Assessing Parents’ Knowledge, Attitudes, and Practices Toward Vaccinating Children (Five to 15 Years Old) Against COVID-19 in the United Arab Emirates

Background Since the approval of the Coronavirus disease 2019 (COVID-19) vaccine for children in 2021, there had been ongoing debates about the necessity of vaccinating children, owing to the seemingly mild nature of the infection in children, despite causing significant morbidity and mortality in the 5-11 age group in 2020-2021, and its association with complications such as Multisystem Inflammatory Syndrome in Children (MIS-C). This sparked the need to evaluate parents’ perceptions, knowledge, and the effect of information sources on their decision-making. It is important to understand the various drivers and concerns expressed by parents locally, to shape vaccination campaigns to address such issues. While numerous studies across the world have extensively investigated parental willingness and intention to vaccinate children against COVID-19, it is important to acknowledge that these studies have been conducted before COVID-19 vaccines became approved for children in the respective countries. There is an obvious scarcity of data on the parental knowledge, attitudes, and acceptance of the vaccine for children after the respective countries have approved and provided the vaccine. The present study aims to provide data that could reveal possible barriers to vaccine uptake such as deficits in knowledge, negative attitudes, and poor practices towards the COVID-19 pandemic, and hence address these factors to make the ongoing COVID-19 vaccination campaign, as well as future childhood vaccination campaigns, more successful. Methods This is a cross-sectional online-based survey targeting parents living in the United Arab Emirates (UAE) with children aged 5-15 years. Data collected from June 23 to July 20, 2022 were analyzed using IBM SPSS (Statistical Package for Social Sciences) 28 software. The survey included questions concerning parental and children demographics, parents’ level and sources of knowledge about COVID-19 infection and vaccine, attitudes of parents about the COVID-19 pandemic and vaccines, and finally parental practices concerning pandemic preventive measures and COVID-19 vaccine uptake. Results Out of 437 participants, 212 (48.5%) vaccinated their children against COVID-19, and of those who did not, only 22 (9.8%) intended to vaccinate. The most commonly cited reason by parents for vaccinating their children was to reduce complications. The most frequent concern was the novelty and lack of information, and consequently, getting more information was the most selected driver to vaccinate as well as being advised by a doctor. Significant predictors were acceptance of childhood and influenza vaccines, trust in vaccine safety and trust in information provided by health authority websites, and lastly, exposure to positive information on social media. Conclusion A considerable proportion of parents have vaccinated their children against COVID-19; however, concerns about novelty and lack of information persist, leading to a high level of vaccine hesitancy. It is imperative that public health efforts maintain momentum, and that pediatricians incorporate parental education on the COVID-19 vaccine for children, which could potentially play a major role in combating vaccine hesitancy.


Introduction
The questionnaire included five parts: the first part focused on the demographics of parents, their COVID-19 infection history and that of their contacts, COVID-19 vaccination status, and lastly, their experienced side effects. Questions about the demographics of children included age group (5 to 8, 9 to 12, 13 to 15), number of children (1, 2, 3, ≥4), and history of chronic medical illnesses. The second part assessed parents' knowledge about COVID-19 infection, and awareness about the availability of vaccines, followed by questions about the sources and nature of information about COVID-19. The next section addressed parents' attitudes about the transmissibility, seriousness, and preventability of COVID-19 infection, as well as the safety, efficacy, usefulness, and role of COVID-19 vaccines. The final part evaluated parental adherence to protective measures and their children's previous vaccination history including seasonal influenza vaccines.
Parents were asked about whether they had immunized their children against COVID-19, and to specify their reasons from a provided list of suggestions. Parents who did not vaccinate were questioned about their future plans to do so, as well as possible concerns from a provided list. Finally, parents were asked to choose from a list of scenarios the ones that would motivate them to accept the COVID-19 vaccine for their children.

Sampling type, sample size, and statistical analysis
OpenEpi website [20] was used to calculate the sample size, based on Dubai Statistics Center data from 2021 [21]. The required sample size at a 95% significance level and a 5-percentage point margin of error were 385. Convenience sampling was used, in which all possible individuals were invited to participate in the study. Data from the online questionnaire were analyzed with IBM SPSS (Statistical Package for Social Sciences) 28 software. Descriptive statistics in this paper were reported as frequencies, percentages, averages, standard deviations (SD), and ranges. Children's vaccination status was used as the dependent variable. Bivariate Analysis was carried out using category appropriate tests (Chi-square test, Fisher's exact test, t-test). A pvalue of <0.05 was considered significant. Consequently, significant variables were assessed through the multivariate logistic regression model, to identify independent predictors of the explored parents' willingness. Finally, independently significant factors were demonstrated through the adjusted odds ratio (OR) and 95% confidence interval (CI).

Parent demographics
The total number of parents who agreed to participate was 640; however, only 437 met the inclusion criteria. The survey was completed in Arabic by 70.9% of respondents. Table 1 describes the sociodemographic characteristics of the participants. The mean age of the parents was 39 years old (39 ± 8.71 with a range of . The vast majority of responding parents were females (82.2%), non-Emirati (81%), and nonhealthcare workers (87.2%). It is important to note that the expatriate community constitutes the majority of the UAE population, which explains the large proportion of non-Emirati respondents. The majority of the participants were distributed across Dubai, Sharjah, Abu Dhabi, and Ajman (28.4%, 26.8%, 23,1%, and 16.7% respectively), with a significantly lower response rate from the remaining emirates. Moreover, 59% of parents had a college degree and 23.6% had attained higher education. There were 36.6% of respondents reported having two children, and 26.1% reported they had one child. Furthermore, 51.7% of parents had at least one child aged 5-8 years old, 58.8% had at least one child aged 9-12 years old, and lastly, 42.6% had at least one child in the 13-15 age category. It was found that 63.32% of participants had been infected with COVID-19 and that a similar percentage of the participants' household members (63.4%), friends and colleagues (63.6%), and family members (62.2%) had the disease as well. Most parents were vaccinated against COVID-19 (90.2%), and of those, 54.5% experienced mild side effects while 37.8% experienced no side effects. A minority of children had at least one chronic disease (10%), of which 20% were lung diseases.  . When asked about the main source of information about COVID-19, 55.40% chose health authority websites, and in a subsequent question, it was found to be their most trusted source of knowledge. Meanwhile, TV and radio were the least reported sources used and trusted at 2.10%. Concerning exposure to COVID-19-related information on social media, 28.6% reported the information to be neutral, while 31.8% encountered positive information (20.6% somewhat positive, and 11.2% mostly positive). On the other hand, 22.9% were exposed to negative information (12.4% somewhat negative and 10.5% mostly negative).

Parents' attitudes toward COVID-19 infection and vaccine
Among participants, 56.1% believe that COVID-19 was a serious disease. Additionally, 83.8% of parents believe that COVID-19 is a preventable disease and 75.3% are concerned that their child contracts it or transmits it to others (84%). Regarding COVID-19 vaccines, 68.9% of parents believe they are effective, 67.7% believe they are safe, and 68.9% believe they can contribute to controlling the pandemic. Figure 1 illustrates that 92.4% of participants reported adherence to face masks. In addition, 82.4% followed social distancing, 80.3% avoided crowded places, 78.3% abided by hand washing, 71.2% avoided touching face/mouth/nose/eyes, and 65.9% avoided social gatherings. The majority of children had been vaccinated with childhood vaccines (86%); however, only 41% were vaccinated against influenza. Likewise, 48.5% of children had already received their COVID-19 vaccine. The most frequently reported reason for vaccinating children against COVID-19 was "I vaccinated my child as it decreases their chance of catching COVID-19 and its complications" (66.5%), followed by "I vaccinated my child for return to school purposes" (62.3%).

FIGURE 1: Reasons for vaccine acceptance
In Figure 2, parents who have chosen not to vaccinate their children (51.5%) were asked the same question about their decision. Their most common reasons were "The vaccine is new" (45.3%) and "I don't have enough information about the vaccine" (44.3%). Among those parents who did not vaccinate their children, a mere 9.8% reported intent to vaccinate in the future, 54.7% reported no intent, and the rest were undecided (35.6%). Parents who did not immunize their children were presented with possible scenarios which would increase their likelihood of vaccinating, and their responses are presented in Figure 3. Many stated that they would vaccinate if "The vaccine was made mandatory" with a 46.3% pick rate, followed by, if "I was given adequate information about it" (38.4%), if "The doctor recommends it" (30%), if "a more dangerous variant arises" (23.6%), if "the vaccine was taken by many in the public" (10.8%), and lastly if "the vaccine was produced locally" (9.90%).

Independent factors associated with vaccine uptake
The results of the univariate analysis are shown in Table 2. Analysis of vaccination rate with relation to various factors revealed that parents who vaccinated their children (aged 41.2 years SD ± 9.084) were found to be older than parents who did not (aged 37.

TABLE 2: Univariate analysis -parental factors associated with increased vaccine uptake
Factors found to have p<0.05 were included in the multivariate logistic analysis as shown in Table 3. Parents with at least one child aged 5-8 had a lower likelihood of vaccination than parents whose children are not in this age group (OR 0.531, CI 0.292-0.967, p=0.038). Additionally, parents who had two children were less likely to vaccinate (OR 0.379, CI 0.192-0.748, p=0.005). In fact, more parental practices than demographic factors were found to predict vaccine acceptance. Parents vaccinated against COVID-19 were ten times more likely to vaccinate (OR 9.528 C.I. 3.129-29.014, p<0.001), and parents who had at least one child aged 13-15 were nine times more likely to accept the vaccine than parents who had no children in this age group (

Discussion
While numerous studies across the world have extensively investigated parental willingness and intention to vaccinate children against COVID-19, it is important to acknowledge that these studies have been conducted before COVID-19 vaccines became available for children in the respective countries. There is a shortage of data on the parental acceptance of the vaccine for children after the approval and provision of the vaccine in the respective countries. To our knowledge, the present study is among the first ones to explore the knowledge, attitudes, and practices of parents concerning vaccinating their children against COVID-19 in the UAE, after a few months of having the vaccine approved for children ages ≥5.
Our reported rate of COVID-19 vaccine uptake in children at 48.5% is in concordance with a recently published regional study across eight Eastern Mediterranean countries, revealing an interestingly similar rate at 48.9% in the UAE [22]. This similarity in results provides a valuable insight into the progression, or lack thereof, of the vaccination campaign in children, given that the latter study was carried out from November to December of 2021, a few months before the timeframe of our present study. The plateau in progression could be explained by parents' reported reasons for vaccine refusal presented in this study. These include vaccine novelty, lack of information, perceived lack of susceptibility and mildness of the disease, concern about efficacy and safety, and belief that naturally acquired immunity is better. Parents in other studies cited similar reasons [17,19,23]. It is worth noting that no participant has stated that they have no access to the vaccine, indicating that parents are well-informed of the vaccine's availability. The present study identifies that increasing vaccine-related education by doctors could reduce vaccine hesitancy, seeing as over two-thirds of hesitant parents mentioned that physicians' recommendation of the vaccine could be an encouraging factor.
Concerning socio-demographic characteristics, older parental age was shown to be strongly correlated with an increased likelihood of vaccination, which was supported by numerous studies carried out in Turkey, the United States, and Saudi Arabia [24][25][26][27]. Other parental demographics such as gender, geographical distribution, and profession in healthcare were not factors contributing to the vaccination likelihood in our study. This contrasts with other regional studies namely in Jordan and Saudi Arabia, which found all those factors to be predictors of vaccination [17,19,23]. Furthermore, parents vaccinated against COVID-19 were found to be more likely to have vaccinated their children, and this was the single most significant independent factor in the present study. This is supported by many studies regionally and globally [13,14,17,19,27].
With regards to children's demographics, parents with one child were more likely to vaccinate than their counterparts, which is corroborated by some other studies [8,19]. Parents of children in the 13-15 age group were more likely to vaccinate their children, whereas parents of younger children were significantly less likely to do so. A previous Saudi study reported that parents with children in the 13-18 age group were less likely to vaccinate due to perceived fear of the vaccine's effect on puberty and fertility [14].
Though the spread of misinformation has been a growing concern during the COVID-19 pandemic, our study presents promising information regarding parents' levels and sources of knowledge about children's COVID-19 vaccine. The main and most trusted source of information for parents about the COVID-19 vaccine was health authority websites. Health authority websites and online news outlets as sources of information were predictors of parental acceptance of the vaccine. This reflects the continuous efforts undertaken by the UAE's health authorities in verifying news published across its official sites and platforms, as well as national online news sites.
Assessing the impact of social media as a source of parental knowledge of the COVID-19 vaccine was of the utmost importance, given the increasing influence of social media platforms on their users' decisionmaking. In the present study, exposure to positive information was a strong predictor of vaccination uptake, while exposure to negative information was associated with increased vaccine hesitancy, and the lowest vaccination rate was found to be among those with no exposure to COVID-19-related information on social media. Similarly, studies in China and Turkey concluded that a higher frequency of information exposure on social media was associated with higher parental acceptability of the vaccine [10,24]. On the contrary, a Saudi study did not find a significant correlation [14]. The increased presence of public health authorities on social media platforms can serve as a powerful tool to combat false information and increase parental acceptance of the vaccine. It has been shown that people tend to retain more of the encountered negative information during a pandemic [16]. In the present study, the absence of a statistically significant correlation between negative information exposure on social media and vaccine uptake indicates a commendable level of parental awareness and critical judgment.
Parents' adherence to the childhood immunization schedule, and to the seasonal influenza vaccine for their children was found to be a predictor of COVID-19 vaccine uptake in children. This was supported by previous studies, namely, a study carried out in 6 countries in Europe and the Americas. This study revealed that the influenza vaccination status for both parents and children was correlated with increased parental likelihood to vaccinate their children [26]. It is probable that the success of present vaccination campaigns likely impacts future ones, hence why continued public health efforts to reduce parental COVID-19 vaccine hesitancy are crucial.
Assessment of parental beliefs and perceptions reveals a positive attitude concerning COVID-19 and the vaccine. Parental perception of COVID-19 as a serious disease was a predictor of increased vaccine acceptance, as in previous studies [17]. This is further evidenced seeing as the most cited reason by parents for vaccination was the belief that the vaccine protects their children from COVID-19 and its complications. A belief that the COVID-19 vaccine is effective was the strongest attitude-related predictor of vaccine uptake, as corroborated by an Italian study [12].
Despite the findings presented in this study, there are a few limitations. Firstly, data were collected through a self-administered online questionnaire, which raises concerns about recall bias. Secondly, this also increases the level of selection bias as it limits the number of participants to people who have access to the internet and social media. Thirdly, due to the fact that the questionnaire was mainly disseminated through school-related social media communities, 82.2% of the responses were from mothers. As such, our findings may not adequately represent the outlook of fathers. As mothers in the Middle East are generally the main caregivers for their children's health, it can be assumed that the responses are accurate indications of the children's current vaccination status or likelihood of vaccination in the future. Fourthly, the sample size remains relatively small despite exceeding the target sample size required to attain generalizable results. Lastly, although the questionnaire was shared across all the emirates to ensure broad national coverage, most of our participants were from the major emirates of Dubai, Abu Dhabi, Sharjah, and Ajman with less representation from the remaining three emirates, making the results perhaps less generalizable across those areas.

Conclusions
Many parents in the UAE have vaccinated their children against COVID-19. Our study revealed that previous parental practices related to the vaccination of children, as well as positive parental attitudes, were strong predictors of COVID-19 vaccine uptake in children. It was reassuring that parents who relied on official online news websites and local health authorities, as well as those exposed to positive information on social media, were more likely to vaccinate. Nevertheless, equally as many parents are still vaccine-hesitant, mainly due to the novelty and lack of information about the vaccine. It is imperative that public health efforts maintain momentum, and that pediatricians incorporate parental education on the COVID-19 vaccine for children, which could potentially play a major role in combating vaccine hesitancy.