Caregiver’s perceptions of COVID-19 vaccination, and intention to vaccinate their children against the disease: a questionnaire based qualitative study

Coronavirus disease 2019 (COVID-19) vaccine side effects have an important role in the hesitancy of the general population toward vaccine administration. Another reason for vaccine hesitancy might be that healthcare professionals may not address their concerns regarding vaccines appropriately. Regardless, hesitancy in the form of delay, refusal, or acceptance with doubts about its usefulness can limit the downward trajectory of the COVID-19 pandemic. Therefore, the authors conducted a national cross-sectional study (n=306) to assess causes and concerns for vaccine hesitancy in caregivers in Pakistan toward getting their children vaccinated. The questions identified caregivers by socioeconomic demographics, perceived COVID-19 pandemic severity, and concerns toward the COVID-19 vaccine. The majority of the participants were 45–59 years of age (42.8%) with a mean age of 36.11 years (SD: 7.81). A total of 80% of these participants were willing to vaccinate their child with any COVID-19 vaccine. Present comorbidities had a frequency of 28.4% (n=87/306) and only 26.9% (n=66/245) participants were willing to vaccinate their child. Participants with high social standing were 15.4% (n=47/306) with the majority of them being willing to vaccinate their children (45/47). Socioeconomic status (OR:2.911 [0.999–8.483]), and the child’s vaccinations being up to date (OR:1.904 [1.078–3.365]) were found to be independent factors for caregivers to be willing to vaccinate their child. Around 62% (n=191/306) were not willing to vaccinate due to the concern for side effects, 67.6% (n=207/306) were not willing because they did not have ample information available, and 51% (n=156/306) were not willing as they were concerned about vaccine effectiveness. Further studies on vaccine safety in the pediatric population are required to improve caregivers’ perceptions.


Introduction
The coronavirus otherwise known as severe acute respiratory syndrome coronaviruses including SARS-CoV and SARS-CoV-2, first appeared in China [1] .Despite the extensive research performed on SARS, there is limited understanding of the pathophysiological impact of coronavirus disease 2019 (COVID- 19).Research shows that SARS-CoV-2 causes acute pneumonia with clinical symptoms similar to those reported for SARS-CoV and MERS-CoV [2] .In regard to SARS-CoV-2 infection (COVID- 19), the most concerning complication to date is acute hypoxemic respiratory failure, which requires patients to be on mechanical ventilation.
As of mid-March 2022, more than 960 000 U.S. residents have died of COVID-19 [3] ; however, the true number of deaths resulting from COVID-19, both directly and indirectly, is likely to be much higher.According to the recent Center of Disease Prevention and Control (CDC) data, 1078 children and adolescents less than 18 years of age died from COVID-19 [4] .As a result, children could benefit both directly and indirectly from the COVID-19 vaccination [5] .Surveys have shown that the rate of hospitalizations and deaths were markedly reduced by 65 and 69% in the U.S., respectively [5] .There is a lack of argument on whether the vaccination rate among children is lower or greater than adults.Despite vaccine introduction, hesitancy in the form

HIGHLIGHTS
• Our study results showed that 80.0% of the studied population were willing to vaccinate their child.• The top reason to vaccinate is the protection of the child and not to vaccinate is side effects.• The most significant predictors were high social status and the child's vaccination being up-to-date.
of delay, refusal, or acceptance with doubts about the usefulness or its impact against COVID-19 can limit the downward trajectory of the COVID-19 pandemic [6] .Vaccine hesitancy stems from fear and mistrust toward healthcare services and is recognized by the WHO as one of the top 10 most important threats during the pandemic [7] .Even though there is a clear public perception of the high-risk associations regarding the pandemic, many studies show that subgroups around the world are reluctant about vaccination mainly because of its side effects and the conspiracy theories surrounding it.In many countries; however, a considerable fraction of healthcare workers is influenced by vaccine hesitancy due to a lack of information of its safety and long-term efficacy [8] .At the end of the day, most healthcare professionals are not experts on COVID-19 vaccination because of disease novelty that is still under extensive research.They may face a dilemma on how transparent they should be about the risk and benefits of vaccines to individuals without undermining their confidence in an important public health measure.
Another reason for vaccine hesitancy might be that healthcare professionals may not address their concerns regarding vaccines appropriately.This remains the only significant factor despite full access to vaccine services possibly due to fear and mistrust toward healthcare services [9] .COVID-19 vaccine hesitancy perhaps stems from similar reasons.Despite the uncertainties about its risk and benefits, healthcare professionals strongly support COVID-19 vaccination considering its impact in reducing disease mortality and hospitalizations.
Vaccine hesitancy, most importantly, is derived from the exposure to criticism of vaccination, misinformation, and 'antivax' activists through social networks [10] .False and misleading information about COVID-19, potentially dangerous treatments, and eventual vaccination continue to grow on social media platforms.As the number of people reluctant to get vaccinated is increasing rapidly, with many downright refusing to get vaccinated in the midst of a global pandemic, it is getting increasingly important to understand the causes of vaccine hesitancy to combat it and identify solutions that ameliorate people's concerns regarding vaccinations in a healthy and cooperative way.Therefore, we conducted a national cross-sectional study to assess causes and concerns for vaccine hesitancy in caregivers in Pakistan toward getting their children vaccinated.

Study's general characteristics
A qualitative study was conducted amongst caregivers with children in Pakistan between September 2021 and October 2021.Three hundred and fifty individuals representing each of the four provinces of Pakistan, Sindh, Punjab, Khyber Pakhtunkhwa, and Baluchistan between the ages of 18 and 69 years provided consent for participation.Research protocol approval was taken from the local registry and carried out according to qualitative study protocols [11] .The sample size was calculated through the WHO sample size calculator by estimating a population proportion with specified absolute precision [12] , using the formula = Z 2 P (1 − P)/d 2 where n = sample size; Z = CI; P = anticipated prevalence, and d = absolute precision.
An online questionnaire was administered through popular social media platforms such as WhatsApp, Facebook, and via e-mail that was completed by each participant individually.
Bloggers and social media influencers were propagating the questionnaire to caregiver's who consented via online written authorization to access the questionnaire.The consent was provided before responding to the actual questionnaire.Anonymity was part of consenting authorization, and was filled up by the responders.The outline of the questionnaire was adapted and modified from the previous study conducted by Goldman et al. [13] and consisted of several multiple-choice questions as well as questions requiring a yes or no response.The survey tool was translated into Urdu and the questionnaires were provided and subsequently completed between dates.The participants were informed that their data would be anonymous and that it would be kept confidential to minimize response bias.Out of 350 individuals, 306 were selected for final analysis.Results were presented according to guidelines set by strengthening the reporting of cohort, cross-sectional and casecontrol studies in surgery (STROCSS) group [14] .

Questionnaire details
The objective of the questionnaire was to investigate predictors associated with Pakistan caregivers' intent to vaccinate their children against COVID-19.Questions identified caregivers by socioeconomic demographics, perceived COVID-19 pandemic severity, and concerns toward the COVID-19 vaccine.Additionally, questions were included to investigate the age of the caregiver, whether the individual and their child had been vaccinated against influenza and maintained up-to-date records.Participants were also questioned regarding their self-reported health and comorbidities as well as their child's.Furthermore, it was specifically documented if the child had a chronic illness or if they were using any chronic medications.

Statistical analysis
Data were analyzed using SPSS version 25.0 (SPSS Inc.).Frequencies were calculated for all categorical responses.A multivariable logistic regression model was used using the odds ratio to predict caregiver-dependent factors for choosing to vaccinate the child or not with dependent variables being the caregiver's willingness to vaccinate their child.A P-value of <0.05 was considered to be statistically significant.
The willingness to vaccinate children was calculated using the multivariable logistic regression analysis.Two factors were found to be statistically significant in predicting the willingness to vaccinate children in parents/legal guardians, including higher socioeconomic status (OR = 2.911, P = 0.050, 95% CI = 0.999-8.483),and the child's vaccinations being up to date (OR = 1.904,P = 0.027, 95% CI = 1.078-3.365).The complete breakdown of the multivariable regression model is shown in Table 2.
The reasons for these inclinations were reported as 97.1% (n = 297/306) participants were willing to vaccinate their child to protect them, 93.8% (n = 287/306) were willing to do so their children could return to a normal life and 96.1% (n = 294/306) were vaccinating their children to protect others.Whereas 62.4% (n = 191/306) were not willing to vaccinate due to the concern for side effects.67.6% (n = 207/306) were not willing because they did not have ample information available.Lastly, 51% (n = 156/ 306) were not willing to vaccinate their children as they were concerned about the efficiency and effectiveness of the vaccine, as shown in Table 3. Figure 1 showcased scaled responses of the studied population regarding the vaccine hesitancy.

Discussion
Our primary finding was that higher socioeconomic status predicts a higher willingness to vaccinate children for COVID-19 as well as having an up-to-date vaccination portfolio.This finding is like the results found by multiple other studies [15][16][17] where high income and education levels were associated with lower vaccine hesitancy.Medical individuals can better help them understand certain medical procedures and pharmacological interventions such as vaccines as well as help dispel any misinformation or biases that they may hold [18] .However, this finding can be further complicated as recent studies [19,20] have found that the type of media resource being used to conduct research, especially concerning vaccines can be extremely important in directing decisionmaking regarding vaccination hesitancy as well as general trust in the national healthcare system.One of the greatest impacts promoting vaccine hesitancy, especially in the West, has been had by social media networks owing to the rampant and quick circulation of articles, curiosity-inducing headlines and sensational journalism.Social media has been implicated as being the biggest propagator of misinformation regarding vaccines and their safety  and efficacy.With abysmal rates of fact-checking that occurs on social media, shockingly, the current distrust rates concerning vaccines and medicine in general stand at an extreme high of 48% of individuals not being very likely to accept the COVID-19 vaccines in 2021 [21] .A clear but difficult and long-term solution to increasing vaccine acceptance, trust in the healthcare system and improving willingness to readily accept medical interventions seems to be improving the socioeconomic status of the general population; however, that requires a global economic approach.
Our secondary finding was that individuals with children who had up-to-date vaccination profiles were very likely to be accepting of the COVID-19 vaccines.This finding makes complete sense as these children very likely belong to families who are already of a higher socioeconomic status, as mentioned above, or have trust in the healthcare system as well as understand that popular social media claims about medical practices involving vaccinations are not to be trusted and should be thoroughly verified.This finding is in conjunction with the discoveries made by another study where vaccination history was found to be a leading predictor for COVID-19 vaccine acceptance [22] .
We also found that the leading causes for willingness to vaccinate were to protect the child, followed by protecting others.Perceived severity and the noble notion of protecting the wider community have previously proven to be important causes of vaccine acceptance [23,24] .However, age and sex were also found to be important predictive factors by the aforementioned studies.Our study found no statistical significance regarding age and sex as being predictive.An important cultural reason for this is the highly patriarchal nature of society in Pakistan, where fathers and grandfathers make most family decisions, including but not limited to medical decisions; in many cases, one would be correct in assuming that the dominant male figure in the household decides whether the children as well as the women would be receiving medical interventions or not [25,26] if such is the case, then there would be an absence of differing opinions within families and no sex or age effect would be recognizable within the statistical analyses.
In addition to this, the two most common reasons for not vaccinating were found to be a lack of information and concerns regarding safety and side effects.The lack of information is a relatively simple problem with an easy solution.Physician counseling of patients and individuals is usually the best way to aid in this difficulty.We recommend premade information pamphlets where the most common questions are answered in an easyto-understand language translated into the multiple languages that people in Pakistan tend to speak.These booklets can then be spread enmasse with the national COVID-19 helpline, which currently exists, and the contact details contained within it.This could perhaps hasten the process of spreading correct and relevant information.However, the former obstacle is the hardest to tackle.Safety is by far the globally leading cause of refusing medical intervention at any and all levels [27] .A patient-centered approach with complete delivery of medical knowledge regarding the intervention, the vaccine in this case, and verification of informed consent, while a consistently implicated, and the most important part of medical ethics, has not yet seemed to solve this problem.Furthermore, with individuals refusing to come to the hospital and not seeking out medical care or the consultation of a medical professional, information and counseling becomes even more difficult to provide.Figuring out the solution to this question seems to be the most baffling yet the most necessary part of the equation during a global pandemic.One thing is for certain; however, that the solution cannot be unilateral.A consistent, tireless, and multivariate approach is needed by healthcare professionals, the elected body of Pakistan and relevant countries, social media companies, and news organizations.Several strategies have been offered consisting of expert fact-checking, verified content tags on social media articles and careful and consistent dissemination of hyperbolic yet misleading content regarding medical literature [28] .This has to be coupled with a publicly funded mass media campaign in developing nations like Pakistan, where access to popular social media platforms like Twitter and Facebook is still limited, and the root cause of hesitancy is actually via popular yet cheap mass messaging platforms like WhatsApp instead.
Our study had some considerable limitations.Firstly, we could not evaluate the proportion of the effect social media platforms had on vaccine hesitancy in individuals.Secondly, we did not evaluate the effect religious and cultural practices had on refusing vaccination, which is extremely important in a country like Pakistan where decision-making is greatly impacted by traditional norms and religious beliefs.

Conclusion
The current study supports previous medical literature regarding socioeconomic status and vaccination portfolio status being the most important predictive tools when evaluating vaccine hesitancy.We also identified extremely common reasons for both vaccinating and choosing not to do so.Fear of side effects remains a leading cause of refusal to vaccinate, which has to be tackled quickly yet with great care and consideration.A global, combined public and private effort is needed, which cannot be accomplished without some serious oversight and regulations, especially when it comes to dispelling misinformation regarding medical interventions like vaccines.

Figure 1 .
Figure 1.Population pyramid of the distribution scale of 1-10 on willingness to vaccinate children and parental concerns.

Table 2
Multivariable regression for predictors of caregiver's willingness to vaccinate their child

Table 3
Reasons quoted by caregivers for willingness to vaccinate or not to vaccinate their child