Perceptions of Parents towards COVID-19 Vaccination in Children, Aseer Region, Southwestern Saudi Arabia

Vaccines are an important part of the COVID-19 pandemic response plan. This cross-sectional study aims to assess the attitude and perception levels of parents toward COVID-19 vaccines for children aged 0–18 years in the Aseer region of Saudi Arabia. Data were analyzed using SPSS version 16.0. Out of a total of 1463 parents, 30.6% assumed that COVID-19 vaccination may be more dangerous for children than adults. Nearly 36.5% parents don’t have any concern about children’s vaccination. About 12.8% of children have not received the vaccination, 55% of parents have some sort of hesitation and 32.2% of parents did not hesitate before vaccinating their children against COVID-19. Only 15.4% of parents expect that the COVID-19 vaccine affects their child’s genes. About 23.4% parents strongly agreed and 35.1% agreed about the importance of getting their children vaccinated. About 22.1% of parents strongly agreed and 33.3% agreed regarding their willingness to get their children vaccinated to prevent Coronavirus disease. More than 80% of parents recommended rushing to receive the COVID-19 vaccine. Health professionals and policymakers should implement and support strategies to ensure children are vaccinated for COVID-19. They also need to educate parents and families regarding childhood vaccination.


Introduction
In Saudi Arabia, as of 22 July 2022, there have been 805,879 confirmed cases of COVID-19 with 9233 deaths, reported to WHO. A total of 66,700,629 vaccine doses have been administered in the entire Kingdom [1]. Vaccines are an important part of the COVID-19 pandemic response plan. They resemble one of the most successful and cost-efficient public health interventions developed, saving millions of lives every year [2][3][4]. Following the decoding of the SARS-CoV-2 genome sequence in early 2020 [5] and the World Health Organization's (WHO) declaration of the pandemic in March 2020 [6], scientists and pharmaceutical firms are racing against the clock to create effective vaccines [7]. Around the world, there are now 137 COVID-19 vaccine candidates undergoing clinical trials and 194 candidates in pre-clinical development [8]. Four vaccines (AstraZeneca Oxford, Moderna, Pfizer and Johnson & Johnson) have been approved for use in Saudi Arabia [9]. n =(1.96)2(0.5)(0.5)/(0.5 × 0.05) 2 n = 1537 We removed 74 samples from surveys as these responses do not represent genuine preferences such as incomplete information, or wrong information etc. So, statistical analysis and results were done on a 1463 sample.

Data Collection
Data was collected using an adapted and modified questionnaire from the study of El-Elimat et al. [17]. The questionnaire was distributed online to the parents and comprised of closed ended questions made to meet the study objectives. The online questionnaire was prepared in both English and Arabic language using Google forms and distributed among participants through social media and E-mail for convenience of data collection as face-to-face interviews had to be avoided following the social distancing norms by the government. The questionnaire was translated from English to Arabic (local language) by a bilingual person to enable an easy understanding of the questions and avoid any questionnaire bias. Before administration of the final version of the questionnaire, a pretest was performed among random parents in the region to ensure the reliability and applicability of the questionnaire. The results of the piloted study were not included in the final analysis. The questionnaire comprised of three sections; the first included the participants' sociodemographic characteristics, such as age, sex, and nationality. The second part included questions assessing the attitude of parents towards COVID-19 vaccines for children. The third part consisted of questions assessing the perspectives of parents towards COVID-19 vaccines for children.

Ethical Considerations
The questionnaire started with a brief explanation of its objective and intent and a reminder to participants that their participation is entirely voluntary. The survey didn't collect names, nor will they collect dates of birth or addresses. Electronic informed consent was obtained from all the participants before filling out the survey forms. The confidentiality of data was well-preserved throughout the study by keeping it anonymous and asking the participants to select honest answers and options.

Statistical Analysis
The collected data were coded and entered into an excel software (Microsoft office Excel 2010) database. Data was analyzed using Statistical Package for Social Sciences, version 16.0 (SPSS, Inc., Chicago, IL, USA). Information related to parent's perspectives and their experience towards COVID-19 vaccine were presented in descriptive statistics like, frequency and percentage. Pearson's chi-square test was used to assess the association between perception of parent's expectation that vaccination may be more dangerous for children than adults as a dependent variable and related risk factors such as sociodemographic, queries related to parents' perspectives variables as independent variables. p-value of less than 0.05 was regarded as statistically significant. Table 1 shows the association between parents' socio-demographic variables and their concern towards children's vaccination. A total of 1463 parents were included in the study. In which 449 (30.69%) assumed that vaccination may be more dangerous for children than adults. Out of 449 study subjects, the frequency of female parents was higher as compared to male parents. Approximately one third of parents expect that vaccination may not be more dangerous for children than adults. The majority of parents 534 (36.50%) don't have any concern about children's vaccination. In the age group 20-30 years, more than 205 (40.8%) of parents think that vaccination may not be more dangerous for children than adults and 160 (31.8%) expect that it may be more dangerous for children than adults. The majority of parents whose education levels were above bachelor's degree and those belonging to the medical field perceived that vaccination may not be more dangerous for children than adults. Most of the parents with one child think that vaccination may not be more dangerous for children than adults 224 (42.6%) followed by parents with two children 149 (28.7%). Statistical significant differences were found between parents' sociodemographic variables such as gender, age, marital status, occupation, employment, nationality, monthly income, having children, and the number of children with their concern towards childhood vaccination. Table 2, Figures 1 and 2 shows the distribution of parents' standpoints on the Coronavirus (COVID-19) Vaccination. It was observed that 12.8% of parents have not concern for vaccination, 805(55%) of parents had some sort of hesitation and 471(32.2%) of parents did not hesitate before vaccinating their children. The majority of parents strongly agreed 342(23.4%) and agreed 514(35.1%) about the importance of getting their children vaccinated. Parents strongly agreed 323 (22.1%) and agreed 487 (33.3%) regarding their willingness to get their children vaccinated to prevent Coronavirus disease. The majority of parents do not agree 387(26.5%) that fears prevent them from administering the vaccine to protect their children from the Coronavirus due to the side effects. Most parents do not agree 475 (32.5%) and very few 125(8.5%) strongly agreed that the COVID-19 vaccine could affect their children's puberty or fertility. In Figure 1 yellow represent that the 48% parents don't know about whether corona vaccine affects child genes or not. More than 80% of parents recommended rushing to receive the Corona vaccine. The majority of parents 1030(70.4%) opined that the services provided at the vaccination centres were excellent. Figure 2 shows that the most reliable sources of information for parents about vaccines were health care providers (26.6%) followed by the Food and Drug General Organization (25.2%). Another important source of information were social media (facebook, twitter, whatsapp) (21.8%) and media (tv, radio) (17.4%).     Table 3 shows the frequency distribution of parents experience with coronavirus. About 847(57.9%) of parents had not experienced any bad side effects from receiving vaccinations in the past. About 1041 (71.2%) of parents did not get the seasonal flu shot last year. Nearly 293(20.0%) of the respondent's family members, followed by respondents themselves 180(12.3%) and the respondent's friends 109 (7.5%) had been confirmed to be infected with the Coronavirus through laboratory examination. It was also found that 971 (66.4%) of parents did not think that they may have been exposed to or infected with Coronavirus (without testing) ( Table 3).  Table 3 shows the frequency distribution of parents experience with coronavirus. About 847(57.9%) of parents had not experienced any bad side effects from receiving vaccinations in the past. About 1041 (71.2%) of parents did not get the seasonal flu shot last year. Nearly 293(20.0%) of the respondent's family members, followed by respondents themselves 180(12.3%) and the respondent's friends 109 (7.5%) had been confirmed to be infected with the Coronavirus through laboratory examination. It was also found that 971 (66.4%) of parents did not think that they may have been exposed to or infected with Coronavirus (without testing) ( Table 3).  Figure 3 shows that the nearly 30.7% thought that vaccination may be more dangerous for children than adults, whereas 32.8% of parents admitted that vaccination may not be more dangerous for children than adults. In Figure 3 yellow represent that the 36% parent's don't have concern about vaccination being more dangerous for children than adults. Figure 4 shows that the fear of infection by a family member (13.0%) was the commonest worry followed by fear of contracting the virus (7.6%) in the parents. However, 11.8% of parents were not worried about any problem.

Results
Which of the following has been confirmed to be infected with the Coronavirus through laboratory examination?  Figure 3 shows that the nearly 30.7% thought that vaccination may be more dangerous for children than adults, whereas 32.8% of parents admitted that vaccination may not be more dangerous for children than adults. In Figure 3 yellow represent that the 36% parent's don't have concern about vaccination being more dangerous for children than adults. Figure 4 shows that the fear of infection by a family member (13.0%) was the commonest worry followed by fear of contracting the virus (7.6%) in the parents. However, 11.8% of parents were not worried about any problem.     Figure 5 depicts that the parents' attitudes towards vaccination, immunity, and the coronavirus (COVID-19) pandemic. In which majority of parents strongly agreed 306 (20.9%) and agreed 541 (37.0%) that vaccines are generally considered safe.
Parents who believe that COVID-19 vaccine is more dangerous for children than adults among them almost half of them 225(47.8%) showed hesitancy for their children being vaccinated, 126 (56%) have concerns that Corona vaccine affects child genes, majority of them 57 (60%) were not willing to give the vaccine to prevent Coronavirus disease to your children, half of them 65 (52%) showed concerns that the COVID-19 vaccine could affect your son/daughter's puberty or fertility and 167 (45.6%) had any bad side effects from receiving vaccinations in the past whereas statistical significance differences were found Vaccines 2022, 10, 1222 9 of 15 between parents who believe that COVID-19 vaccine is more dangerous for children than adults with the hesitancy before your children being vaccinated, have concerns that Corona vaccine affects child genes, willing to give the vaccine to prevent Coronavirus disease to your children, have concerns that the COVID-19vaccine could affect your son/daughter's puberty or fertility and who had any bad side effects from receiving vaccinations in the past (Table 4). Parents who believe that COVID-19 vaccine is more dangerous for children than adults among them almost half of them 225(47.8%) showed hesitancy for their children being vaccinated, 126 (56%) have concerns that Corona vaccine affects child genes, majority of them 57 (60%) were not willing to give the vaccine to prevent Coronavirus disease to your children, half of them 65 (52%) showed concerns that the COVID-19 vaccine could affect your son/daughter's puberty or fertility and 167 (45.6%) had any bad side effects from receiving vaccinations in the past whereas statistical significance differences were found between parents who believe that COVID-19 vaccine is more dangerous for children than adults with the hesitancy before your children being vaccinated, have concerns that Corona vaccine affects child genes, willing to give the vaccine to prevent Coronavirus   Table 5 shows that the queries related to parents' perspectives as response in strongly agree/agree strongly disagree/I do not agree. Eight hundred ten parents strongly agreed/ agreed for query 'willing to give the vaccine to prevent Coronavirus disease to your children'. While, only 180 parents expect that vaccination may be more dangerous for children than adults. Three hundred twenty-three parents strongly agreed/agreed about that COVID-19 vaccine could affect your son/daughter's puberty or fertility. Results show statistically significant association.

Discussion
Vaccination is one of the most useful scientific interventions which have been proved for controlling many infectious diseases and has helped to eradicate some diseases. Our aim of the study was to identify factors driven towards COVID vaccine hesitancy or acceptance for children among parents. One of the major factors towards any vaccine acceptance and hesitancy is the parental perception of that vaccine [20]. The report of the World Health Organization (WHO) regarding immunization revealed that in 2020, the number of unvaccinated children increased by 3.4 million as compared to the number of children who received vaccination during 2019 which was showing a decline in the total percentage from 86% to 83%. Certain misconceptions are being circulated about different vaccines although studies are being done to find the reasons for this decline [21].
We are observing similar problems related to myths and beliefs in the general population regarding acceptance of COVID-19 vaccination not only for children but for adults as well. Therefore, it is necessary to quantify the extent of the problem and to identify measures to reduce the COVID-19 vaccination hesitancy among parents and children [22].
COVID-19 vaccine is the most powerful tool that we have in combating the battle against the COVID-19 pandemic, but we found an increased rate of vaccine refusal and scepticism toward the vaccine. A recently published report demonstrated that four out of ten Americans will definitely or probably not take the vaccine and about 21% of American adults are "pretty certain" that they will not take the vaccine. The increasing rate of vaccine refusal or hesitancy is driven by diverse factors in different countries or community groups [23].
Our online survey targeted those parents who were interested in participating in the study and provided a relevant snapshot of the COVID-19 vaccine perspective of parents. Mei-Xian Zhang et al. demonstrated quite many similarities in their study, female parents were more responsive to questionnaires, and female parents were having more concerns about vaccine safety, although they reported 46% willingness of parents to vaccinate their children whereas in our study 55% parents (22% parents strongly agree and 33% parents agreed) for vaccination for their children [24]. A higher proportion of highly educated Saudi parents thought that vaccine is not dangerous for children in our study. Other researchers have also reported that higher educational levels were associated with higher confidence toward vaccination [25][26][27].
Around 40% of parents in the age group 20-30 years in our study believed that vaccine is not dangerous for children indicating that the young Saudi generation is more educated than the older age group and hence has more information and knowledge about vaccination and its effects.
Similar to our study findings, Mei-Xian Zhang et al. also reported that mothers were having more fears than fathers regarding the dangers of the COVID vaccine for their children [2,24].
Similarly, Diego Urrunaga-Pastor et al. demonstrated that parents with one child have more attitude toward getting vaccination similarly our study also showed parents with one child showing a good attitude towards COVID vaccine and having less fear of vaccine than parents with two children probably parents with one child are young and more educated as compared with the parents having more children, as the young generation is more educated in Saudi Arabia than older generation here [2,28]. Multiparty is one of the known factors for delayed immunization or avoiding immunization for young children [2,29].
There are many reasons behind the parental concerns about vaccine safety and its side effects. Many studies have showed concerns not only for the COVID-19 vaccine but Measles, mumps, and rubella (MMR) vaccine and its relation to autism has also played a significant role in vaccine hesitancy and refusal in the past [30,31]. People have some similar beliefs and concerns regarding the COVID-19 vaccine as well because of undefined safety related to the COVID vaccine and certain myths related to vaccine-associated infertility as well [3,32]. Our study findings are also in agreement to this, as more than 50% of parents had concerns that the COVID-19 vaccine could affect their children's genes, puberty or fertility.
Although 55% of parents showed hesitancy before their children's vaccination in this study.
Around 88% of children in our study population were vaccinated because it is mandatory by the Ministry of health of Saudi Arabia that all kids will be vaccinatedfor COVID therefore the rate of vaccination in the study region of Saudi Arabia is higher than other parts of the world. Alfieri et al. reported only 33% vaccination rate in US [35].
In our study majority of parents strongly agreed (23.4%) and agreed (35.1%) about the importance of getting their children vaccinated, 22.1% of parents strongly agreed and (33.3%) agreed regarding their willingness to get their children vaccinated to prevent Coronavirus disease. Marco Montalti et al. also reported that about 60% of the guardians of children under 19 years of the Metropolitan City of Bologna are also inclined to vaccinate their children [3,27].
About 26% of parents did not agree to vaccinate their children against COVID-19 because of the fear of side effects whereas the majority of them were thinking vice versa.
Only 15.1% of parents believe that the COVID-19 vaccine can effect the genes of their children. This is probably as they were mistaken with the type of vaccines like the Messenger RNA (mRNA) vaccine and the technique which is known as reverse genetics (RG) that is widely used for the genetic manipulation of RNA viruses from their full-length cloned DNA (cDNA) and can lead to the development of successful counter measures [3,36]. Nearly 8.5% and 13.5% of parents respectively strongly agree and agree that vaccines can affect the puberty and fertility of their children. Malik Sallam et al. also reported that 23% of the Kuwaiti and Jordanian population believe that vaccines can cause infertility [3,37].
Studies are still insufficient in number regarding the long-term side effects of the COVID-19 vaccine among human beings. Although studies conducted on rats have showed no adverse effects of BNT162b2 (mRNA COVID-19 vaccine) on female rat fertility and reproduction [3,38].
The most reliable sources of information for parents in our study about vaccines were health care providers (25.5%) followed by the Food and Drug General Organization (25.2%) although the most common source of information about COVID-19 vaccines was reliance on medical doctors, scientists, and scientific journals (36.4%) among Jordanian and Kuwaiti population [38].
In contrast, mass media communication and social media platforms are also sources of information but they are associated with more doubts, myths, and disbeliefs regarding the COVID vaccine. This might be linked to the easier spread of misinformation through social media, including inaccurate and wrong information regarding the safety of COVID-19 vaccines [4,39].
More than 80% of parents in the Aseer region of Saudi Arabia recommended rushing to receive the COVID-19 vaccine, indicating good health-seeking behaviour in the study population. There is also an urgent need by the administrations and public health agencies to seek political support for full coverage of the COVID-19 vaccination not only in Saudi Arabia but also worldwide [4,40].
The majority of parents (57.9%) agreed (strongly agreed 20.9% and agreed 37.0%) that the vaccines are generally considered safe in our study. Katherine Kricorian reported a 41% positive response regarding vaccine safety among the American population [4,41].
Around 20% of respondents' family members have been affected by COVID-19, whereas 13% of respondents were having fear of COVID infection in their family members, which is lower than that reported (34%) by Liliana Cori et al. [4,42]. Previous research explored the various determinants of vaccine hesitancy among parents and showed that parents who did not have any plan to vaccinate their children for the COVID-19 vaccine had significantly higher levels of misconceptions and mistrust for the COVID-19 vaccines, they also have lower levels of confidence regarding the COVID-19 pediatric vaccine safety and efficacy [4,43].
Previous studies have stated that the safety and efficacy of the pediatric COVID-19 vaccine influences parents' hesitancy toward pediatric COVID-19 vaccine acceptance by the parents by 19.5% and influences their plan to get their children vaccinated. Whereas in our study parents were showing hesitancy in 20.2% who were thinking that vaccine is more dangerous for children than adults [4,44]. Almalki OS et al. also concluded that parents who perceived low benefit from the vaccine (OR = 16.3; 95% CI, 12.1-21.9) or who had safety or efficacy concerns (OR = 3.76; 95% CI, 3.10-4.58) were among the most hesitant to vaccinate their children [1,19].
In our study, about 52.9% of parents were not thinking that vaccine is more dangerous for children than adults. Similarly, another study showed that 59.8% of parents stated that the vaccine would protect their children from COVID-19 and its complications that's why they were willing to vaccinate their children [4,45].
There are certain other myths reported related to children's vaccination for COVID-19 that this vaccine can cause autism (15.2%), mistrust of big pharmaceutical companies (54.2%), and coronavirus has been developed by the government (48.6%) [4,46].
In a worldwide survey, nearly 37.7% were afraid of adverse effects of the COVID vaccine and 5.6% opined that COVID-19 is a self-limiting disease so there is no need for vaccination [47].In a recent students survey in Egypt, about 22.88% believed that vaccines have some long-term genetic side effects [48].Overall female gender is reported to bemore hesitant toward COVID-19 vaccination worldwide [49].Most likely they are worried about puberty and fertility in the future. A massive project conducted across 50 statesalso reported that 37% of the population believe that vaccines have health effects specific to girls and women, and 34% believe that vaccines have health effects specific to boys and men [50].
Parris Diaz et al. also reported that about 41% of adults believed that the COVID-19 vaccines can negatively impact their reproductive health and or fertility, and about 38% of respondents were unsure of the effects on fertility [51]. The above findings are similar to what has been reported by our study. Less than one-half of US participants in a National survey reported that they are likely to have their child receive a COVID-19 vaccine [52]. Majority of parents were going to vaccinate their children against COVID-19 in a previous study in a Saudi population [53]. The prevalent level of hesitancy, fear, and other health concerns observed among the parents towards their children's vaccination should be reduced. The following factors may have led to certain limitations in the present study. The cross-sectional nature of this study cannot confirm the causality association between the compared variables. The self-reported responses could over or underestimate the results. The required sample size according to sample size calculation was 1537. However, the final sample size was 1463 after removal of 74 samples. This is below the required target and had to be compensated by collection of more samples which could not be done due to time and resource constraints. This study was conducted at one center in Saudi Arabia and our findings may not present parents' view regarding COVID-19 vaccine across Saudi Arabia.
We hope in the future to have all the required resources to do multicentric/nationwide studies However the data included children of all age groups between 0-18 years and an extensive analysis has been made is the strength of our study. This study assessed the parent's attitude and perception regarding vaccine acceptance for children in the study population. We learnt that, 30.6% parents assumed that COVID-19 vaccination may be more dangerous for children than adults. About 12.8% of children have not received the vaccination and 55% of parents have some sort of hesitation before vaccination. Nearly 15.4% of parents expect that the COVID-19 vaccine affects their child's genes.

Conclusions
Thus our study shows significant differences between parents who believe that the COVID-19 vaccine is more dangerous for children than adults with the hesitancy before your children being vaccinated, have concerns that COVID-19 vaccine affects child genes, willing to give the vaccine to prevent Coronavirus disease to your children and have concerns that the COVID-19 vaccine could affect your son/daughter's puberty or fertility. Health professionals and Policymakers should implement and support strategies to ensure children are vaccinated for COVID-19. They also need to educate parents and families regarding importance of vaccination against COVID-19. A support program for health education for these parents should be introduced. This can go a long way to reduce the impact of hesitancy, fear, among them. The study might be helpful in designing interventions to address the impediments in the current COVID-19 vaccination drives and vaccinate a wider child population to limit the pandemic.