Are parents’ willing to vaccinate their children against COVID-19? A qualitative study based on the Health Belief Model

ABSTRACT

In response to the COVID-19 pandemic, several countries have started implementing voluntary or involuntary mass vaccination programs. Although vaccine acceptance is high among adults, uncertainty about whether to vaccinate children against COVID-19 remains a controversial theme. To date, few qualitative studies have explored parents’ views on this topic. A qualitative descriptive study design was used to collect data and individual in-depth interviews were conducted with 50 parents in the Makkah region of Saudi Arabia. The Health Belief Model (HBM) was used as a guide in developing the interview guide. Each question was related to a construct of the HBM. The data were then analyzed using thematic content analysis and interpreted using NVivo software. Two major themes emerged: motivation to vaccinate children, which was influenced by perceived benefits, perceived severity, perceived suitability, collective responsibilities, confidence, and cues to action; and barriers to vaccination in children, which included complacency, rapid vaccine development, and uncertainty about the long-term side effects of the vaccine. The findings of this study revealed that the public is not sufficiently informed about the efficacy or side effects of the COVID-19 vaccine, increasing the awareness of which will help parents make informed decisions regarding vaccinating their children and potentially increase vaccine acceptance.

Plain Language Summary

Currently, the debate about whether children should be vaccinated for COVID-19 is ongoing worldwide. This research explored the thoughts of Saudi Arabian parents in this regard through in-depth interviews. The viewpoints were grouped into two themes: motivators and barriers toward vaccination. The motivators included factors such as parents’ beliefs that the vaccine would help protect their children and the aged against the severity of the disease, especially those with existing conditions such as obesity. They also felt that the vaccination would help develop the society’s herd immunity against the virus and felt an obligation to have their children vaccinated. Barriers toward vaccination included factors such as concerns about the long-term side effects of the vaccine on children, and the belief that children’s immune systems are strong enough to fight the virus and that the vaccine might negatively affect their immune systems. This study showed that parents need to be educated on the benefits and side effects of COVID-19 vaccination for children. The results of this study will help health authorities and the government to increase the uptake and acceptability of the COVID-19 vaccine for children.

KEYWORDS:

• COVID-19
• Health Belief Model
• parents
• qualitative
• Saudi Arabia
• vaccine

Introduction

COVID-19 continues to spread worldwide with an ongoing increase in the global death toll.^1,2 As of December 13, 2021, 270 million confirmed cases were diagnosed and over five million deaths reported worldwide.² In Saudi Arabia, over 550,000 cases have been reported, including 9,383 deaths.³ Although these numbers continue to rise, the development of multiple COVID-19 vaccines has provided hope to curb the spread of the disease and end the pandemic.

In 2020, the vaccine received emergency authorization from the United States Food and Drug Administration (FDA)⁴ and many countries approved the vaccines.⁵ In Saudi Arabia, over 48 million vaccine doses have been administered. Despite the successful implementation of the adult vaccine program, questions remain as to whether it is possible to achieve herd immunity and whether children should be offered vaccinations to achieve this.⁶

The issue of whether children, particularly those under 12 years of age, should be vaccinated is controversial, even among the scientific community. Such controversy has been fueled by conflicting arguments regarding the risk-benefit ratio of offering vaccinations to children.⁷ Arguments supporting vaccinating children against COVID-19 include reducing the transmission of the disease to adults, improving the vaccine’s safety profile, preventing severe illness in children, and avoiding school closures.⁶ Apart from potential long-term consequences, others argue that children should not be vaccinated because of the rarity of the severe form of the disease.^8,9

Studies have shown that parents are reluctant to vaccinate their children.¹⁰ Vaccine hesitancy among parents could be a cause for major public concern. Addressing this hesitancy through increased awareness could potentially promote vaccine acceptance and play a role in controlling the pandemic. Researchers have conducted surveys exploring parents’ acceptance and/or reluctance to vaccinate their children against COVID-19.^11,12 Rhodes et al. investigated vaccine acceptance of putative COVID-19 vaccines among a national sample of vaccine-hesitant parents in the USA. They found that parents of preschool children were extremely hesitant to vaccinate their children against COVID-19.¹³ To our knowledge, few studies have investigated parents’ perceptions regarding vaccinating their children in Saudi Arabia. The existing studies mainly utilized a questionnaire or web-based survey in a cross-sectional design to quantitatively assess vaccine acceptance or hesitancy among the Saudi population. These studies mainly included adults of different age groups, with or without chronic disease, but did not particularly examine parents’ attitudes or perceptions toward vaccinating their children.^14–17 A systematic review published in 2020 examining knowledge, perceptions and behavior toward childhood vaccinations in Saudi Arabia reported that while up to 90% of parents were supportive of childhood vaccination and close to 100% agreed that they were important, there remained a degree of hesitancy in around 20% of parents.¹⁸ Therefore, this study aimed to gain a deeper understanding of parents’ perception about the COVID-19 vaccination in children.

Theoretical conceptualization: The Health Belief Model

To understand the perceptions of mothers about vaccinating their children against COVID-19, we used the health belief model (HBM), which can be used to interpret various factors that influence the decision-making process regarding vaccination.¹⁹ The HBM states that a person must be psychologically willing to change their health behavior.¹⁹ In vaccine decision-making, the perception of how dangerous a disease is to the person, as well as the perception of how protective the proposed vaccine is, influences their actions.

The HBM states that people’s beliefs about the efficacy and risks of vaccines influence their health behaviors. These constructs can help predict the likelihood of getting vaccinated.²⁰ Six domains of the HBM are known to influence people’s health behaviors: perceived severity, perceived susceptibility, perceived benefits of vaccines, perceived barriers, cues to action that prevent people from getting vaccinated, and other modifying factors.¹⁹

Perceived benefits are related to people’s beliefs that they can reduce the threat of disease. However, various barriers prevent people from being vaccinated. These include psychological factors such as fear of the dangerous side effects of COVID-19 vaccines.²¹ The perceived severity of a disease is related to people’s perceptions that the consequences of the disease are serious.

Perceived susceptibility is related to people’s beliefs that they are at a higher risk of developing the disease. Some studies have shown that people who feel threatened, or believe that there is an increased risk of becoming sick, are more likely to get vaccinated against COVID-19.^21,22

Studies have also suggested that the perception of risk and susceptibility can predict the likelihood of people engaging in protective behaviors during an infectious disease outbreak. For instance, a study conducted during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2000 revealed that approximately 3% of the respondents believed that the seriousness of the disease was high, while the remainder thought that they could avoid it by adopting precautionary measures.²³

The perceived barriers (e.g., long-term side effects and interference with daily activities) that people encounter can decrease their likelihood of protective behavior. In the context of COVID-19 vaccines, many people have decided not to vaccinate their children because of the emergence of new information about the side effects of COVID-19 vaccines.²⁴ Individuals need to be motivated by various cues to act on their health goals. These include actions based on health professionals’ recommendations and other reliable sources.^25–27 Besides being able to identify and implement these actions, individuals also need to develop psychological readiness to perform them.¹⁹ A study on the effects of various cues on the vaccination rate of the HPV vaccine among women revealed that those who received counseling or advice from their friends had an increased likelihood of being vaccinated.²⁸

Parents adopt different pathways to minimize the risk of COVID-19.²⁹ One of these is the implementation of compression bias, which suggests that they are more likely to mistakenly assume that a particular disease will cause severe consequences if vaccinated.³⁰ Another strategy is to use ambiguity aversion, which indicates that individuals are more likely to favor a known risk over a new unknown risk.³⁰ More research is required to understand how threat perception affects the behavior of people who are willing to adapt to mitigate this risk. Researchers have discussed that the perception of vaccine threat is influenced by various factors such as the type of vaccine.^31,32 Therefore, it is essential to explore how this perception affects mothers’ behaviors and intentions regarding their children’s vaccinations.

Methodology

Study design

The study was conducted using a qualitative descriptive methodology to explore parents’ beliefs about vaccinating their children with a COVID-19 vaccine between October 2021 and December 2021. A qualitative descriptive design is commonly used in the literature to capture the various experiences of individuals to understand phenomena or events better.^33,34 Qualitative descriptive is considered the most appropriate technique for obtaining information that can inform the development of policies or interventions; hence it is a suitable methodology for the study.³⁴

A purposive sampling was used to ensure representation of parents living in the Makkah region, Saudi Arabia, and having at least one child under 18 years of age. The sample size was adjusted until saturation was reached, which means that no new themes emerged from the interviews and that further interviews would not yield new information. We interviewed parents living in the Makkah region, as this was the most feasible and cost-effective location for the study. A snowball sampling technique was used. Participants were recruited through social media platforms to request their participation and by asking participants to recommend other potential participants who would be interested in engaging in the study. Ethical approval of the study was obtained from the Research Ethics Committee of the Faculty of Dentistry in King Abdulaziz University. Ethical approval number: 363-12-21. The study was carried out following the relevant ethical guidelines and regulations.

Data collection

Eligible participants who agreed to participate in the study were contacted by the research team via e-mail to schedule a convenient day and time for the interview. The study was conducted using in-depth semi-structured interviews and the lead author and study investigators adopted open-ended questions during the interviews. All participants were interviewed virtually through the Zoom platform to increase participation rates and feasibility given that some participants lived in Makkah city, and because of the lockdown and restrictions at the time of the study. Interviews were conducted in English, Arabic, or a mixture of both languages, depending on participants’ preferences.

To define areas that required exploring, the research team developed a topic guide that included several key questions, including the following core aspects: perceptions of COVID-19 vaccines, concerns about vaccinating their children, and facilitators and barriers that would influence their decision to vaccinate them. The questions used in the current study were directed toward: 1) parents’ intention to vaccinate their children; 2) factors that could influence their decisions to vaccinate their children; and 3) fears and concerns regarding vaccinating their children.

The interviews lasted approximately 30–45 min. Each interviewer’s response influenced the time and process of each interview. Verbal consent for participation and recording of the interviews was obtained from participants prior to commencement. Free discussion was encouraged among the participants, but prompts were applied if required. The interviews were audio recorded to reduce possible bias due to poor notes taken by interviewers. Personal identifying information was removed to ensure confidentiality and protect the participants’ identities.

Data analysis

Data analysis was performed using a thematic content analysis approach similar to that developed by Clarke and Braun.^35,36 The English transcripts were first transcribed verbatim. The Arabic transcripts were translated into English and then transcribed. The study team conducted multiple transcript reviews to familiarize themselves with the content. The transcripts were then broken down into smaller meaningful units, which were defined by different words and ideas expressed by the participants. The researchers then developed their ideas about the data by coding them into distinct categories. They also identified various themes that emerged from the data based on the HBM and the study objective. The initial set of transcripts was used to identify various themes that emerged from the data in accordance with the HBM. After coding the initial set of transcripts, the remaining data were indexed using identified codes. As the analysis progressed, additional codes were generated and subsequently applied for additional indexing. The codes were grouped into emergent themes.

The research team then discussed the various codes to identify code meanings and emerging themes to reach agreement. They also reviewed the codes to confirm that they reflected the study topic and to organize the final subthemes and themes. The team members then discussed the results and developed emerging themes with the lead author to ensure that the interviews were correctly interpreted and to enable triangulation of the results. The members of the research team checked the credibility of the data collected using member checking. They reviewed the results with the participants to determine whether they were genuinely representative of their views.

Results

Sample

A total of 50 interviews were conducted. The mean age of the participants was 38.1 ± 6.5 years. Table 1 presents the demographic characteristics of the participants. Two major themes and eight subthemes emerged during the data analysis process (Figure 1).

Figure 1. Factors affecting parents’ willingness to accept COVID-19 vaccines for their children as underpinned by the Health Belief Model.

Table 1. Demographics of the participants.

	N	%
Gender
Female	47	94%
Male	3	6%
Education
High school	1	2%
Bachelor	32	64%
MSc	10	20%
PhD	7	14%
Number of children
1–3	42	84%
>4	8	16%
Working status
Yes	30	60%
No	20	40%

Theme 1: Motivators to vaccinate children

Perceived benefits

Most participants willing to vaccinate their children were confident that the vaccines would protect them from COVID-19. They believe that this is the best way to control the spread of the disease: “It mitigates symptoms and reduces the risk of entering the intensive care unit, consequently hindering the disease.” (Participant 1)

Other factors that influence participants’ willingness to vaccinate their children include a reduction in the severity of the disease and its symptoms: “I will vaccinate my children because I noticed that vaccination relieved many symptoms and decreased the death rate. The percentage of people who were sick has decreased.” (Participant 16)

After the World Health Organization (WHO) declared COVID-19 a global pandemic,

the Saudi government implemented various measures to prevent the spread of the disease. One of these included the establishment of new rules and procedures to break the transmission chain. Some respondents noted that they and their children could return to their regular routines if vaccinated: “My motivation to vaccinate my children is mainly to return to normal life, so they can return to school, see their friends, and practice an everyday, regular life.” (Participant 29)

Perceived severity

One of the elements of this study was the assessment of how severely children are affected by COVID-19. This question asked participants to think about the severity of the disease and how it would affect their decisions regarding vaccinations. The seriousness of COVID-19 among children is a concern for some parents. Participants who had previously vaccinated their children against specific types of diseases felt more optimistic about the COVID-19 vaccine. Others claimed that it is a complex disease causing an unpredictable crisis that affects everyone, including their children. Their children were more likely to experience stress and anxiety than the adults, which consequently influenced their decisions to vaccinate their children: “If she did not receive the vaccination and was infected with the virus, we do not know how badly she (or other non-vaccinated children) would have been infected.” (Participant 10)

Perceived suitability

In the context of COVID-19 as a potential illness, many participants believed that children are most likely to be infected with the virus and develop severe symptoms that can lead to hospitalization or even death. Our results indicated that participants understood that the risk of a severe outcome from COVID-19 was higher for children with chronic and preexisting medical conditions. For instance, those who perceived themselves to be at a higher risk for acquiring COVID-19 were more likely to vaccinate their children.

My son is obese. I am afraid that he will get sick. He wants to get out and I cannot control him. In this case, I am worried that this virus will infect him, and you hear this is dangerous for them, so I will vaccinate him. (Participant 35)

“I am for vaccinating children who suffer from chronic diseases, such as diabetes, cardiovascular disease, or a neurological issue.” (Participant 39)

Collective responsibilities

Some believe that vaccination could benefit society by contributing to the overall population’s herd immunity, preventing the spread of the disease, and therefore assisting the community. A healthy population provides indirect protection against diseases. Individuals who were willing to vaccinate their children noted that it was their social responsibility to protect their families and communities. They believed that this was the best way to prevent the spread of the virus: “I mean, we are also afraid for our parents. I mean my mother, father, and father-in-law. The children always greet them. They go to their houses and play. I did not want my children to infect them.” (Participant 44)

Parents also believe that the vaccination of children could help protect vulnerable members of society, such as grandparents. They believe that even though children may not be infected with COVID-19, they can still spread the virus.

I am terrified because my mother is a cancer patient and her immunity is low, so I did not want my children to be around her because of her health condition. I did not want them to catch the virus or infect her. This matter was so scary that it made me decide to vaccinate my children. (Participant 10)

Confidence

Most respondents were confident that the authorities would do their best to ensure that COVID-19 vaccines were approved for children. They have full confidence in the various health organizations that have been authorized to market vaccines, such as the Food and Drug Administration (FDA) and the Ministry of Health in Saudi Arabia.

I didn’t have any doubts about the vaccination. As I told you, it is the same concept for all vaccinations that has existed for a long time, and the vaccine is FDA Approved. It has passed in three phases, so I have never had any doubt. (Participant 44)

Some participants indicated that they were confident that the COVID-19 vaccine was both effective and safe. They believed that the vaccine was similar to other childhood vaccines that helped to cure and prevent certain types of diseases. They believe in science and are grateful for the evolution of science. They agreed that despite the rapid development of vaccines, it is important to note that researchers worldwide have worked hard since the start of the pandemic to speed up the process by working together with various distributors and manufacturers.

So, I don’t understand why someone would decide not to take the vaccine. Since we were children, we have been vaccinating for seasonal flu and other diseases, so why not for coronavirus? It’s the same. As long as the vaccination prevents diseases and causes no harm, I do not mind. (Participant 46)

Science is developing every day, evidenced by the corona vaccine, which has not taken much time to be invented and will help humanity and our children. I cannot be against something that serves humanity and protects our children. (Participant 39)

Others had trust and confidence in the companies providing vaccines. They believed that such reputable companies would not risk their reputation in the marketplace: “Pfizer is a well-known company and has a good reputation in the market, and the company will not put anything in the market that harms its reputation.” (Participant 10)

Cues to action

Most participants talked about how the media negatively impacted their awareness of the importance of vaccines. They said that it was their primary source of information, affecting their decision-making. Despite being aware of the adverse effects of the media on their confidence in vaccines, many participants still used social media as a source of information. They were caught up in the paradox of how the media affected their perception of the effectiveness of the COVID-19 vaccine, but most participants cited the government and health professionals as their most trusted sources of information regarding vaccines. They also believed that the Saudi government was trustworthy when implementing vaccination programs for children.

If the government told us to have the vaccine, I am sure they did their experiments and tests, as our country will not rush into such stuff, and they are working hard to protect us and our children. (Participant 14)

“I believe in our doctors and our government, and I believe that they will not introduce something which could hurt our children.”

Theme 2: Barriers to vaccinate children

Perceived barriers

Respondents stated that they were not confident about the effectiveness of the COVID-19 vaccine due to its short development time. They also noted that various factors prevented them from vaccinating their children, such as the lack of large-scale clinical trials and reliable data: “I’m for it; however, one is a little fearful that it appeared so quickly, and it was not enough to experiment, nor did they determine its effectiveness and its side effects.” (Participant 38)

Another major factor that prevented people from accepting the COVID-19 vaccine was the lack of information regarding its safety and effectiveness. Many respondents noted that they were not informed of the various aspects of vaccines. In addition, other factors such as the liability of the manufacturer and compensation for any loss caused by vaccine failure were also considered. Owing to the widespread use of the Internet and social media, many people have become aware of the negative effects of COVID-19 vaccines through news reports and articles posted on the Internet: “I don’t want to give my children something that might contain toxins. I do not know what constitutes the vaccine; these vaccines are unknown. I use natural medicine and trust natural products like lemons and thyme leaves.” (Participant 8)

Although the long-term effects of the vaccine are still unknown, different participants believe that it might weaken the heart muscles of children or decrease their natural immunity.

I don’t know, but according to what doctors say, the vaccination may affect immunity in the long term. Now, I hear that it can cause inflammation in the heart. Sometimes they say it causes heart inflammation and they withdraw the vaccines saying that children do not need vaccinations. (Participant 39)

Complacency

Many parents are uncertain about the safety and efficacy of vaccines for their children. Although some believe that children are less susceptible to the immediate effects of the COVID-19 vaccine, they are more prone to experiencing long-term side effects. Parents said they needed more evidence of vaccine safety to feel confident about their child’s vaccination: “Children have milder symptoms, stronger immune systems, and their body recognizes and fights the virus faster. The virus does not threaten their body as it does adults.” (Participant 13)

Most respondents stated that their children were healthy. Some participants, especially those without chronic conditions, were unwilling to vaccinate their children because of their belief that their body’s immune system could respond adequately to an infection and was powerful enough to protect them from the disease. They also believe that they take good care of their health and that it is unnecessary to receive the vaccine: “Let their immune system play its role because, as I told you before, it is not a fatal disease and will not kill the children.” (Participant 10)

Others strongly believed that most children infected with COVID-19 develop mild symptoms, most did not develop severe disease, and were less susceptible to complications. However, some participants were unwilling to vaccinate their children because of their belief that the vaccines were ineffective and could not prevent infection, as many caught the disease even after being vaccinated. They preferred to use currently available natural medicines: “I will not give them until I see many experiences and make sure it prevents or reduces the symptoms. If I am not obligated to vaccinate them, I will not give it to them.” (Participant 13)

Discussion

Using the HBM framework, we identified various factors influencing parents’ decisions regarding the COVID-19 vaccination of their children. The main themes identified in this study were motivation for vaccination and barriers to vaccination. Although there were varying views about the issue, most participants agreed that it was a gray area. However, some parents place high value on vaccines, and most are willing to vaccinate their children. This finding is similar to the findings of several studies conducted in different countries, which found that parents are willing to vaccinate their children with the COVID-19 vaccine.^37–40

Some factors that influence parents’ willingness to vaccinate their children are the severity of the illness and the benefits of the vaccine. Notably, the vaccine was perceived to have protective benefits, primarily by respondents who also perceived COVID-19 as serious. Regarding perceived severity, some parents expressed concern that COVID-19 was unpredictable and dangerous. They feared that the disease would severely harm children or transmit the infection to the elderly. Therefore, vaccinating children helps prevent the spread of the disease. In line with a study by Skjelfe et al.,¹¹ being concerned about the seriousness of the disease and being confident that the vaccine is effective were some of the factors used to predict the willingness of parents in different countries to accept the COVID-19 vaccine.

Some parents also stated that vaccinating children could benefit society by contributing to the overall immunity of the population and reducing the infection rate. Contrary to our findings, a previous study found that those who believed that vaccination was a collective action were more likely to be hesitant about the vaccine.⁴¹ In contrast, those who believed that vaccination was an individual act were more likely to be supportive of the vaccine.⁴¹ Our participants believed that they were collectively responsible for controlling the spread of the disease and acting (i.e., them and their children being vaccinated) to return to normal life. Regulations in Saudi Arabia during the pandemic stipulate that individuals who have close contact with people infected with COVID-19 and those residing in the same household or working in the same office are required to quarantine. The feeling of collective responsibility among parents helped contain the spread of COVID-19. It also motivated people to become vaccinated. Some believed that it was a way to protect themselves from potential moral fault if they contracted the virus or spread it to others.

The themes identified in our study were similar to those of an international cross-sectional survey, in which they were asked about their willingness and perceptions about the COVID-19 vaccine for children. The reasons caregivers were willing to vaccinate their children were to protect the child and others, the presence of a high-risk child or family member, the perceived pandemic severity, and the desire to return to normal life.⁴²

The participants’ views were also framed in terms of their trust and confidence in the Saudi government. For example, they believed that the government could be trusted with the decision to extend the vaccination program for children. The values of liberty, purity, and anti-authority are associated with vaccine hesitancy.⁴³ According to previous studies, the political affiliation of past presidents can have a significant impact on the acceptance of vaccines among Americans.⁴⁴ A national survey also indicated that the public’s confidence in the effectiveness of the vaccine grew after the former president’s daughter was vaccinated.⁴⁵ Similar to the findings of studies on the motivation for vaccination, social support can help individuals overcome barriers to vaccinating their children.^46,47 For instance, family members, friends, and health professionals’ acceptance of vaccines can motivate parents toward vaccination. Public Health officials and social support agencies should consider the importance of social support when promoting the COVID-19 vaccinations for children. This can help decrease individuals’ hesitancy to be vaccinated and increase their motivation to vaccinate their children. One of the most effective ways to motivate parents to vaccinate their children is to use real-life stories and examples. This can help parents to understand the importance of keeping their children healthy.

The prevalence of vaccine hesitancy has been acknowledged in literature.^31,42,48,49 Two sub-themes emerged as barriers to acceptance of the vaccine for children. These factors were found in similar studies to influence parents’ willingness to vaccinate their children.^42,50,51 As a newly developed vaccine, the rush to develop the vaccine, the lack of reliable information about vaccines, and various types of vaccines have become major barriers to vaccination, as was reported in another study.⁴² In an international cross-sectional survey, 52% of 1541 caregivers, refused giving the COVID-19 vaccine to their children, due to its novelty.⁴² Our findings show that one of the main reasons parents were unwilling to vaccinate their children is the lack of reliable information about the safety and efficacy of the COVID-19 vaccine. Similarly, in a national survey in the United States, the primary concern among vaccine-hesitant parents was safety. Parents were more concerned about the safety of the vaccine than about its effectiveness.⁴⁹ In another study, it was reported that the main predictor of COVID-19 vaccine acceptance was parents’ perceptions about the safety and efficacy of the vaccine.⁴⁰ Some parents also had doubts about the safety of the mRNA vaccine and noted that they would instead consider a well-established vaccine type, such as an inactivated vaccine. The lack of clinical trial data regarding vaccines added to these concerns.

Potential side effects of the COVID-19 vaccine are another reason why parents are reluctant to vaccinate their children. Although some participants believed that children were less susceptible to COVID-19, they noted that they were more prone to long-term side effects. Parents stated that more evidence is required to confirm the safety of the vaccine in children. A cross-sectional study documented that among the factors contributing to vaccine hesitancy were concerns over the long-term effects of the vaccine, especially regarding the development of children.³⁸ This issue needs to be addressed in future clinical trials.

Parents who refused the vaccination believed that children’s immune systems are capable of fighting the virus. A US national survey estimated that one in four parents preferred that their children receive COVID-19 immunity through getting infected rather than through the vaccine.⁴⁹ This is in line with a study that indicated that being in a younger age group can influence a person’s decision not to be vaccinated.⁵² They also believed that the available treatment for COVID-19 was more effective than the vaccine. A study conducted in Hong Kong revealed that the number of people in the third wave who were unwilling to be vaccinated against COVID-19 was lower than in the first wave. The decline in the willingness to be vaccinated was attributed to various factors, such as concerns about vaccine safety, lack of clinical trial data, and the increasing number of people who follow precautionary measures.⁵³

The COVID-19 vaccine hesitancy model is prominent also with adolescents,⁵⁴ and some of the COVID-19 vaccine acceptability and hesitancy patterns followed a similar pattern as caregivers. In a survey among a sample of adolescents in Hong Kong, slightly more than a third of them intended to vaccinate. The main drivers for their willingness to vaccinate were having at least one parent vaccinated, knowing someone infected with COVID-19, and receiving the influenza vaccine. While reasons for refusing the COVID-19 vaccine were mainly concerns about the safety and efficacy of the vaccine.⁵⁴ In a cross-sectional study among adolescents in China showed that COID-19 vaccine hesitancy was associated with not receiving the influenza vaccine, no perceived susceptibility, and perceiving no cues for action.⁵⁵ The uncertainty about long-term health risks of COVID-19 vaccine, vaccine efficacy, and potential side effects were the main reasons of COVID-19 vaccine refusal among adolescents in another cross-sectional study.⁵⁶

Using a qualitative methodology, the study provided insight to establish the acceptability of the COVID-19 vaccine for children in Saudi Arabia. The study quality was enhanced using detailed and rich responses, which allowed us to gain deeper insight into the factors influencing the development and maintenance of quantitative research in this field. In addition, the study was conducted with a relatively large sample size, which allowed us to use the concepts of the HBM as a theoretical framework for assessing vaccine acceptability.

The findings of this study are limited because the participants were from a single region of Saudi Arabia. Consequently, the findings of this study are generally not generalizable. Second, the recruitment process might have caused selection bias. Third, researcher bias may also be a limitation of this study. The interviewees’ responses may have been affected due to the presence of the interviewers, as to provide responses that would achieve social desirability. Fourth, due to the pandemic, interviews were conducted online instead of face-to-face. This method could have resulted in different outcomes. Although it is usually preferred to conduct in-person interviews, the online interviews made the participants feel more comfortable and relaxed. Also, it was easier to communicate with the participants, given their busy schedules. Finally, only caregivers were interviewed, which may be different from adolescents’ views; we believe that caregivers are the decision-makers regarding vaccination. Nevertheless, our findings may provide direction for future research, such as a longitudinal study, to evaluate the acceptability of a COVID-19 vaccine for children.

Implications

It is essential that the public’s acceptance of these interventions is monitored. The results of this study suggest that the factors influencing parents’ decisions to vaccinate their children may vary. Besides the role of healthcare providers, other factors such as personal beliefs also influence parents’ decisions. The findings of this study can help guide future efforts to increase the uptake and acceptability of the children’s COVID-19 vaccine. In addition to the availability of vaccines, other factors such as the development of better communication structures and the establishment of effective information dissemination should be considered when it comes to increasing parents’ acceptance of vaccines.

Conclusion and policy recommendation

The success of children’s vaccination programs depends on parents’ willingness to accept the vaccine. The study revealed that participants’ views on the COVID-19 vaccine for children are complex; while some parents showed strong support for childhood vaccination due to their perceptions of the burden of the disease and the ability of the vaccine to protect their children, others were worried that the new and rushed vaccine might not be safe or effective. They also expressed concerns about the transparency surrounding the testing and development of the vaccines. However, parents generally agreed that they had faith in governmental decisions and would follow the recommendations regarding childhood vaccinations.

The study findings have strong implications for governments and health organizations. It is evident that vaccination hesitancy still exists, especially regarding the quickly developed COVID-19 vaccine. Parents need assurance on the efficacy of the vaccine; perhaps be presented with the results of the clinical trials that had taken place before the vaccine was made available to the public. In the current day, where invalid and unreliable information can be amplified and quickly disseminated, health authorities must provide the public with enough scientific information to assure them of the vaccine safety, perhaps shed light on previous medications that were also quickly developed in certain circumstances. While some parents would comply with governmental recommendations in any case, the uptake and acceptability of the vaccine would increase if parents had confidence in it and felt that they were making uncoerced decisions for themselves. The positive impact of such transparency from health authorities will go beyond that pertaining to the COVID-19 vaccine.

Acknowledgments

We acknowledge all the respondents for their time in participating in this study. We would like to thank the Deanship of Scientific Research at King Abdulaziz University, for funding this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data presented in this study are available on request from the corre-sponding author. The data are not publicly available due to participant’s privacy concerns.

Additional information

Funding

The study was funded by the Deanship of Scientific Research at King Abdulaziz University, (G: 206-140-1443).