Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), as of yet, has caused hundreds of millions of infections and millions of deaths among elderly, adults, and children (1), with mortality risk among hospitalized patients ranging between 10 and 20% including studies from Saudi Arabia (2–4). The urgency to combat such pandemics has led to accelerated competition among scientists and pharmaceutical companies around the globe to create potent and safe vaccines against this disease (5). Such rapid development of these vaccines, as well as other factors, have raised concerns among the general population on safety and efficacy (6). However, these vaccines have been granted emergency use authorizations after they showed large safety and efficacy levels (7, 8).

Hesitancy to vaccination is listed among the top ten threats to global health (9). As per the WHO Strategic Advisory Group of Experts on Immunization (SAGE), vaccine hesitancy is defined as the delay in acceptance or refusal of vaccines despite the availability of vaccine services (10). At our country level, a pre-pandemic study revealed that almost 20% of parents were hesitant with childhood routine vaccination (11), highlighting the magnitude of the vaccination hesitancy in a country that mandates childhood vaccination.

During the pandemic of COVID-19, the crucial role of the COVID-19 vaccine against the pandemic was opposed by a massive infodemic of misinformation and conspiracy theories (12, 13). For many reasons, COVID-19 vaccines evaluation was delayed in the pediatric age group and therefore authorization was granted later in the pandemic. Although COVID-19 had a milder rate of morbidity and mortality among children compared to adults, there are more reasons to vaccinate children against COVID-19. Children might have similar nasopharyngeal viral loads to adults (14), therefore they potentially have a similar risk of viral transmission and rates of secondary infections (15, 16). Moreover, if infected, children are at risk to develop multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) (17).

The assessment of parents' willingness to provide their children with a vaccine against COVID-19 was performed in different parts of the world, but not in our region. A report by Goldman et al. from six different countries (USA, Canada, Japan, Switzerland, and Spain) where they interviewed parents presenting to emergency departments with their children revealed that only 65% of the parents were willing to vaccinate their children. The likelihood of vaccination was higher if the child was older, free from any comorbid conditions, and in those who were up-to-date in their routine vaccination schedule. The main concerns of hesitant parents were the novelty of the COVID-19 vaccine (18), not being convinced by the vaccine's effectiveness (19), or being unconcerned about COVID severity in childhood (20).

In Saudi Arabia, since July 2021, the BNT162b2 vaccine (Pfizer, USA), mRNA-1273 vaccine (Moderna, USA), ChAdOx1 vaccine (AZD1222, AstraZeneca, UK), and Ad26.COV2.S vaccine (Janssen Inc., USA), remains part of the national vaccination campaign and had shown a high degree of safety (21–23). Until January 2022, 51 million doses of these vaccines have been administered in the kingdom (24). When this study was undertaken, people younger than 18 years of age were denied vaccination as per the Saudi ministry of health protocol.

Thus, we aim to assess the willingness of parents to vaccinate their children against COVID-19 compared to the parent's willingness on the childhood routine vaccination. We also aimed to explore the determinants of the parents' hesitancy on the childhood COVID-19 vaccine.

In this study, we found a quarter of parents in Saudi Arabia were hesitant toward children's COVID-19 vaccination. In the same cohort, such hesitancy was found three times more than the hesitancy toward routine childhood vaccination, especially among mothers, parents who were younger the 40 years of age, and parents of children with allergies.

Children's vaccination has been successful in preventing many infectious diseases and was considered more effective than elderly vaccination to achieve community-wide prevention of certain infectious diseases (29). In COVID-19, children's vaccination does not only protect them but might provide an indirect advantage in protecting the older unvaccinated people (30). Globally, early in the pandemic or recent data both have revealed an elevated parental hesitancy toward the children's COVID-19 vaccination (18, 31, 32). Regionally, a recent study from Kuwait showed substantially higher parental rejection (55.8%) for children's COVID-19 vaccination (33). In our study, however, the majority of the participants were not hesitant toward the COVID-19 or routine childhood vaccination. COVID-19 vaccine-hesitant respondents in the current study were concerned that it is a new vaccine of unknown adverse events and do not trust its effectiveness, which replicates similar local studies' findings (34, 35). Some of them have expressed a lack of trust in the information provided by the official agencies. The fact that the hesitancy is more when it comes to COVID-19 compared to the routine childhood vaccination disfavor anti-vaccination ideology, but rather a lack of enough public awareness on the safety and efficacy among the pediatric age group. An additional consideration is the timing of the survey to the status of the pandemic. For example, a surge in the acceptance of enrollment in the COVID-19 trial was noted during the stages of higher disease spread (36), thus, a relatively controlled COVID-19 status in Saudi Arabia during the study period of June 2021 (37), might have affect intention of vaccination. Without a doubt, the massive spread of misinformation during the pandemic of COVID-19 has caused significant challenges to public health strategies, especially in the era of social media, and is still a hard task to counteract (12).

Sociodemographic determinants of a higher parental hesitancy toward children COVID-19 vaccination in this study were replicated from previous studies. First, parents who were mothers were found more hesitant, compared to fathers (18, 38, 39). Further exploration in our cohort revealed that the mothers had higher rejection of flu vaccination (57 vs. 41%, p < 0.001) and self-vaccination against COVID-19 (25.1 vs. 12.1%, p < 0.001) compared to the fathers. Although this needs further investigations including special concerns on pregnancy outcome, but also could alarm early antivaccination behavior among mothers in Saudi Arabia. The other consideration is that mothers in our cohort know more children with a history of COVID-19 diagnosis (61 vs. 42%, p < 0.001) than fathers, which probably has decreased their anxiety toward COVID-19 in children. Second, parents who were younger than 40 years of age or those with higher educational backgrounds were more hesitant toward children's COVID-19 vaccination, as seen in previous studies (18, 31, 35, 38, 40). Previous studies found these groups were more likely to have selected sources of information and they base their decision on a critical-thinking attitude (40). Thus, public health messaging should consider such targets of the population with the appropriate mode of messaging. It is worth mentioning that such parent gender and age differences were not found significant after the multivariate regression analysis.

Consistent with previous studies (18, 38), vaccinated parents would be more willing to vaccinate their children, while those who had COVID-19 in a mild form would be more hesitant. This alerts toward the effect of parental self-experience on children's healthcare decisions.

This study has several limitations. We did not evaluate the impact of family income and the impact of the child's age on the parent's decision of childhood COVID vaccination. Although the sample size was deemed adequate statistically, the recruited sample was at risk of selection bias to those who use social media as the recruitment tool which might underestimate vaccine hesitancy among other populations. Future studies investigating the beliefs and cultural influences of parental hesitancy are recommended.

Only one in every four parents in Saudi Arabia was hesitant toward children's COVID-19 vaccination, which is similar to the rate reported worldwide. The focus of public health campaigns on the hesitant population, including mothers, younger parents, highly educated parents, and parents with a history of COVID-19 infection might help to decrease parents' hesitancy toward children's COVID-19 vaccination aiming to achieve further control of COVID-19 in the community.

The datasets presented in this article are not readily available because it could compromise the privacy of research participants. Requests to access the datasets should be directed to AAlm, almohayaam@gmail.com.

The studies involving human participants were reviewed and approved by the Institutional Research Board (KFMC/KACST-IRB: H-01-R-012, OHRP/NIH: IRB00010471) dated June 13, 2021. The patients/participants provided their written informed consent to participate in this study.

AAlm, SFA, and BA: proposal preparation. AAlm, SFA, AAlt, and KA: manuscript writing. All authors contributed in study concept and methodology, data collection, analysis, interpretation, manuscript review, and final approval.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.