https://orcid.org/0000-0001-9831-7572
ABSTRACT
The question of whether children should be vaccinated against COVID-19 is currently being argued. The risk-benefit analysis of the vaccine in children has been more challenging because of the low prevalence of acute COVID-19 in children and the lack of confidence in the relative effects of the vaccine and the disease. One of the most convincing arguments for vaccinating healthy children is to protect them from long-term consequences. The aim of this study was to assess Jordanian parents’ intention to vaccinate their children. This is an Internet-based cross-sectional survey. The researchers prepared a Google Forms survey and shared the link with a number of Jordanian Facebook generic groups. Data were gathered between September and November 2021. In this study, convenience sampling was used. Knowledge about COVID-19 and preventive practices against COVID-19 were calculated for each participant. A total of 819 participants completed the survey (female = 70.9%). Of these, 274 (30.2%) participants intended to vaccinate their children, whereas the rest were either unsure 176 (21.5%) or intended not to vaccinate their children 396 (48.4%). The variables that increased the odds of answering “No” vs “Yes” to “will you vaccinate your children against COVID-19” included not willing to take the vaccines themselves (OR 3.75; CI, 1.46–9.62) and low protective practice group (OR 1.73;CI, 1.12–2.68). Participants had significant levels of refusal/hesitancy. Several barriers to vaccination were identified; attempts to overcome these should be stepped up.
JEL CLASSIFICATION:
Introduction
The primary method to restrict the spread of COVID-19 and the risk of additional variations emerging is universal COVID-19 vaccination.Citation1–3 The immunization of large sections of pediatric and adult populations in low/middle-income countries where COVID-19 variants of concern have been discovered is critical to the effectiveness of vaccination campaigns.Citation4,Citation5
Jordan had fully vaccinated 3.67 million persons (36%) against COVID-19 by 22 November 2021.Citation6 Vaccination coverage in Jordan is greater than in low-income nations (on average <2.5%).Citation7 Jordan approved the vaccination of children aged 12 years and older recently (July 2021)Citation8and considering providing the vaccines for children between the ages of 5-11
Parental vaccine hesitancy, defined as parents’ delay in accepting or refusing vaccines for their children despite their availability, may be a significant barrier to immunization.Citation9 However, few studies have investigated parental attitudes for COVID-19 vaccination, and findings have been inconsistent. A survey conducted in the United States (US) and Australia, prior to the first COVID-19 vaccination approvals in December 2020, indicated that 50% of pregnant women were willing to vaccinate their children against COVID-19. Similarly, in lower income countries, such as Brazil, Colombia, and Mexico, over half of expectant women were willing to vaccinate their children.Citation10 Furthermore, a survey conducted in the United Kingdom has reported that about 48% of participants were willing to vaccinate their children against COVID-19.Citation11 In another study conducted in Brazil, only a small percentage of caregivers (2.8%) were hesitant about immunizations.Citation12 Similar results were reported in a survey done in Italy between December 2020 and January 2021, with only a minority of participants (10%) hesitant to vaccinate their children against the COVID-19.Citation13 However, investigations conducted a few months following the establishment of COVID-19 immunization programs indicated that around half of US parents remained hesitant to vaccinate their children against COVID-19.Citation14,Citation15 Importantly, a previous study conducted in Turkey revealed that 56.8% of parents were willing to vaccinate their children with “national” (domestically produced) COVID-19 vaccines. Their acceptance rates were significantly lower when asked about an “International/foreign” vaccine as only 28.9% were willing to vaccinate their children with a foreign vaccine. Most reported reasons for vaccine hesitancy were concerns about vaccine side effects, a lack of knowledge regarding vaccine effectiveness, and a suspicion of vaccines originating from other countriesCitation16 Furthermore, in a Saudi Arabian study, 24% of others were reluctant to give their children COVID 19 vaccinations due to concerns about side effects.Citation17 In another study conducted in Saudi Arabia,Citation18 52% were hesitant to vaccinate their children and the need for a reliable source of information about the vaccine was a significant reason behind the hesitancy.Citation18 A lower percentage of hesitancy was reported in a study conducted in QatarCitation19,Citation23,1as with only 17.9% showed parental vaccine hesitancy, with the main reason cited being “wait and see”, indicating reluctance due to potential vaccine side effects. There is therefore a pressing need to understand attitudes toward current information on vaccine views and COVID-19 vaccine attitudes among parents. The aim of this study was to investigate the prevalence and extent of COVID-19 vaccine hesitancy among parents of children and adolescents living in Jordan.
Materials and methods
Design
This is a web-based cross-sectional study. The study formulated a questionnaire on Google Forms and distributed the link via different Jordanian Facebook generic groups. The study data were collected from September to November 2021. The inclusion criteria included being Jordanian, above the age of 18 and having children who were not yet vaccinated against COVID-19. To ensure that the participants met the inclusion criteria, questions about place of residency and having children who were not yet vaccinated were included in the beginning of the questionnaire (see ). Those who did not meet the inclusion criteria were automatically directed to submit the form. A prologue that describes the aims of the study and contains an informed consent form were included in the questionnaire. Ethical approval was obtained from Al-Zaytoonah University of Jordan ethical committee. The current study was conducted with accordance to the Declaration of Helsinki ethical principles.
Figure 1. Recruitment flowchart.
Instrument
A questionnaire was constructed after conducting thorough literature review.Citation20,Citation21,Citation22,Citation23 The questionnaire was then presented to an expert committee that confirmed the content validity of the questionnaire. The questionnaire was initially developed in English, the language that was used to conduct the literature review, then translated to Arabic, the most spoken language in Jordan, back-translation was also performed, and the two versions were found to be comparable. A pilot study was conducted to confirm the questionnaire’s face validity, in the pilot study the questionnaire was circulated to 30 participants that who confirmed the clarity of the questions. The data of the pilot study was not included in the final analysis.
The questionnaire included five sections. The first section contains questions related to demographic information, including household monthly income, and the participants were classified into low-middle- and high-income groups based on the average household monthly income as stated by the Jordanian department of statisticsCitation24 The second section included questions about the participants’ experiences with COVID-19; if they, their children, or close friend/relative were ever infected with COVID-19, and if the participants were vaccinated or planning to be vaccinated against COVID-19. It also contained questions that evaluated the participants’ perceived seriousness of COVID-19 on them and on their children. The third section evaluated the participants’ knowledge about COVID-19 symptoms, protection methods, mood of transmission and available vaccines. The fourth section evaluated participant’s adherence to protective measure against COVID-19. The fifth section evaluated the participants perception towards COVID-19 vaccines efficacy and safety and their willingness to vaccinate their children. The sixth and final section evaluated the reasons behind vaccine hesitancy/refusal of those who answered ‘no’ or ‘not sure’ regarding intent to be vaccinate their children.
The children of the participants were classified into high-risk and low-risk groups of developing severe illness due to COVID-19. Pre-term children and children who have at least one of the following conditions: asthma, allergies, diabetes, cancer, cardiovascular disease, sickle cell anemia, liver disease and thalassemia, or taking steroids or immunosuppressants medications were included in the high-risk group while the rest were included in the low-risk group.
Knowledge and practice scores were computed for each participant. The knowledge score was calculated based on the participants’ knowledge of COVID-19 symptoms, transmission method and protective measures against the infection as one point was granted for each correct answer, the maximum possible score of 21 (Table A1). Practice score was calculated as the sum of the practice statements for the question ‘What procedures have you done to protect yourself from COVID-19?’ (Table A1), which represent the participants’ adherence to protective measures with answers ranged from “Never” (1 point) to “All the time” (5 points) with a maximum possible score of 25.
The medians for the knowledge and practice scores were calculated and the participants were divided into two groups, the first, group (high-level, group) included participants who got higher than the median scores and the rest were included in the low-level group.
Sampling type and sample size
Convenience sampling was used in this study. The required sample size at 95% significance level and a 5-percentage-point margin of error was 385. To perform a logistic regression that evaluated variables associated with participants intent to vaccinate their children, the rule of Events Per Variable criterion (EPV) ≥10Citation25 was utilized, and as the events of the smallest group in three possible outcomes were 176 (not sure), the number of independent variables that can be included in the model are 17. The model used in the current study included only 15 variables.
Statistical analysis
Categorical variables were presented as frequency and percentages, and continuous variables were presented as means and standard deviations (SD). Cronbach’s alpha was conducted to evaluate the internal consistency of the items used to compute the knowledge and practice scores.
The minimum acceptable Cronbach’s alpha for the practice score was .7, while for the knowledge score it was determined to be above .5 as lower Cronbach’s alphas are expected in binary data.Citation25 The computed Cronbach’s alphas were .83 and .55 for the practice and knowledge scores respectively.
Univariate analysis using Kruskal–Wallis and Chi-square analyses were used to identify variable association with participants intent to vaccinate their children. Variables that yielded p ≤ .20 in the univariable analysis were included in the multinominal logistic regression as independent variables, while participants’ intent to vaccinate their children was the dependent variable.
Results
Overall, 819 participants completed the survey (). The majority of participants (70.9%) were females, almost half (49.6%) had a child aged between 7 to 12, while 9.9% had a child under the age of one year. Most (85.6%) participants were married, and (7.7%) of the female participants were pregnant. The majority of participants (57%) had both boys and girls. Most participants (75.6%) were nonsmokers. Most of the participants were from Amman (50.4) followed by Zarqa (14.4)
Table 1. Sample characteristics
Bachelor’s degree holders made up 53.5% of the participants, while 1.2% were university students and (43.7%) earned $700-$1400 per month. Lastly, 63.9% did not work or study in a medical field. Participants were classified into high and low adherence to protective practices against COVID-19 and knowledge about COVID-19 and its vaccine, based on the median scores. The median for the practice and knowledge scores were 16 (Quartiles:14–18) and 17 (Quartiles:15–18) respectively. Those who scored above the median were included in the high -level group while the rest were included in the low level group.
In the current sample, only 274 (30.2%) participants intended to vaccinate their children, while the rest were either ‘not sure’ (176; 21.5%) or intended not to vaccinate their children (396; 48.4%). Univariate analysis was conducted using Chi-square and Kruskal Wallis test (). These indicated that several factors were significantly associated with parents’ intention to vaccinate their children against COVID-19 including: perceived seriousness of COVID-19 on participants’ health (p < .001), children’s sex (p = .05), area of residency (p < .001), household average monthly income (p < .001), working/studying in a medical field (p = .02), knowing someone close infected with COVID-19 (p = .03), if participants’ children had ever had COVID-19 (p = .04), the participant had COVID-19 (p = .05), perceived degree of COVID-19 seriousness for their children (p < .001), perceived degree of COVID-19 vaccine safety and effectiveness on the children (p < .001), opinions about the likelihood that any of their children would be infected during the next 6 months (p < .001), adherence to protective practices against COVID-19 (p < .001) and if the participant was/or planning to be vaccinated against COVID-19 (p < .001).
Table 2. Intention to vaccinate children by different sample characteristics presented as means (SD) or frequencies (percentages)
Multinomial regression was applied to evaluate the factors associated with responding “Not Sure” or “No” regarding the intent to be vaccinated. As the results indicate (), the perceived safety of COVID-19 vaccine on children decreased the odds of responding ‘No’ or ‘Not sure’ vs. ‘Yes’ (OR .28; CI .21–.36) and (OR .52; CI .40–.67) respectively. The perceived effectiveness of the COVID-19 vaccine for children reduced the odds of responding ‘No’ vs ‘Yes’ (OR .76; CI .58–.99). The participants who reported having a chronic disease were significantly less likely to answer ‘No’ vs ‘Yes’ when compared with participants who do not have a chronic disease (OR .43; CL .23–.81).
Table 3. Multivariate predictors of responding “not sure” or “no” regarding intent to vaccinate your children
Participants who answered ‘maybe’ to the question ‘Do you know somebody close to you that was infected with COVID-19?’ where more likely to answer ‘No’ vs ‘Yes’ (OR 3.05; CI,1.03–8.98) when compared with those reported that they do not know someone close to them that was infected with COVID-19. Participants who answered “maybe” to “Has any of your children ever been infected with COVID-19?” compared to those answered no were significantly less like to refuse to vaccinate their children (OR .32, CI, .14–.69). Participants who were classified into the low practice group were more likely to answer ‘No’ vs ‘Yes’ (OR 1.73; CI, 1.12–2.68). Those who did take and not planning to receive the vaccine against COVID-19 were significantly more likely to answer ‘No’ or ‘Not sure’ vs ‘Yes’ (OR 3.75; CI, 1.46–9.62) and (OR 2.78; CI, 1.04–7.42) respectively.
shows the reported reasons for vaccination hesitancy/refusal. The most frequently mentioned causes for participants’ responses regarding their hesitancy to vaccinate their children were: ‘The vaccine will be new, I don’t want to be the first to get the vaccine’ (95%), followed by ‘I don’t want a vaccine I know nothing about; I’ll make my decision if/when one becomes available’ (88.5%), and the least mentioned cause was ‘Vaccine causes autism’ (15.2%).
Table 4. Reasons participants provided for responding “No” or “Not sure” regarding intent to be vaccinated
Discussion
The main objective of the present research was to investigate the prevalence of COVID-19 vaccine hesitancy among parents of children and adolescents in the Jordanian population. Another key task was to identify significant predictors associated with COVID-19 vaccine indecision. The questionnaire covered a range of issues related to COVID-19 including knowledge, attitudes and practices toward COVID-19 and its vaccines.
Worrying findings were reported in the present study as only 30.2% of participants were willing to vaccinate their children—significantly lower than acceptance rates reported in several countries around the world including the US,Citation14 UK,Citation11 BrazilCitation12and ItalyCitation13and in the region including Saudi Arabia,Citation17,Citation18 TurkeyCitation16and Qatar.Citation26
Univariate analysis was utilized to categorize participants based on the parents’ intention/willingness to vaccinate their children against COVID-19. This revealed that perceived seriousness of COVID-19, geographic area of residency in Jordan, average monthly income, the perceived degree of COVID-19 seriousness on children, perceived degree of COVID-19 vaccine safety and effectiveness on children, personal opinions about the likelihood that children would be infected by COVID-19, adherence level to protective measures against COVID-19 and if the participants have been/are planning to be vaccinated against COVID-19 were strong predictors associated with the tendency to vaccinate their children.
To a lesser extent, children’s gender, working/studying in a medical field, knowing someone close who was infected with COVID-19, any of the participant’s children ever having COVID-19, and the participant having had COVID-19 influenced participants’ hesitancy to vaccinate their children against COVID-19.
These findings were concordant to some extent with the literature. Many studies revealed that seriousness of COVID-19 is associated with the beliefs about COVID-19 vaccination.Citation27,Citation28 Geography was also a strong predictor of vaccine hesitancy. A recent report by the U.S. Office of Assistant Secretary for Planning and Evaluation (ASPE) revealed that although hesitancy toward COVID-19 vaccination has dropped significantly in early 2021, different geographic areas in the USA illustrated different rates of hesitancy.Citation29 This is similar to the results of the present study as parental vaccination intention was associated with residency area as indicated in the univariable and multivariable analysis. The difference found in paternal vaccination acceptance between the capital Amman and southern governates may be associated with income and education levels, as according to the statistics department of Jordan the income and education levels in southern governates are significantly less than the capital Amman (the reference group) and one of the lowest in the kingdom in general.Citation23 This can be also confirmed by the results of the univariable analysis that indicated that the monthly income is a strong predictor of hesitancy toward COVID-19 vaccination. Previous studies have reported the association between education/income levels and parental vaccine acceptanceCitation30,Citation31
A further crucial determinant of vaccine acceptance is beliefs about the safety and efficacy of COVID-19 as they are newly developed vaccines. Several studies conducted in the region reported concerns about vaccine safety as a major reason for hesitancyCitation16–18,Citation26 A recent study reported that Americans were also unwilling to receive the vaccine as they had concerns about safety and efficacy.Citation32 Working in the medical field was expected to improve acceptance of vaccination. Research conducted in Thailand found that most physicians were willing to take COVID-19 vaccine, yet a significant proportion were hesitant to vaccinate their family members.Citation33
Our univariate analysis also revealed an interesting finding. Parents with children who they reported have risk factors of high infectious severity of COVID-19 like preterm birth, diabetes, cardiovascular disease, asthma and respiratory conditions did not differ from other parents in terms of their plans regarding their children vaccination. This is a worrying finding as it shows that parents with vulnerable children were unaware of the seriousness of COVID-19 infection for their children.
Multinomial logistic regression was used to identify the factors that might affect parents who expressed low intention to vaccinate their children. Estimated seriousness of COVID-19 on children was a significant predictor of vaccine hesitancy in parents. This was expected as perceived seriousness of COVID-19 can play a crucial role in vaccine acceptance.Citation34 In a Saudi Arabian study, participants felt that routine vaccination was significantly more important to their children’s health when compared with COVID-19 vaccination.Citation18 In the current study, those who suspected that their children may have had COVID-19 were less likely to refuse the vaccine compared to those who reported that their children were not infected with COVID-19. Nevertheless, a study conducted in Qatar indicated that parents of children who had had COVID-19 were more hesitant to vaccinate their children when compared to parents who did not have previously infected children.Citation26 This may be due to the perceived lower severity of symptoms experienced by the children.
Perceived efficacy of COVID-19 vaccine in children reduced the odds ratio in the refusing group. A Saudi Arabian study reported that participants doubted the efficacy of COVID-19 vaccine when compared with routine vaccination.Citation18 A cross-sectional survey conducted in Canada concluded that parental acceptance toward COVID-19 vaccination for children would be improved by public health communication highlighting the safety and necessity of COVID-19 vaccination in children to support a return to normal activities.Citation35 Perceived safety of COVID-19 vaccine in children was also a significant predictor of parental refusal of children’s vaccination and hesitancy both globallyCitation36and in the region.Citation16–18,Citation26
Absence of chronic diseases was also a strong predictor of parental children vaccination refusal. A systematic reviewCitation37 concluded that presence of chronic diseases is associated with willingness to receiving COVID-19 vaccine. Being doubtful of knowing a close person who was infected with COVID-19 was also associated with parental children vaccination refusal and hesitancy. Participants who had low adherence to preventative practices against COVID-19 were less like to state that they would vaccinate their children. Participants who were not vaccinated and were not planning to have the COVID-19 vaccine themselves were significantly more likely to reply ‘No’ or ‘Not sure’ to their intention to vaccinate their children. Similar findings were reported in a Saudi study as vaccinated parents were more willing to vaccinate their childrenCitation18
The main three reasons for vaccine refusal were the vaccine being a new product, no adequate information about the vaccine available to the public, and the concern of injecting a “mysterious” material into humans’ bodies. Therefore, public education regarding the safety and efficacy of COVID-19 vaccine is urged. Public awareness of COVID-19 vaccine should improve the acceptance and reduce hesitancy regarding vaccination.Citation38 A structured public awareness campaign regarding COVID-19 vaccine addressing issues raised about the vaccine is essential. For example: yes, the vaccine was developed quickly, but it was thoroughly tested for its safety and efficacy. COVID-19 vaccine side effects are temporary and mild.
Taking the vaccine protects us from being sick, and can preserve many people’s lives. Most people with allergic conditions can still take the vaccine without worries of developing allergies against the vaccines. Furthermore, having the vaccine after COVID-19 infection will improve the immune response and further protect against future viral infection. Having the vaccine is not only meant to provide personal protection, it also indirectly delivers protection to other community members by reducing the chance of spreading the COVID-19. Population-wide vaccination will help return us all to a normal “pandemic free” lifestyle. Public awareness should also shed the light on enabling individuals to conduct a personal “risk-benefit assessment” especially for vulnerable individuals. Finally, recent safety reports confirmed the safety and efficacy of the vaccine in pregnant and breastfeeding femalesCitation39
Strengths and limitations
This study evaluated participants’ knowledge about COVID-19 and its available vaccines, their protective practices against COVID-19 and the intent to vaccinate their children. The data of the present study was collected form most Jordanian governates to ensure a broad national coverage. As this is a self-administered questionnaire, the results may be subjected to selection and recall biases, for instance, 70% of the participants were mothers. Nevertheless, the large sample size included in the present study could limit the bias effect, moreover, in Jordan, and the Middle East generally, mothers are typically more concerned with and in charge of children’s affairs. Furthermore, previous studies have shown that web-based studies are a cost-effective method that can produce a representative sample, provide a safe environment for the respondents to answer questions honestly and accurately and eliminate interviewer biaCitation40, Citation41As mentioned previously the main objective of the present research was to investigate the prevalence of COVID-19 vaccine hesitancy among parents of children and adolescents. Therefore, although some of participants had offspring above the age of 18, the vast majority of them had children aged under 18 (other siblings) and only 21 participants solely had offspring above the age of 18. Nevertheless, the data of the 21 participants were retained in the analysis because in conservative communities, like Jordan, parents have a substantial influence on their children’s decisions, even if their children are older than 18 and into their early 20s.
Conclusion
We found high parental hesitancy toward vaccine acceptance. These results illustrate the necessity to increase the awareness among the general population about childhood COVID-19 vaccination, in particular the relative risks and rewards.
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Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2022.2044257
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References
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Appendix A
Table A1. Knowledge toward COVID-19 and its vaccines