Parental COVID-19 vaccination hesitancy among parents of children aged 5-18 years in Thailand: a cross-sectional survey study

Abstract

Background:
To promote an acceptance rate of COVID-19 immunization among Thai children, concerns about parental vaccination hesitancy should be urgently studied. This study aimed to examine the parental COVID-19 vaccination hesitancy (PVh) level and influencing factors among Thai parents of children 5-18 years of age.

Methods:
This cross-sectional survey was conducted in Thailand during May and June of 2022. The Google forms for data collection were distributed to parents (a father, a mother, or one who nurtures and raises a child) via various online social media. Data regarding PVh level, relevant attitudes, experiences of COVID-19 and COVID-19 vaccination (EC&V), and family contexts (FC) were collected and analyzed using descriptive statistics. Mann-Whitney U test was used to compare the differences among groups of parents based on EC&V and FC. The factors influencing PVh were assessed by multiple regression analysis.

Results:
Four hundred and eighty-eight parents completed the online questionnaire. Their median (IQR) age was 41 (35-47) years. They lived in different provinces from all regions across Thailand. Ninety percent of them were authorized persons to make decision about children vaccination. Fifty-eight percent of the respondents had vaccine hesitancy, defined as PVh level at moderate or above. Parents who had ever refused COVID-19 vaccination for themselves or refused to vaccinate their children against any other diseases had statistically significant higher levels of PVh (p value < 0.001). Conversely, the parents who had finished the initial COVID-19 vaccine had lower PVh levels with statistical significance (p value = 0.001). Attitude towards COVID-19 (AC), attitude towards COVID-19 vaccine (AV), and perceived behavioral control (PC) of the parents negatively influenced PVh with statistical significance, according to the results of the multiple regression analysis (Betas = - 0.307, - 0.123, and - 0.232, respectively).

Conclusions:
COVID-19 vaccination hesitancy was commonly found among Thai parents. The factors of the hesitancy were multifaceted. Different experiences regarding COVID-19 vaccination for themselves and any vaccinations for their children were associated with different PVhs. The attitudes especially AC, AV, and PC statistically influenced PVh. These findings should be exploited for national and local policy planning as well as public campaigns.

Full text

Parinyaruxetal.
Journal of Pharmaceutical Policy and Practice (2022) 15:59
https://doi.org/10.1186/s40545-022-00455-7
RESEARCH
Parental COVID-19 vaccination hesitancy
amongparents ofchildren aged 5–18years
inThailand: across-sectional survey study
Pantira Parinyarux1 , Kanokkarn Sunkonkit2 and Kitiyot Yotsombut3*
Abstract
Background: To promote an acceptance rate of COVID-19 immunization among Thai children, concerns about
parental vaccination hesitancy should be urgently studied. This study aimed to examine the parental COVID-19 vac-
cination hesitancy (PVh) level and influencing factors among Thai parents of children 5–18 years of age.
Methods: This cross-sectional survey was conducted in Thailand during May and June of 2022. The Google forms
for data collection were distributed to parents (a father, a mother, or one who nurtures and raises a child) via various
online social media. Data regarding PVh level, relevant attitudes, experiences of COVID-19 and COVID-19 vaccination
(EC&V), and family contexts (FC) were collected and analyzed using descriptive statistics. Mann–Whitney U test was
used to compare the differences among groups of parents based on EC&V and FC. The factors influencing PVh were
assessed by multiple regression analysis.
Results: Four hundred and eighty-eight parents completed the online questionnaire. Their median (IQR) age was
41 (35–47) years. They lived in different provinces from all regions across Thailand. Ninety percent of them were
authorized persons to make decision about children vaccination. Fifty-eight percent of the respondents had vac-
cine hesitancy, defined as PVh level at moderate or above. Parents who had ever refused COVID-19 vaccination for
themselves or refused to vaccinate their children against any other diseases had statistically significant higher levels of
PVh (p value < 0.001). Conversely, the parents who had finished the initial COVID-19 vaccine had lower PVh levels with
statistical significance (p value = 0.001). Attitude towards COVID-19 (AC), attitude towards COVID-19 vaccine (AV), and
perceived behavioral control (PC) of the parents negatively influenced PVh with statistical significance, according to
the results of the multiple regression analysis (Betas = − 0.307, − 0.123, and − 0.232, respectively).
Conclusions: COVID-19 vaccination hesitancy was commonly found among Thai parents. The factors of the hesi-
tancy were multifaceted. Different experiences regarding COVID-19 vaccination for themselves and any vaccinations
for their children were associated with different PVhs. The attitudes especially AC, AV, and PC statistically influenced
PVh. These findings should be exploited for national and local policy planning as well as public campaigns.
Keywords: COVID-19, Vaccination hesitancy, Vaccination refusal, Parents, Children
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Background
e coronavirus disease 2019 (COVID-19) is an emerging
contagious disease caused by the SARS-CoV-2 that was
recognized by the World Health Organization (WHO)
as emerging global health on January 30, 2020, due to
its rapid spread to all other countries around the globe
[1, 2]. Although various preventive measures including
Open Access
*Correspondence: kitiyot.y@pharm.chula.ac.th
3 Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences,
Chulalongkorn University, Bangkok 10330, Thailand
Full list of author information is available at the end of the article

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Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
social distancing, good hand hygiene with alcohol rub-
bing, as well as mask-wearing have been advocated, the
number of COVID-19-infected persons is still rising. Due
to the infectious nature of the disease, immunization was
hopefully expected to be one of the most effective ways to
fight the COVID-19. As such, the COVID-19 pandemic
situation fostered the development of vaccines against
the disease with various newly invented platforms [3].
e vaccination program in ailand has been imple-
mented since February 28, 2021 [4]. e overall rate of
completed initial COVID-19 vaccination among ai
people is around 76%, mainly adults and elderly. Besides,
only 54.1% of ai children have received the complete
initial COVID-19 vaccination [5]. Based on the estimated
R0 of COVID-19 ranged from 1.4 to 6.68, the herd immu-
nity threshold would range from 28.57 to 85.03% [6]. e
available COVID-19 vaccines are effective in reducing
morbidity and mortality, rather than infection preven-
tion. erefore, at least 85% of ai people should receive
the complete course of COVID-19 vaccine. ese data
pointed out that there was an urgent need to promote
access to vaccination programs for both adults and chil-
dren in ailand.
Although the perceived severity of COVID-19 in chil-
dren is less than in adults, long-term serious complica-
tions of COVID-19 in children have been increasingly
reported including long-COVID symptoms and mul-
tisystem inflammatory syndrome in children (MIS-C).
ese complications could be prevented by COVID-19
vaccines. As a result, every child should be managed
to receive the vaccine timely [7]. On January 5, 2022,
the Food and Drug Administration (FDA) of ailand
approved the Pfizer BioNTech mRNA COVID-19 vac-
cine for ai children aged 5years and older [8, 9]. How-
ever, the rate of vaccine acceptance among children aged
5–11 years and 12 years and older in ailand is still
lower than the recommended herd immunity threshold.
Vaccine hesitancy has long been one of the major
obstacles to immunization among people of all age
groups. e WHO defined vaccine hesitancy as “a delay
in acceptance or refusal of vaccination even though vac-
cination services are available”. Factors that determine
individual vaccine hesitancy consists of (1) complacency
which indicates a low perceived risk of disease (2) con-
fidence in the safety and efficacy of the vaccine (3) con-
venience in acquiring and accessing vaccines [10–12]. In
the case of COVID-19 vaccination, studies have found
that the main causes of vaccine hesitancy were concerns
about the safety and potential side effects and distrust in
the vaccine efficacy and quality. Given that COVID-19
vaccines were manufactured by brand-new production
platforms without long-term safety evaluation, misin-
formation regarding COVID-19 and the vaccines was
also commonly found in every popular social media [3,
10, 13–15]. e vaccine hesitancy among people is com-
plicated, because it is influenced by both the context and
personal factors including the national health policy, the
available information, the actual and perceived vaccine
efficacy and safety, perceptions about the seriousness
of the epidemic, religious, social norms, health literacy,
educational levels, and individual past experiences [11].
ese factors may be different among countries and
unique to each community of people. Understanding the
vaccine hesitancy situation and relevant factors of the
target population is vital for policy planning and public
campaign. To date, there has been no published study of
the hesitancy of ai parents regarding COVID-19 vac-
cination for their children. erefore, the purpose of this
study was to examine the parental COVID-19 vaccina-
tion hesitancy (PVh) and influencing factors among ai
parents of children 5–18years of age.
Methods
is research was a cross-sectional survey study con-
ducted in ailand. e data were collected between May
and June 2022 after being approved by the Human Exper-
imentation Committee Research Institute for Health Sci-
ences, Chiang Mai University, Chiang Mai, ailand (No.
22/2022).
Population andsample
e parent in this study means a father, a mother, or one
who nurtures and raises a child. e inclusion criteria of
the study were ai parents of children aged between 5
and 18years old that are eligible for the COVID-19 vac-
cination. [9] Parents who could not read or complete the
questionnaire were excluded from the study.
e main outcome of this study was the prevalence
of PVh. Based on a previous survey in Japan, 57.1% of
parents expressed hesitation to vaccinate their children
against COVID-19 [16]. A formula for estimating a pro-
portion of events in a single population [17] was used
with a precision level of 0.05. e sample size should not
be less than 380 people. e authors decided to increase
a 10% of the sample for missing or incomplete data. As
a result, the sample size of this study was 420 people.
e sample was selected using a convenience sampling
method. [18].
Data collection
e data were collected online using Google forms for
survey. e authors distributed a QR code and a link to
the questionnaire and informed consent form via online
social media including Facebook and LINE applications,
for institutional alumni groups, general online market-
places and stores, and provincial news channels, where

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Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
the public was members. e data collection was con-
ducted between May and June 2022.
Research tools
e authors developed a questionnaire based on a litera-
ture review from previous studies [3, 12, 15, 19, 20]. Con-
structs of the theory of planned behavior (TPB), namely,
attitude towards object (the COVID-19 and the COVID-
19 vaccine), attitude towards behavior (the COVID-19
vaccination program), subjective norm, and perceived
behavioral control, were adopted in the questionnaire
development [21]. e content validity of the draft ques-
tionnaire was assessed by three experts. ey were a
pediatrician and two pharmacy residents who specialized
in pediatric pharmacotherapy. e item-objective con-
gruence index (IOC) values of the questionnaire items
were 0.67–1, indicating good content validity. As for the
reliability test and language clarity of the draft question-
naire, it was conducted with a pilot group of 14 people.
e Cronbach’s alpha coefficient was found to be 0.78.
is indicated fact that the questionnaire developed was
valid and reliable. e draft questionnaire and the final
questionnaire were developed in ai language. e final
questionnaire consisted of two parts. e first part of the
questionnaire comprised general information about the
respondents and characteristics relevant to their health
and experiences regarding COVID-19 and COVID-19
vaccination. e second part included 19 questions to
collect opinions about parents’ hesitancy to vaccinate
their children against COVID-19 and five related atti-
tude domains: four items for attitude towards COVID-19
(AC), five items for attitude towards COVID-19 vaccine
(AV), four items for attitude towards COVID-19 vac-
cination program (AP), two items for attitude towards
subjective norm (SN), and three items for parental per-
ceived behavioral control (PC). e responses were clas-
sified into five Likert scales that were 5-extremely high or
strongly agreed, 4-high or agreed, 3-moderate or neutral,
2-less or disagreed, and 1-least or strongly disagreed.
Data analysis
Quantitative data from the survey were interpreted using
descriptive statistics consisting of percentages, means,
standard deviations (SD), medians, and interquartile
range (IQR). e prevalence of PVh was calculated based
on the PVh level at moderate or above. e Mann–Whit-
ney U test for non-normally distributed data sets was
used to compare the hesitancy score between groups
with different experiences towards COVID-19, COVID-
19 vaccination, and family context. e multiple regres-
sion analysis (MRA) was used to estimate the impact
of the attitude domain on the hesitancy level. e enter
technique with statistical significance at p value < 0.05
was applied in the MRA. All analyses were performed
using SPSS version 22.0 (IBM Corp, Armonk, NY).
Results
General characteristics oftherespondents
A total of 488 people completed the survey. Most of
them (70.5%) were females. e median (IQR) age was
41 (35–47) years and 66.6% of survey respondents had a
bachelor’s degree or higher. ey lived in different prov-
inces across ailand, which were primarily in Southern,
Eastern, and Western regions. Altogether, 72.3% were
not healthcare professionals. Over 90% of respondents
were parents who hold the right to make a final deci-
sion regarding their child’s vaccination. About two-thirds
of respondents were a father or a mother of the chil-
dren, while the remaining were relatives of the children.
About one-fourth of their children had a history of vac-
cine refusal, since they were extremely trpanophobic
(Table1).
Experiences towardsCOVID‑19 andvaccination (EC&V)
andfamily context (FC)
Most of the respondents, their family members, and
their children had not been diagnosed with COVID -19
(68%, 58.8%, and 72.5%, respectively). e refusal rate of
COVID-19 vaccine or any other vaccines for themselves
or their children were low (between 12.7% to 15%). e
result showed that 96.7% of respondents had completed
the initial COVID-19 vaccination with a median (IQR)
of 3(2–3) shots. Around 80% of the children were living
in areas, where COVID-19 was prevalent at the time of
the survey. Most of the respondents (90.4%) did not have
children with a high risk of serious COVID-19 compli-
cations due to congenital diseases. However, nearly all
of them (94.3%) had at least one senior family member.
Besides, 27% of the respondents had family members
with a high risk of serious COVID-19 complications
due to comorbidities, such as diabetes mellitus, asthma,
chronic obstructive pulmonary disease, cardiovascular
diseases, chronic kidney disease, or immunosuppression
(Table1).
Parental COVID‑19 vaccination hesitancy (PVh) levels
e respondents who answered moderate, high, and
extremely high to the question “what is your hesitancy
level regarding the COVID-19 vaccination of your chil-
dren?” were 32%, 16.8%, and 9.2%, respectively (Table2).
As a result, the prevalence of PVh among ai parents in
our study was 58%.
The comparison ofPVh levels based onEC&V andFC
Parents who had previously refused to vaccinate them-
selves against COVID-19 and those who had previously

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Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
refused to vaccinate their children against any other
diseases had statistically significant higher levels of
PVh than the opposite groups (3 (IQR 2.7–4) vs. 3 (IQR
2–3), and 3 (IQR 2–4) vs. 3 (IQR 2–3), respectively; p
value < 0.001). Contrarily, the parents who had completed
the initial COVID-19 vaccination had a statistically sig-
nificant lower level of PVh than others (3 (IQR 2–3) vs.
4 (IQR 2–5); p value < 0.001). e statistically significant
difference between median PVh level among parents
Table 1 General characteristics, EC&V, and FC of the respondents (n = 488)
* Median (IQR)
Information Yes N (%)
General characteristics of the respondents
Age (years) 41 (35–47)*
Gender
Male 140 (28.7)
Female 344 (70.5)
Not identified 4 (0.8)
Highest education qualification
Primary or lower 35 (7.2)
Secondary or equivalent 128 (26.2)
Bachelor’s or equivalent 232 (47.5)
Higher than bachelor’s 93 (19.1)
Living region
Central 77 (15.8)
Northern 136 (27.9)
Southern, Eastern, and Western 195 (40.0)
Northeastern 80 (16.4)
Relationship to children
Father/Mother 330 (67.6)
Relative 158 (32.4)
Hold the right to make a final decision regarding their child’s vaccination 442 (90.6)
Children had a history of trypanophobia 130 (26.6)
Health care professionals 135 (27.7)
Experiences towards COVID-19 and vaccination (EC&V)
Had ever been diagnosed with COVID-19 156 (32.0)
Family members had been diagnosed with COVID-19 201 (41.2)
The children had been diagnosed with COVID-19 134 (27.5)
Ever refused COVID-19 vaccination 66 (13.5)
Ever refused any other vaccinations 73 (15.0)
Ever refused any other vaccination for the children 62 (12.7)
Complete initial COVID-19 vaccination 472 (96.7)
Number of received COVID-19 vaccinations (shots) 3 (2–3)*
The children were living in a COVID-19 outbreak area 382 (78.3)
Family context (FC)
Number of the children in family 2 (1–2)*
Number of family members (including the children) 4 (4–5)*
There were the children with high risk of serious COVID-19 complications due to congenital diseases 47 (9.6)
There were family members who are 60 years of age or older 460 (94.3)
There were family members with high risk of serious COVID-19 complications due to comorbidities 132 (27.0)
Table 2 Parental COVID-19 vaccination hesitancy (PVh) levels
Parental COVID‑19 vaccination hesitancy (PVh) levels N (%)
Least 94 (19.3)
Less 111 (22.7)
Moderate 156 (32.0)
High 82 (16.8)
Extremely high 45 (9.2)

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Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
with yes or no answer to other EC&V and FC question-
naire items were not found (Table3).
Parental attitudes inuencing PVh
Although the respondents had a neutral attitude towards
COVID-19, they had high levels of positive attitude
towards COVID-19 vaccine, attitude towards the vacci-
nation program, parental subjective norm, and parental
perceived behavioral control (Table4 and Fig.1). Based
on the multiple regression analysis, it was found that
all five domains explained PVh with their R square at
0.238. However, only attitude towards COVID-19, atti-
tude towards COVID-19 vaccine, and parental perceived
behavioral control negatively influenced PVh with statis-
tical significance (Betas = − 0.307, − 0.123, and − 0.232,
respectively) (Table5).
Discussion
is online survey examined the parental COVID-19
vaccination hesitancy among parents of children aged
5–18 years in ailand. Most of the respondents were
parents who hold the right to make a final decision
regarding their child’s vaccination. ey probably had a
high acceptance level of the COVID-19 vaccination, since
96.7% of them had completed the vaccine program, and
the average number of the vaccines they received was
around 3 shots which included the initial and booster
doses.
Even though their children were living in an outbreak
area and there were senior or at-risk family members, our
findings revealed that 58% of ai parents had moderate
to extremely high levels of PVh. is result was in line
with earlier studies conducted in other countries, such as
Turkey [15], Japan [16], Italy [22] and Saudi Arabia [23–
25]. e percentages of PVh in such countries had been
reported as high as 52.4–72.2%. Issues regarding con-
fidence in the vaccine efficacy and safety, quality uncer-
tainty, and lack of adequate available information were
cited as the contributing factors to the high level of PVh
in those studies [15, 16, 22, 23]. Although some recent
studies conducted in the United States [26, 27], Malaysia
[28], and South Korea [29] found that PVh prevalences
were considerably lower than our finding (15–28.9%),
the above contributing factors of PVh were still indicated
[26–28].
Previous refusal to receive the COVID-19 vaccine for
themselves and completing the initial COVID-19 vac-
cination were associated with higher and lower PVh,
respectively. ose results indicated that the direct expe-
rience of the parents with their COVID-19 vaccination
was one of the key factors influencing PVh. is hypoth-
esis was supported by previous studies which found that
there was an inverse relationship between COVID-19
vaccination history of the parents and PVh [15, 16, 28,
30]. erefore, a campaign to create a positive attitude
towards vaccination for themselves and increase the rate
of COVID-19 vaccination among parents, in addition
to the promotion of their child’s vaccination should be
conducted.
Our study also found that PVh was higher with statis-
tical significance among parents who previously refused
any other vaccinations for their children. ese parents
Table 3 PVh levels based on EC&V and FC
* Mann–Whitney U test statistically signicant dierence
Information Median PVh level (IQR) p value
Parents with “yes” answer Parents with “no” answer
Experiences towards COVID-19 and vaccination (EC&V)
Had ever been diagnosed with COVID-19 3 (2–4); n = 156 3 (2–3); n = 332 0.546
Family members had been diagnosed with COVID-19 3 (2–4); n = 201 3 (2–3); n = 287 0.937
The children had been diagnosed with COVID-19 3 (2–4); n = 134 3 (2–3); n = 354 0.220
Ever refused COVID-19 vaccination 3 (2.75–4); n = 66 3 (2–3); n = 422 0.000*
Ever refused any other vaccinations 3 (2.5–4); n = 73 3 (2–3); n = 415 0.055
Ever refused any other vaccinations for the children 3 (2–4); n = 62 3 (2–3); n = 426 0.000*
Complete initial COVID-19 vaccination 3 (2–3); n = 472 4 (2–5); n = 16 0.001*
The children were living in a COVID-19 outbreak area 3 (2–4); n = 382 3 (2–4); n = 106 0.080
Family context (FC)
There were the children with high risk of serious COVID-19 compli-
cations due to congenital diseases 3 (2–4); n = 47 3 (2–4); n = 441 0.467
There were family members who are 60 years of age or older 3 (2–3); n = 460 3 (2–4); n = 28 0.120
There were family members with high risk of serious COVID-19
complications due to comorbidities 3 (2–4); n = 132 3 (2–4); n = 356 0.137

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Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
may have misunderstandings, distrust, excessive fear,
and concerns about any vaccination, especially COVID-
19 vaccines which had been manufactured by newly
invented platforms for an unfamiliar emerging disease
[31]. As a result, a history of incomplete vaccination for
other diseases of the children may be a screening tool
for this group of parents [32]. Special consultation with
emphasis on the seriousness of COVID-19 problems in
their children and the positive facts and information with
proper media should be applied [33–35].
In previous studies, parents who had a family member
who suffered or died from the disease showed a lower
level of PVh [30]. Although those devastating experi-
ences can increase the perceived threat of the disease,
the perceived benefits and risks of the vaccine may not be
changed. Unsurprisingly, our study did not find a statisti-
cal difference in PVh between parents who had or did not
have direct experiences with COVID-19. us, measures
to increase the perceived benefits and decrease the per-
ceived risk of the vaccine should be considered.
Parental subjective norm (SN), perceived behavioral
control (PC2), and attitude towards vaccine regarding
the unavailability of long-term safety (AV4) were rated
with high levels of agreement in our study. However,
the multiple regression analysis found that only attitude
towards COVID-19, attitude towards COVID-19 vaccine,
and parental perceived behavioral control statistically
influenced PVh with negative beta values indicating the
inverse relationship between those factors and the level
of hesitancy. As a result, communication to increase the
perceived risk of COVID-19, the perceived benefit of
COVID-19 vaccine, and the perceived behavioral control
could be the most effective directions to reduce the level
of parental COVID-19 hesitancy [36, 37].
To our knowledge, this is the first study to explore the
parental COVID-19 vaccine hesitancy in ailand. Most
of the respondents were parents who hold the right to
make a final decision regarding their child’s vaccina-
tion. e questionnaire was systematically developed in
ai language and tested for its validity and reliability.
Table 4 Parental attitudes
No Questionnaire items Level of agreement
Mean (SD)
Attitude towards COVID-19 (AC)
AC1 Chance of getting COVID-19 is high in children 3.26 (1.42)
AC2 Chance of complications from COVID-19, such as MIS-C or long COVID, is high in
children 3.16 (1.27)
AC3 Infections with COVID-19 are more severe in children 3.13 (1.23)
AC4 Complications from COVID-19, such as MIS-C or long covid, are more severe in
children 3.21 (1.26)
Attitude towards COVID-19 vaccine (AV)
AV1 I am knowledgeable and know enough about the COVID-19 vaccine 3.78 (0.86)
AV2 The COVID-19 vaccination is effective when administered to children 3.68 (0.85)
AV3 The COVID-19 vaccine is safe when administered to children, including mine 3.66 (0.91)
AV4 Long-term safety data of the COVID-19 vaccination in children is not available 3.91 (0.85)
AV5 Potential benefits of the COVID-19 vaccination outweigh risks in my children 3.85 (0.79)
Attitude towards vaccination program (AP)
AP1 I am satisfied with the available brand of the COVID-19 vaccine, approved for
children 3.85 (0.79)
AP2 There are sufficient supplies of the COVID-19 vaccine for children with need 3.70 (0.90)
AP3 COVID-19 vaccination centers for children are sufficient and conveniently acces-
sible 3.70 (0.89)
AP4 Time spent for receiving the COVID-19 vaccination is acceptable 3.75 (0.85)
Parental subjective norm (SN)
SN1 Parents have a duty and responsibility to vaccinate their children 3.92 (0.90)
SN2 I wanted to fulfill my parental responsibility to live up to societal expectations 3.94 (0.86)
Parental perceived behavioral control (PC)
PC1 To vaccinate my children is not a financial burden 3.67 (1.02)
PC2 I am certain that I can manage to vaccinate my children with the COVID-19 vaccine
on time 3.97 (0.84)
PC3 I am certain that I can take care of my children if they experience any common side
effects of the COVID-19 vaccine 3.69 (0.91)

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Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
erefore, their opinions collected in our study could be
highly correlated with the actual decision for their chil-
dren in the near future.
Although our study was conducted in various liv-
ing regions which improved the generalizability of our
results, some limitations require consideration. First,
the study was an online survey. is could be of con-
cern that only parents who were familiar with an online
questionnaire and well-equipped can participate in the
data collection. anks to several national projects of
the ai government such as ai-Cha-Na (mobile
application for tracking COVID-19 contact persons)
and Mor-Prompt (mobile application for COVID-19
vaccine services) which most ai people used in eve-
ryday life, nowadays, ai parents could participate
in the online survey without any limitations as afore-
mentioned. Secondly, we conducted this study dur-
ing a period when the incidence of severe COVID-19
was relatively low. e parental vaccine hesitancy was
sensitive to the context of data collection, e.g., out-
break situation and trend, news, rumors on public
and social media, national and local policy, as well as
local availability of the vaccine. e prevalence of PVh
in this study was calculated based on the PVh level at
moderate or above. Different cutoff PVh levels for data
transformation, such as determining only high and
extremely high PVh levels could lead to remarkably
different prevalence [32]. erefore, it is important to
use caution when applying the study’s findings to other
contexts. Further prospective multi-centered studies
should be conducted in a larger population to increase
the generalizability and address the effective measures
to overcome the COVID-19 vaccination hesitancy.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
AC1
AC2
AC3
AC4
AV1
AV2
AV3
AV4
AV5
AP1
AP2
AP3
AP4
SN1
SN2
PC1
PC2
PC3
Level of agreement %
Parental Atudes
AC1AC2 AC3AC4 AV1 AV2 AV3 AV4AV5 AP1AP2 AP3AP4 SN1SN2 PC1PC2 PC3
Strongly agreed 25.4 18.4 15.4 18 16.8 14.1 15.6 24.4 21.3 17.2 16.2 14.3 14.8 24.4 25.6 19.3 24.8 14.3
Agreed 27.5 26.6 30.1 29.2 54.9 49.6 47.2 49 54.7 57.2 50.5 53.4 55.1 54.1 50.1 46.5 55.4 55.2
Neutral 8.4 16.2 14.5 17.6 18.9 28.3 26.8 20.3 20.5 20.1 22.5 22.1 21.9 12.1 18.4 20.3 13.3 17.6
Disagreed 25.4 30.4 32.6 26.4 8.4 6.6 8.4 5.7 2.7 4.5 9.2 8.2 6.4 84.5 10 5.3 11.1
Strongly disagreed 13.3 8.4 7.4 8.8 1 1.4 20.6 0.8 1 1.6 2 1.8 1.4 1.4 3.9 1.2 1.8
Fig. 1 Parental attitudes towards the COVID-19, the COVID-19 vaccination program, subjective norm, and perceived behavioral control
Table 5 Multiple regression analysis of the factors influencing
the PVh
R = 0.487, R2 = 0.238, SEE = 1.06, F = 30.052, Sig. of F < 0.001
Domains b SE Beta p value
AC: attitude towards COVID-19 − 0.323 0.042 − 0.307 < 0.001
AV: attitude towards COVID-19
vaccine
− 0.259 0.112 − 0.123 0.021
AP: attitude towards vaccination
program
− 0.092 0.098 − 0.048 0.353
SN: subjective norm − 0.006 0.084 − 0.004 0.939
PC: perceived behavioral control − 0.388 0.095 − 0.232 < 0.001
Constant value 4.649 0.384 < 0.001

Page 8 of 9
Parinyaruxetal. Journal of Pharmaceutical Policy and Practice (2022) 15:59
Conclusions
e parental COVID-19 vaccination hesitancy among
ai parents of children aged 5–18 years was preva-
lent. e hesitancy level was higher among parents who
refused their COVID-19 vaccination or denied any other
vaccinations for their children. Contrarily, parents who
had completed the initial COVID-19 vaccination had
lower vaccine hesitancy. Past experiences regarding the
parents and children vaccination could be considered as
a screening tool for the risk of vaccine hesitancy. Factors
influencing the hesitancy of ai parents were multifac-
torial, especially attitudes towards COVID-19, attitudes
towards COVID-19 vaccine, and perceived behavioral
control. Parents and public education should empha-
size on threats and consequences of COVID-19 and the
risk–benefit ratio of COVID-19 vaccine as well as inspire
the confidence of the parents regarding their child’s
vaccination.
Abbreviations
AC: Attitude towards COVID-19; AP: Attitude towards COVID-19 vaccination
program; AV: Attitude towards COVID-19 vaccine; COVID-19: The coronavirus
disease 2019; EC&V: Experiences towards COVID-19 and vaccination; FC: Family
context; IOC: Item-objective congruence index; IQR: Interquartile range; MRA:
Multiple regression analysis; PC: Perceived behavioral control; PVh: Parental
COVID-19 vaccination hesitancy; SD: Standard deviation; SN: Attitude towards
subjective norm; TPB: The theory of planned behavior; WHO: The World Health
Organization.
Acknowledgements
The authors acknowledge the assistance of the medical native-English
speaking specialist Stephen Pinder for conducting a comprehensive English
language review of our manuscript.
Author contributions
KY and PP made a substantial contribution to the concept and design of the
research, data acquisition, analysis, and interpretation of data. All authors
drafted and revised the manuscript critically for important intellectual content.
All authors read and approved the final manuscript.
Funding
This research received no specific grant from any funding agency in the pub-
lic, commercial, or not-for-profit sectors.
Availability of data and materials
The data sets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The data were collected between May and June 2022 after being approved
by the Human Experimentation Committee Research Institute for Health Sci-
ences (RIHES), Chiang Mai University, Chiang Mai, Thailand (No. 22/2022).
Information sheet and informed consent were sent to the potential partici-
pants prior to data collection. Only participant who voluntary consented were
included in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Department of Social Pharmacy, Faculty of Pharmacy, Payap University,
Chiang Mai, Thailand. 2 Division of Pulmonary and Critical Care, Department
of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
3 Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chula-
longkorn University, Bangkok 10330, Thailand.
Received: 15 July 2022 Accepted: 1 October 2022
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