In this study that focuses on the willingness of Malaysian parents to allow their children < 12 years old to receive the COVID-19 vaccine, nearly three-quarters of the parents were keen to vaccinate their children. In general, having parents that already received the COVID-19 vaccine was the strongest independent predictor of allowing children to be vaccinated. Other independent predictors of willingness to vaccinate the children include being a single parent, having a lower education level, working as a healthcare worker, and having a history of significant exposure to COVID-19. Parents from the Northern zone of the country were less keen to vaccinate their children compare to those from the Central zone.
To date, studies focusing on parents’ willingness to vaccinate children < 12 years old against COVID-19 were still limited. Teasdale et al reported 49.4% of parents in the USA were willing to vaccinate their children < 12 years old against COVID-19.(23) On the other hand, Almusbah et al reported only 25.6% of parents in Arab were willing to vaccinate their children < 12 years old against COVID-19.(24) Another study by Hetherington et al reported 60.4% of mothers in Canada were keen to obtain the COVID-19 vaccine for their 9 – 12 years old children.(19) More studies were looking at the willingness of the parents to vaccinate children < 18 years old against COVID-19. For example, multinational studies by Skjefte et al and Goldman et al respectively reported 69.2% and 65.2% of the parents were willing to vaccinate their children < 18 years old against COVID-19.(25, 26) The willingness of parents to vaccinate children < 18 years old against COVID-19 ranged 44.3 – 73.0% in the USA,(27–30) 59.3 – 72.7% in China,(31, 32) 64.2% in Korea,(33) 60.4% in Italy,(34) 51.0% in Germany,(35) and 48.0% in the United Kingdom.(17) Parents in Turkey consistently reported a lower willingness (29.0 – 36.3%) to vaccinate their children < 18 years old against COVID-19.(20, 36) When compared to these studies, parents in our study were more willing to vaccinate their children against COVID-19, even though previous evidence had shown parents were more likely to vaccinate their older children, especially those teenagers.(26, 30) This study was conducted after the majority of the adults in Malaysia had been vaccinated and in the midst of nationwide vaccination for teenagers could be the explanation. Goldman et al had reported caregivers in the USA, Canada, and Israel were more willing to accept the expedited approval of the COVID-19 vaccine for children < 12 years old after the emergency approval and commencement of the national vaccine program for COVID-19 in adults.(37)
Based on the available literature, independent predictors of parents that willing to vaccinate their children < 12 years old against COVID-19 include male respondents,(23, 24) higher educational level,(19, 23) higher household income,(19, 23) Asian in origin,(23), more willing to get COVID-19 vaccine for themselves,(23) and having children that completed standard immunization.(19) In children < 18 years old, independent predictors of parents that willing to vaccinate their children against COVID-19 include male respondents,(20, 26, 28, 34, 36) older age,(25, 28, 34) higher household income,(25, 28) willing or already taken COVID-19/influenza vaccine,(20, 26, 28, 30) perceived threat to COVID-19,(20, 28) working as healthcare workers,(20) and having children that completed routine immunization.(25) Even though the majority of the studies showed parents with higher education were more willing to vaccinate their children,(25, 30, 34) Wang et al,(31) Yigit et al,(36) and Temsah et al reported the opposite result.(38)
The psychological domain gradient of the Health Belief Model stated parents who neither delay or refuse their vaccination were more likely to allow vaccination in their children, and vice-versa.(39) This explained parents who already received the vaccine in our study were more willing to get their children vaccinated against COVID-19. Besides, Bourassa et al also reported the health behaviour during the COVID-19 pandemic was heavily influenced by past health behaviour,(40) for example, willingness for vaccination. Single parents, healthcare workers, and those with a history of significant contact in our study were more willing to vaccinate their children against COVID-19 due to a higher level of perceived threat. The influence of education level on vaccination attitude was conflicting. Opel et al and Smith et al attributed higher vaccination hesitancy in parents with higher education to safety concerns.(41, 42) The lower vaccination rate and COVID-19 cases in the Northern zone compared to the Central zone during this study was conducted explained the lower willingness of parents there to vaccinate their children.
Common reasons that were given by the parents that are willing to vaccinate their children < 12 years old against COVID-19 include believing the vaccine can protect their children, the vaccine can protect family and others, the vaccine was effective, and if the vaccination was recommended by healthcare workers or government.(19, 24) Similar reasons were also given by the parents who were willing to vaccinate their children < 18 years old against COVID-19, with additional reasons of believing the vaccine can help to control pandemic, and the benefits of vaccination outweigh the harms.(17, 20) On the other hand, uncertainty to the new vaccine, the concern of efficacy, side-effect, and safety of the vaccine, as well as perception that children were at lower risk to get COVID-19 were the main reasons parents hesitate or not keen to vaccinate their children < 12 years old or < 18 years old against COVID-19.(17, 19, 20, 23, 24) Parents in our study also reported similar reasons for willing and not willing to vaccinate their children against COVID-19, except the outcome of the vaccination program in other countries, and severity of COVID-19 in the community/among children were the main concern among parents who still hesitate. Previous literature had shown acceptance of vaccine was frequently associated with external factors (such as information about vaccine protection, and recommendation of vaccine by healthcare workers or government), while hesitancy and refusal of the vaccine were mainly due to vaccine-specific factors (such as perceived vaccine safety, efficacy, and disease susceptibility) explained the results observed in the current study.(43)
Children comprised 28.3% of Malaysian’s population of 32.7 million, of which more than half of them were still < 12 years old. Therefore, the finding of the current study that a quarter of Malaysian parents with children < 12 years were unwilling or hesitate to vaccinate their children against COVID-19 was worrying. Besides, the finding that parents who haven’t received their COVID-19 vaccine were at a fifteen times higher risk of refusing or hesitating to vaccinate their children against COVID-19 is worth prompt attention. The current study also identified vaccine-specific factors that led to COVID-19 vaccine refusal and hesitancy, as well as external factors that promote a positive attitude towards COVID-19 vaccination. Based on these findings, more targeted health education can be planned to mitigate COVID-19 vaccination refusal and hesitancy in parents of children < 12 years old.
First, more health education is needed to increase parents’ awareness towards COVID-19 vaccination in children < 12 years old. Its’ contents should be comprehensive, multilingual, and layman-friendly in order to reach out to parents from all walks of life. The common channel for Malaysians to obtain COVID-19 vaccine information such as electronic media and social media could be the ideal education platform, while printed materials and face-to-face public talks may still benefit certain populations particularly those from the rural area and less educated.(44) Second, health education should target parents at risk of vaccine refusal or hesitant, such as those who still haven’t received the COVID-19 vaccine. This group of parents could be reached on the social platform (such as Facebook and WhatsApp group) that provides inaccurate information to them. A recent study by Johnson et al highlighted Facebook pages that against vaccine were greater in number, cross networking, and more common in parenting or school groups.(45) MySejahtera, a mobile application developed by the Malaysian government to facilitate contact tracing and vaccination of COVID-19 could assist in identifying unvaccinated parents and subsequently deliver correct information to them. Third, health education should focus to address the common reasons for refusing the COVID-19 vaccine, such as uncertainty of new vaccine, worry of vaccine contents, the concern of vaccine safety, and lack of information from the doctors. Fourth, health education should highlight the benefits of the COVID-19 vaccine thus able to promote more vaccination rollout, such as being able to protect children, being able to protect family and others, as well as the good efficacy. Fifth, experimental and real-world data comparing health outcomes of children < 12 years old that vaccinated versus unvaccinated against COVID-19 should be provided to parents once available.
This is among the very few studies that assess parents’ willingness to vaccinate their younger children against COVID-19, and the first in Malaysia. This study had a large sample size and involved population throughout the country. The reasons why parents were willing, unwilling, and hesitate to vaccinate their children against COVID-19 were comprehensively evaluated, including open-ended questions for them to express opinions. There were several limitations in this study. First, snowball sampling was a non-probability sampling method. Second, only parents with internet access could participate in this online survey. Third, the respondents from the Northern zone were relatively smaller. Forth, influenza vaccination history was not assessed because it was not routinely administrated among adults or the younger population in Malaysia. Fifth, the parents’ knowledge of COVID-19 and their source of information about COVID-19 was not assessed, which could be a confounding factor.