The Impact of COVID-19 Vaccine Controversy on Parents’ Perceptions of Routine Vaccinations

Background The COVID-19 pandemic has significantly influenced public perceptions and behaviors related to vaccination. Understanding parental attitudes, knowledge gaps, and vaccination practices post-pandemic is crucial for informing effective public health strategies. This study aimed to investigate parental attitudes, knowledge, and practices toward routine childhood vaccination in the post-COVID-19 era, emphasizing shifts in perspectives and implications for vaccination strategies. Methodology A cross-sectional survey was conducted among 498 parents to assess their attitudes, knowledge, and practices regarding vaccination. Data were analyzed using descriptive statistics, chi-square tests, and t-tests where applicable, with p-values <0.05 considered statistically significant. Results The study revealed diverse parental attitudes toward vaccination post-COVID-19. While a majority (72.9%) maintained positive attitudes toward vaccination schedules and benefits, concerns regarding vaccine safety and efficacy were noted. Knowledge gaps persisted, with 16.5% strongly agreeing that children’s vaccinations are weak and have no impact on disease prevention. Despite high adherence to vaccination schedules (68.9%), motivations behind vaccine administration were questioned, as 48.2% strongly disagreed that vaccination was solely for regulatory purposes. Conclusions Post-COVID-19, parental attitudes toward vaccination have evolved, reflecting increased concerns about safety and efficacy. Addressing knowledge gaps, combating misinformation, and enhancing trust in vaccination programs are imperative. Tailored communication strategies, education campaigns, and policy interventions are essential to promote vaccination acceptance and safeguard public health resilience in the post-pandemic era.


Introduction
Vaccination is the administration of a vaccine to trigger immunity by activating the immune system to produce defenses against a specific illness.Community immunity begins when a substantial percentage of a population has received a vaccination [1].The success stories of eradicating smallpox from the world and poliomyelitis from four World Health Organization zones highlight the importance of immunization efforts.They have made significant contributions to reducing the mortality and morbidity associated with several infectious illnesses.The success of vaccination programs is based on a high percentage of vaccine coverage.This directly protects vaccinated individuals and indirectly the entire community by establishing herd immunity and, as a result, decreasing the spread of vaccine-preventable diseases (VPDs) [2].
Even in areas where vaccination rates are high, some parents continue to have various worries and misconceptions about child immunizations even though their efficacy has been demonstrated [3].Vaccine hesitancy occurs along a spectrum ranging from full acceptance to open refusal of all vaccines, i.e., when certain immunizations are accepted but others are delayed or refused.Factors such as complacency, convenience, and confidence all have an impact on it.
Vaccine-hesitant parents (VHPs) are parents who may deny one or two vaccines but agree to all others, postpone vaccines, or accept vaccines but are unsure [4].VHPs are critical for understanding and combating vaccination resistance.They are a significantly larger group than those who entirely reject vaccines [5], and they may be more receptive to behavior modification as they seek information about vaccines from their child's healthcare provider [6,7].While VHPs play a crucial role in understanding and combating vaccination resistance, it is important to recognize that their significance extends beyond routine immunizations.In the context of the broader vaccination landscape, their attitudes and concerns became even more relevant, especially during the COVID-19 pandemic.Universal COVID-19 immunization is regarded as the most important method for limiting the spread of SARS-CoV-2 and the risk of new emerging variants.The success of vaccination campaigns is dependent, among other factors, on the immunization of large populations of children and adults in low/middle-income countries where SARS-CoV-2 variants of concern have been found.Lack of faith in the vaccination's safety and effectiveness is the most consistent predictor of parental COVID-19 vaccine hesitancy, followed by distrust of the government and beliefs that children are not vulnerable to the disease.Demographic factors have also been linked to parental acceptance of the COVID-19 vaccination.Lower parental income and education, as well as whether the parent has gotten the COVID-19 immunization, are examples of these [8].
Parental vaccine hesitancy is becoming an increasingly important public health concern in the United States.In March 2020, an assessment of the latest Centers for Disease Control and Prevention National Immunization Survey data found that more than one-third of U.S. children between the ages of 19 and 35 months were not following the recommended early childhood immunization schedule.Furthermore, a 2019 national survey found that approximately one in four parents reported serious concerns about vaccinating their children.Vaccine hesitancy is now associated with a decrease in vaccine coverage and an increase in VPD outbreaks and epidemics in the United States [8].
Freed and co-workers administered online surveys to a nationally representative sample of parents with children under the age of 18 to assess parents' trust in vaccine information received from various sources.The study's key finding was that parents trusted the source of vaccine safety information they used.In the questionnaire, parents said they trusted their child's pediatrician the most (76%), followed by other healthcare providers (26%), government vaccine experts (23%), and relatives and friends (15%) [9,10].At least 26% of parents expressed some faith in celebrities.Overall, 73% of parents had some faith in other parents who claimed that a vaccine had injured their child.There were also gender differences among the parents.Parents who claimed a vaccine harmed their kids followed celebrity talks, television shows, magazines, and news articles about vaccine safety [10].
The expanded vaccination program in the Kingdom of Saudi Arabia (KSA) began in 1979 and initially included vaccines for diphtheria, tetanus, and pertussis (DTP); poliomyelitis; and tuberculosis before being expanded to include other vaccines [11].At the time, the legislation supported the practice of linking birth certificate issuance to completion of primary vaccines within the first two years of life.This procedure was altered 10 years ago to associate the vaccination card with school admission at the age of six.The National Immunization Program eliminated neonatal tetanus and polio.Measles, mumps, and rubella are considered to be eradicated by 2020 [12].According to the Saudi Ministry of Health's 2021 immunization coverage figures, BCG coverage is 94%, DTP coverage is 97%, and inactivated polio vaccine coverage is 97%.However, high immunization coverage rates do not reflect a great trust in the vaccines.Many parents' decisions to immunize their children are likely influenced by the legal requirements of a complete vaccination card for a child's admission to school in various countries.Furthermore, even parents who vaccinate their children have ignorance and concerns about vaccinations; consequently, initiatives aimed at modifying their views will likely reduce their level of reluctance [13].
This study aimed to investigate parental attitudes, knowledge, and practices regarding vaccination in the post-COVID-19 era in Mecca, KSA, focusing on the impact of the COVID-19 vaccine controversy on their beliefs and behaviors about routine vaccinations.

Study design
A cross-sectional study design was employed to investigate parental attitudes, knowledge, and practices about vaccination in the post-COVID-19 era.The study was conducted over a period of six months, from January to June 2023, in the Mecca region of KSA, encompassing both urban and rural settings.This setting was chosen to ensure a representative sample of parents from different socioeconomic backgrounds and geographic locations, enhancing the generalizability of the study findings.

Participants
The participants included parents or legal guardians aged 18 years and above with at least one child aged 0-18 years residing in the study area.Individuals who did not meet the inclusion criteria, non-residents of the study area, and those unwilling to participate or provide informed consent were excluded.A total of 498 participants were included in the study, who were selected through convenience sampling to ensure the feasibility and accessibility of data collection.

Data collection
A structured questionnaire was developed as the primary data collection tool, comprising both closed-ended and Likert-scale questions.The questionnaire was designed based on a comprehensive literature review and expert input to ensure content validity and relevance to the study objectives.It included sections on parental attitudes, knowledge, practices, demographic information, and sources of information related to vaccination.
Data were collected through face-to-face interviews conducted by trained research assistants.The interviews were conducted in a confidential and non-coercive manner, ensuring participant privacy and autonomy.Interviewers followed a standardized protocol to maintain consistency and accuracy in data collection across all participants.

Data management and analysis
Data obtained from the interviews were entered into a database using SPSS version 26 software (IBM Corp., Armonk, NY, USA).The database was organized with appropriate variables and coding to facilitate data analysis.Data cleaning and validation were performed to identify and rectify any inconsistencies or errors in the dataset.
Descriptive statistics were used to summarize the sociodemographic characteristics of the participants.Inferential statistics, including chi-square tests, were employed to examine associations between sociodemographic factors and attitudes, knowledge, and practices regarding vaccination.The significance level was set at p-values <0.05 for all statistical tests.

Ethical considerations
The study adhered to ethical guidelines, and ethical approval was obtained from the Scientific Research Ethics Committee, Taif University, KSA (approval number: 44-366, Date: 13-06-2023).Informed consent was obtained from each participant before data collection, emphasizing confidentiality and the voluntary nature of participation.

Participant characteristics
Table 1 provides a comprehensive overview of the characteristics of the study participants and their sources of knowledge about vaccines.The study included 498 participants, representing diverse sociodemographic parameters.The age distribution showed that most participants were aged 30-34 years (82 participants, 16.5%), 35-39 years (76 participants, 15.3%), and 40-44 years (92 participants, 18.5%).Only 10 (2%) participants were under 20 years old, and one (0.2%) participant was over 65 years old.

Discussion
The COVID-19 pandemic has profoundly impacted global healthcare systems and public health perceptions, including attitudes toward vaccination.Understanding how parental perspectives have evolved in the aftermath of the pandemic is crucial for shaping effective vaccination strategies [1][2][3].This discussion delves into our study's findings regarding parental attitudes, knowledge, and practices toward vaccination, emphasizing post-COVID-19 stances and implications.
Our study revealed notable shifts in parental attitudes toward vaccination post-COVID-19.While a significant proportion maintained positive attitudes toward vaccination schedules and benefits, there was an evident increase in concerns regarding vaccine safety and efficacy.For instance, 123 (24.7%) strongly agreed that the COVID-19 vaccine has more serious side effects than benefits, reflecting heightened apprehensions following pandemic-related vaccine developments.
This shift is understandable given the rapid development and emergency use authorizations of COVID-19 vaccines, which may have raised questions about long-term safety and efficacy [9].The emergence of vaccine hesitancy clusters post-pandemic highlights the need for targeted education campaigns, transparent communication, and continuous monitoring of vaccine sentiment to address evolving concerns effectively [10,13,14].
Despite widespread access to information during the pandemic, our study identified persistent knowledge gaps and misinformation regarding vaccines.While a majority recognized the importance of vaccination, misconceptions about vaccine risks and benefits persisted.For instance, 82 (16.5%) strongly agreed that children's vaccinations are weak and have no impact on disease prevention, indicating persistent myths that vaccines are ineffective or unnecessary [15][16][17].
The proliferation of misinformation, especially on social media platforms, has contributed to vaccine hesitancy and skepticism.Post-pandemic, combating misinformation and promoting evidence-based information remain critical challenges.Health authorities and stakeholders must prioritize targeted communication strategies, leveraging credible sources and engaging with communities to address misconceptions effectively [18][19][20].
The controversies surrounding COVID-19 vaccines have had a significant impact on broader vaccination attitudes and practices.Our study found that 190 (38.2%) agreed that the controversy surrounding the COVID-19 vaccine increased their concerns about other vaccinations.This ripple effect underscores the interconnectedness of vaccine perceptions and the need for nuanced approaches to address hesitancy comprehensively [20][21][22].
Policy implications post-COVID-19 include enhancing vaccine access, promoting vaccine literacy, and fostering trust in immunization programs.Tailored interventions targeting specific hesitancy drivers, such as safety concerns and misinformation, can bolster vaccine acceptance.Additionally, integrating vaccination education into school curricula and leveraging community influencers can facilitate positive behavioral shifts toward vaccination [22,23].Participants relying on the internet/social media exhibited higher levels of concern, highlighting the influence of online discourse and the imperative to counter misinformation ecosystems effectively.Collaborative efforts among healthcare providers, social media platforms, and public health agencies are essential to promote accurate vaccine information and combat vaccine hesitancy [22][23][24].
While our study indicated high adherence to vaccination schedules, concerns about the motivation behind vaccine administration were raised.Specifically, 240 (48.2%) strongly disagreed that the only reason their child receives vaccinations is for them to enter childcare or school.This signals a broader recognition of vaccination's role beyond regulatory requirements, emphasizing the need for comprehensive vaccination strategies encompassing health promotion and disease prevention [20,23,25].The association between sources of vaccine information and increased concerns about other vaccinations is noteworthy [25][26][27].
Comparing our findings with global trends reveals both convergences and divergences in post-pandemic vaccination stances.Globally, there has been a surge in vaccine hesitancy, driven by safety concerns, distrust in authorities, and misinformation.However, successful vaccination campaigns, transparent communication, and proactive engagement have mitigated hesitancy in some regions [15][16][17][18]20,26,27].
Future research directions should prioritize longitudinal studies tracking post-COVID-19 vaccination attitudes and behaviors.Long-term monitoring of vaccine sentiment, evaluating the effectiveness of interventions, and exploring cultural nuances in vaccine acceptance are crucial.Collaborative research efforts and data sharing across regions can inform evidence-based strategies to address vaccine hesitancy comprehensively.
While the study highlights important aspects of vaccination behavior, it is crucial to acknowledge certain limitations that may impact the generalizability and validity of the findings.First, the reliance on a crosssectional survey design limits the ability to establish causal relationships between variables, as it captures data at a single point in time.Longitudinal studies may provide a more nuanced understanding of how parental attitudes toward vaccination evolve over time.Additionally, the study sample of 498 parents may not be fully representative of the broader population, potentially introducing selection bias.Moreover, the use of self-reported measures for assessing attitudes and knowledge leaves room for response bias and social desirability effects, where participants may provide answers they believe are socially acceptable rather than reflecting their true beliefs.It is also important to consider the cultural and regional differences that could influence parental perspectives on vaccination, which were not thoroughly explored in this study.Future research endeavors could benefit from addressing these limitations to offer a more comprehensive understanding of vaccination behavior post-pandemic and enhance the effectiveness of public health initiatives.

Conclusions
The post-COVID-19 landscape has reshaped parental attitudes, knowledge, and practices regarding vaccination.While challenges such as misinformation and safety concerns persist, opportunities exist to strengthen vaccination advocacy, communication, and policy frameworks.Addressing evolving concerns, leveraging digital health technologies, and fostering community partnerships are integral to promoting vaccination acceptance and safeguarding public health resilience in the post-pandemic era.
The controversies surrounding COVID-19 vaccinations have also had a ripple effect on broader vaccination attitudes, emphasizing the interconnected nature of vaccine perceptions and the need for nuanced strategies to tackle hesitancy comprehensively.Recognizing the influence of different sources of vaccine information on public concerns, collaborative efforts among healthcare providers, social media platforms, and public health agencies are crucial to disseminating accurate information and addressing vaccine hesitancy effectively.Furthermore, while our study highlighted strong adherence to vaccination schedules, it also raised concerns about the underlying motivations for vaccine administration, indicating a growing awareness of the broader health benefits of vaccinations beyond regulatory compliance.Moving forward, comprehensive vaccination strategies that encompass health promotion and disease prevention will play a pivotal role in shaping effective vaccination practices and ensuring public health resilience in the face of evolving challenges.

disagree
It is better to let the child's immune system fight the disease rather than giving the vaccine Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree Vaccinations help prevent the spread of infectious diseases and epidemics Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree Children's vaccinations are weak and have no effect on disease prevention Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree My child/children are in excellent health and there is no need to follow the vaccination schedule Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree It is better for the child not to have many vaccinations at one time Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I am concerned that any dose of immunization may not be safe for my child Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree 2024 Alzahrani et al.Cureus 16(7): e63606.DOI 10.7759/cureus.63606I am concerned that any dose of vaccination will not prevent the disease and will be of no benefit Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree The risks of vaccinations outweigh the benefits Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree Do you know anyone who has had any adverse reactions to a vaccination?Yes, No The only reason for my child to get immunized is to get him into day-care or school Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I trust the information I receive about the effectiveness and benefits of vaccinations Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I can discuss my fears and concerns about vaccinations with my pediatrician Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree Nowadays most vaccinations are for uncommon diseases Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree Has your youngest child received any vaccine doses against the COVID-19 virus?Yes, No Did the rest of your children get any doses of the COVID-19 vaccine Yes, No, I don't have other children I believe that the COVID-19 vaccine is and has an effect in increasing my child's immunity against the virus Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I believe that the COVID-19 vaccine is important to protect other children from spreading the virus between them and their parents Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I only give the COVID-19 vaccine to my child/children because it is mandatory to get it Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I believe that the COVID-19 vaccine has more serious side effects than benefits Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree I believe that the COVID-19 vaccine is just a way of marketing for drug manufacturers Totally agree, Somewhat agree, Neutral, Somewhat disagree, Totally disagree Do you feel that the COVID-19 vaccine controversy has increased your concerns about other vaccinations?Yes, No, Maybe

Table 2
presents parents' knowledge of children's vaccination.A majority strongly agreed that following the vaccination schedule is beneficial for health (363 participants, 72.9%), that multiple vaccinations are beneficial (318 participants, 63.9%), and that many diseases prevented by vaccinations can be severe (312 participants, 62.7%).Furthermore, 330 (66.3%) participants strongly agreed that vaccinations help prevent the spread of infectious diseases.2024 Alzahrani et al.Cureus 16(7): e63606.DOI 10.7759/cureus.636065 of 17 Vaccinations help prevent the spread of infectious diseases and epidemics

Table 3
My child/children are in excellent health, and there is no need to adhere to the vaccination schedule presents an analysis of parents' attitudes toward children's vaccination.The data reflect diverse attitudes and concerns.A majority (57%) strongly disagreed with being hesitant about adhering to the vaccination schedule, and 211 (42.4%) participants strongly disagreed that it is better to let the child's immune system fight instead of vaccinating.Strongly 2024 Alzahrani et al.Cureus 16(7): e63606.DOI 10.7759/cureus.636067 of 17 I am concerned that any dose of vaccination does not protect against the disease and is of no benefit