Neutral |
72 (18.7 %) |
46 (63.9 %) |
26 (36.1 %) |
0.430 |
|
Disagree |
229 (59.3 %) |
162 (70.7 %) |
67 (29.3 %) |
|
|
COVID-19 is
exaggerated, it’s not a risky disease, so no vaccination is needed |
|
|
|
|
|
Agree |
62 (16.1 %) |
41 (66.1 %) |
21 (33.9 %) |
|
|
Neutral |
67 (17.4 %) |
44 (65.7 %) |
23 (34.3 %) |
0.468 |
|
Disagree |
257 (66.6 %) |
185 (72.0 %) |
72 (28.0 %) |
|
|
Masks, hygiene,
social distancing, and other protective measure are enough |
|
|
|
|
|
Agree |
150 (38.9 %) |
102 (68.0 %) |
48 (32.0 %) |
|
|
Neutral |
102 (26.4 %) |
70 (68.6 %) |
32 (31.4 %) |
0.606 |
|
Disagree |
134 (34.7 %) |
98 (73.1 %) |
36 (26.9 %) |
|
|
I oppose all
vaccines for children (not only COVID-19 vaccine) |
|
|
|
|
|
Agree |
73 (18.9 %) |
51 (69.9 %) |
22 (30.1 %) |
|
|
Neutral |
63 (16.3 %) |
41 (65.1 %) |
22 (34.9 %) |
0.639 |
|
Disagree |
250 (64.8 %) |
178 (71.2 %) |
72 (28.8 %) |
|
|
Vaccination is
only needed for the elderly and those with chronic illnesses |
|
|
|
|
|
Agree |
76 (19.7 %) |
54 (71.1 %) |
22 (28.9 %) |
|
|
Neutral |
73 (18.9 %) |
47 (64.4 %) |
26 (35.6 %) |
0.515 |
|
Disagree |
237 (61.4 %) |
169 (71.3 %) |
68 (28.7 %) |
|
|
COVID-19 vaccine
benefits outweigh the side effects |
|
|
|
|
|
Agree |
177 (45.9 %) |
135 (76.3 %) |
42 (23.7 %) |
|
|
Neutral |
119 (30.8 %) |
76 (63.9 %) |
43 (36.1 %) |
0.043* |
|
Disagree |
90 (23.3 %) |
59 (65.6 %) |
31 (34.4 %) |
|
|
Children should
not be vaccinated because the long-term effects of vaccination are unknown |
|
|
|
|
|
Agree |
104 (26.9 %) |
75 (72.1 0%) |
29 (27.9 %) |
|
|
Neutral |
110 (28.5 %) |
75 (68.2 %) |
35 (31.8 %) |
0.819 |
|
Disagree |
172 (44.6 %) |
120 (69.8 %) |
52 (30.2 %) |
|
|
Children must be
vaccinated if it was recommended by a physician |
|
|
|
|
|
Agree |
98 (25.4 %) |
72 (73.5 %) |
26 (26.5 %) |
|
|
Neutral |
57 (14.8 %) |
32 (56.1 %) |
25 (43.9 %) |
0.046* |
|
Disagree |
231 (59.8 %) |
166 (71.9 %) |
65 (28.1 %) |
|
|
The government
has the right to force everyone to get the COVID-19 vaccine |
|
|
|
|
|
Agree |
178 (46.1 %) |
134 (75.3 %) |
44 (24.7 %) |
|
|
Neutral |
104 (6.9 %) |
76 (73.1 %) |
28 (26.9 %) |
0.006* |
|
Disagree |
104 (26.9 %) |
60 (57.7 %) |
44 (42.3 %) |
|
|
COVID-19 vaccine
will end the pandemic |
|
|
|
|
|
Agree |
170 (44.0 %) |
132 (77.6 %) |
38 (22.4 %) |
|
|
Neutral |
117 (30.3 %) |
83 (70.9 %) |
34 (29.1 %) |
0.001* |
|
Disagree |
99 (25.6 %) |
55 (55.6 %) |
44 (44.4 %) |
|
|
Children should
not be vaccinated because vaccination is painful |
|
|
|
|
|
Agree |
199 (51.6 %) |
148 (74.4 %) |
51 (25.6 %) |
|
|
Neutral |
45 (11.7 %) |
25 (55.6 %) |
20 (44.4 %) |
0.039* |
|
Disagree |
142 (36.8 %) |
97 (68.3 %) |
45 (31.7 %) |
|
|
Children should
not be vaccinated due to a lack of scientific studies about COVID-19
vaccination on children |
|
|
|
|
|
Agree |
217 (56.2 %) |
154 (71.0 %) |
63 (29.0 %) |
|
|
Neutral |
63 (16.3 %) |
39 (61.9 %) |
24 (38.1 %) |
0.299 |
|
Disagree |
106 (27.5 %) |
77 (72.6 %) |
29 (27.4 %) |
|
|
Vaccines are not
effective due to frequent mutations |
|
|
|
|
|
Agree |
110 (28.5 %) |
70 (63.6 %) |
40 (36.4 %) |
|
|
Neutral |
140 (36.3 %) |
97 (69.3 %) |
43 (30.7 %) |
0.118 |
|
Disagree |
136 (35.2 %) |
103 (75.7 %) |
33 (24.3 %) |
|
Statistically significant findings (p
≤ 0.05).
Univariate
logistic regression analysis was performed among significantly associated
socio-demographic characteristics of the study participants to assess the
possible predictors of COVID-19 vaccine uptake and vaccine hesitancy for their
children. The participants vaccinated against COVID-19 were 5.131
(2.385─11.039) more likely to get their children vaccinated than
unvaccinated participants. The participants having monthly income of more than
60,000 PKR were 2.730 (1.425─5.227) more like to get their children
vaccinated than those with no income. The participants with one child were
found to be 1.892 (1.075─3.330) times more hesitant than those with three
or more children. The study participants whose children were less than 12 years
were found 8.929 (3.463─23.023) more hesitant than the reference group
(Table 4).
Table 4. Univariate logistic regression analysis to assess the predictors of
COVID-19 vaccine uptake and COVID-19 vaccine hesitancy for their children among
study participants (N = 386).
Discussion
Internationally, there is a dearth of published research on children's
uptake of the COVID-19 vaccine, and the studies that have been done focus more
on parents' intentions than actual immunization rates. The vaccination programs
face various barriers that mostly relate to their attitudes towards vaccines as
explored by a study from Pakistan.(22) The present research demonstrated that 70 % of Pakistani parents who
participated in the study vaccinated their children against COVID-19, and 30 %
of them were hesitant to do it. A previous study conducted in four districts of
Pakistan reported opposite results, with 75 % of the study participants
reporting that their children were unvaccinated against COVID-19.(9) These contrasting results could be due to differences in the beliefs of
the study participants, since 60 % did not consider their children at risk of
infection, while approximately 50 % mistrusted the safety of COVID-19 vaccines
in children. A study from the Eastern Mediterranean Region presented opposite
findings to the current study, where 32 % of participants vaccinated their
children against COVID-19, and 68 % were hesitant to vaccinate their children;(19) this contrast could be related to their belief about the safety and
efficacy of the COVID-19 vaccine. Half of the participants in the previous
study from the Eastern Mediterranean Region believed in the safety and efficacy
of the COVID-19 vaccine(19) and
about three-quarters of the participants from the current study had similar
beliefs. This could also be related to the higher number of Arabic people,
compared to Pakistanis, who believe in conspiracy theories regarding COVID-19
vaccination.(14)
Various significant associations between socio-demographic data and
children’s vaccination status were found in the current study. Statistical
analysis showed (p = 0.003) that parents older than 50 years had a higher
acceptance of COVID-19 vaccination for their children (90.9
%) than younger parents aged less than 30 years (62.6 %). These findings are consistent with previous studies,
where younger parents were more hesitant to vaccinate their children against
COVID-19, indicating that younger parents tend to be more hesitant about
vaccinating their children due to concerns about vaccine safety, potential side
effects, and perceived lower susceptibility of children to severe COVID-19
outcomes,(19,23,24) in contrast, older parents may be more inclined to prioritize vaccination,
influenced by their greater perceived vulnerability to COVID-19 and a higher
level of trust in public health recommendations, often developed through life
experience. In the present research, parents with children under 12 years and
parents having one child, were more hesitant. These findings also correlate
with previous studies,(19,23,24) which could be due to parents' concern regarding the safety of COVID-19
vaccination in children under 12 years. Additionally, parents with a single
child may exhibit greater caution and apprehension about perceived risks, as
they may be more protective of their only child. The current study also
revealed similar findings to different published studies, i.e., parents
vaccinated against COVID-19 were more likely to vaccinate their children.(19,25,26) Vaccinated parents may have greater trust in the safety and efficacy of
vaccines and are more likely to perceive vaccination as a necessary step to
protect their children. Furthermore, their own positive vaccination experience
might reinforce their confidence in the process, reducing hesitancy for their
children. The current study found a significant association between parental
income and children’s vaccination status, with parents earning more than 60,000
PKR/month being 2.73 times more likely to vaccinate their children compared to
those with no income (p = 0.027). Higher-income families may have better access
to healthcare services and can afford transportation costs or other potential
out-of-pocket expenses related to vaccination. Additionally, financial
stability might correlate with higher educational levels and greater health
literacy, which are known to positively influence vaccine acceptance. In
contrast, low-income parents may prioritize immediate financial needs over
preventive healthcare and could be influenced by misinformation or lack of
awareness about the benefits and safety of vaccines.(27)
The current study also revealed that parents’ attitudes toward the
children's vaccination against COVID-19 significantly impacted their children's
vaccination status. Among the significantly associated attitude statements,
those related to the safety and effectiveness of COVID-19 vaccines were
positively associated with vaccine uptake. Parents who mistrusted the safety
and efficacy of the COVID-19 vaccine were hesitant to vaccinate their children.
Participants who believed in natural immunity respect to vaccines were more
hesitant to vaccinate their children; these results are similar to other
published studies from different countries.(17,19,27) Overcoming undecided parents' concerns about the safety and efficacy of
the COVID-19 vaccine could have a positive impact on vaccine acceptance among
their children. Belief in natural immunity over vaccination was a significant
factor influencing vaccine hesitancy (p = 0.018). The fact that parents who
prioritized natural immunity were less likely to vaccinate their children could
be attributed to misconceptions about the adequacy of natural defenses against
COVID-19. Public health interventions addressing the limitations of natural
immunity and highlighting the benefits of vaccination could help counter this
misconception.
This research also found that parents who believed children should be
vaccinated if recommended by a physician were significantly more likely to
vaccinate their children (p = 0.046). This highlights the influence of
healthcare professionals as reliable sources of information. Therefore,
encouraging physicians to actively recommend vaccines could be a critical
strategy in improving vaccine uptake. Lastly, agreement with the statement that
"the government has the right to force everyone to get the COVID-19
vaccine" was positively associated with children’s vaccination status (p =
0.006). This indicates that parents who support regulatory measures are more
likely to comply with vaccination guidelines. However, parents who disagree
could have concerns about personal freedoms, which could lead to resistance to
the vaccination.
The current study has some limitations that may impact the study findings.
The cross-sectional study design and convenient sampling technique could affect
the generalizability of the study findings. Due to the self-administered
questionnaire and online data collection method, only literate Pakistani
parents who had internet facilities participated in the current study, so the
study participants may not be the true representative of Pakistani parents,
which could be counted as a study limitation.
Conclusions
The current study revealed that 30 % of the study participants (Pakistani
parents) were hesitant to vaccinate their children while the remaining 70 % got
vaccinated their children against COVID-19. To explore this topic more
comprehensively, a study especially targeting the unexplored population
(illiterate and without internet facility) with a larger sample size will be
required in the future. Health authorities could address this major public
health threat (vaccine hesitancy) by promoting the factors positively
associated with vaccine uptake. Especially, providing knowledge about the safety
and efficacy of vaccines to neutralize parents' concerns regarding vaccines
could promote vaccination uptake.
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Conflict of interest
The authors declare that
there is no conflict of interest.
Author’s
contributions
Muhammad Subhan Arshad
contributed to conceptualization, methodology, validation, formal analysis,
data curation, and writing (original draft preparation).
Imran Imran
contributed to software, validation, writing (review and editing), and project
administration.
Hamid Saeed contributed to
methodology, investigation, writing (review and editing), and project
administration.
Imran Ahmad contributed to
software, investigation, data curation, and writing (original draft
preparation).
Muqarrab Akbar contributed to
software, investigation, data curation, and writing (original draft
preparation).
Muhammad Omer Chaudhry
contributed to methodology, formal analysis, and writing (review and editing).
Muhammad Fawad Rasool
contributed to conceptualization, methodology, software, formal analysis,
investigation, writing (review and editing), project administration, and
supervision.
All authors have read and
agreed to the published version of the manuscript.
* Chairman, Department of
Pharmacy Practice, Faculty of
Pharmacy, Bahauddin Zakariya
University, Multan, Pakistan.