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Israeli parents` views on coronavirus (COVID-19) vaccinations for children: A cross-sectional study

Published:October 18, 2022DOI:https://doi.org/10.1016/j.pedn.2022.09.023

      Highlights

      • Parents play the decisive role in children's vaccination.
      • More than a quarter of parents not intend to vaccinate their children.
      • Adherence to routine vaccinations is significantly associated with intention to vaccinate with COVID-19 vaccine
      • Social influence is important in adopting a positive attitude toward vaccines.
      • Parents who have vaccinated their children should be incorporated in the vaccination campaign.

      Abstract

      Background

      Parents play the decisive role in children's vaccination. Our study aimed as assessing attitudes of parents toward the COVID-19 vaccine for children aged 5–18 and to define sources of influence on these attitudes, the barriers and reasons for hesitation.

      Methods

      In this cross-sectional study, 138 Israeli parents of 5–18 aged children completed a self-administered structured questionnaire.

      Findings

      More than a quarter of parents reported that they did not intend to vaccinate their children. Independent of other demographic characteristics, parents who do not vaccinate their children accordingly to the routine vaccinations have five-fold significant odds not to vaccinate with COVID-19 vaccine (OR = 4.8, 95% CI: 1.8–12.7). Greater social influence was significantly and negatively associated with intentions not to vaccinate a child. Among parents who do not intend to vaccinate their children, the most frequent reasons were fear of possible side effects (92%), vaccine novelty (92%) and lack of belief in its effectiveness (69%).

      Discussion

      This study found that vaccination in the past as part of routine government immunization programs predict a tendency to vaccinate children during the pandemic. Among the factors associated with the intention not to vaccinate, concerns and uncertainty about the necessity of the vaccine, its side effects and reliability have been emphasized.

      Application to practice

      Cultural-religious adjustments should be applied when implementing interventions aiming to promote vaccination in routines and emergencies. Social influence is important in adopting a positive attitude toward vaccines. Public health professionals should incorporate those parents who have vaccinated their children and have a positive attitude toward vaccination.

      Keywords

      Introduction

      Since its emergence in Wuhan, China in December 2019, the coronavirus disease (COVID-19) has spread worldwide and became a pandemic of international concern. In Israel, there have been >4.5, million people infected and 11,643 deaths occurred due to COVID-19 (
      • Ministry of Health
      Corona virus in Israel - general situation (Hebrew).
      ). Vaccines are critical tools for helping to bring the pandemic under control, combined with effective testing, treatment, and existing prevention measures. In order to proactively manage the COVID-19 pandemic, 15 vaccines have already been licensed or approved for emergency use and at least 140 candidate vaccines are in clinical development (

      World Health Organization. (n.d.). COVID-19 vaccine tracker and landscape. Retrieved January 26, 2022, from https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines

      ).
      The COVID-19 vaccination campaign in Israel began on December 20th, 2020. The Ministry of Health has prioritized the provision of the COVID-19 vaccine, starting with people aged 60 and over, nursing home residents, people at high risk due to serious medical conditions, and front-line health care workers. Later it was extended to all individuals over 18 years (
      • Ministry of Health
      The first ones to have the COVID-19 vaccine within the “Ten Katef” Vaccine Campaign.
      ). In June 2021 vaccination of children aged 12–18 was approved and in November 2021 vaccination of children aged 5–11 started in Israel (
      • Ministry of Health
      COVID-19 vaccine for children aged 5-11 years old.
      ). The COVID-19 vaccine is administered free of charge to every citizen, regardless of age. Since 1995, Israel has had universal national health insurance coverage; all permanent residents are insured in one of four large, competing, nonprofit, health plans (
      • Rosen B.
      • Waitzberg R.
      • Merkur S.
      Health Systems in Transition: Israel Vol. 17 No. 6 2015. In Israel Health system review (Vol. 17, Issue 6).
      ). These health plans have experience in mobilizing staff for vaccinations as well as the rapid and efficient scheduling and processing of members for vaccinations at a wide range of vaccination sites (
      • Rosen B.
      • Waitzberg R.
      • Israeli A.
      Israel’s rapid rollout of vaccinations for COVID-19.
      ). Thus, technical barriers for vaccination which are related to accessibility, availability and price of vaccination are not typical for Israel.
      In Israel, the universal immunization program for the routine administration of childhood vaccines are provided in the public infant welfare centers in Israel, a community-based system of maternal and child health clinics (called Tipat Halav). Most of the children in Israel are vaccinated up-to-date for HBV3, DTaP-IPV-Hib4, PCV3, MMR/MMRV1, HAV1and HAV2 vaccine (96%, 95%, 91%, 96%, 94% and 86%, respectively) (
      • Stein-Zamir C.
      • Israeli A.
      Age-appropriate versus up-to-date coverage of routine childhood vaccinations among young children in Israel.
      ). Booster doses are provided via the school health services. Additionally, in the eighth grade the vaccine against Human Papilloma Virus is provided for both girls and boys. All routine vaccines given at Tipat Halav centers and at schools are free of charge (). Currently, a routine vaccination of children is not mandatory and does not constitute a condition for registration for kindergarten or school. Likewise COVID-19 vaccine is offered and administered today to children (subject to parents' decision) free of charge through the health plans around the country (
      • Ministry of Health
      COVID-19 vaccine for children aged 5-11 years old.
      ).
      High rates of vaccination are required to establish herd immunity and halt the current COVID-19 pandemic progression (
      • Randolph H.E.
      • Barreiro L.B.
      Herd immunity: Understanding COVID-19.
      ). In relation to children's vaccination, parents are proxy decision makers for their children, who are unable to decide for themselves (
      • Damnjanović K.
      • Graeber J.
      • Ilić S.
      • Lam W.Y.
      • Lep Ž.
      • Morales S.
      • Vingerhoets L.
      Parental decision-making on childhood vaccination.
      ). Despite a massive worldwide COVID-19 vaccination campaign and the high efficacy and safety profile of the vaccines, vaccine hesitancy is still a major barrier to achieving herd immunity across different populations, especially children. In the early days of the pandemic, parents took some comfort in the fact that COVID-19 was much less likely to cause serious illness in children than in adults (
      • Castagnoli R.
      • Votto M.
      • Licari A.
      • Brambilla I.
      • Bruno R.
      • Perlini S.
      • Marseglia G.L.
      Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: A systematic review.
      ). Recent data show that over 10.6 million children in the United States have tested positive for COVID-19 since the onset of the pandemic, representing 18.4% of total cumulated cases (). During the Omicron variant surge, these numbers spiked dramatically with children being 26% of the reported weekly COVID-19 cases (). Furthermore, children can experience severe disease outcomes because of COVID-19 illness, including intensive care unit admission, invasive mechanical ventilation, and death (
      • Woodruff R.C.
      • Campbell A.P.
      • Taylor C.A.
      • Chai S.J.
      • Kawasaki B.
      • Meek J.
      • Havers F.
      Risk factors for severe COVID-19 in children.
      ). Long-term complications of the COVID-19 infection include myocarditis, multisystem inflammatory syndrome in children (MIS-C), long COVID and the indirect effects of social isolation and interruption in education (
      • Stein M.
      • Ashkenazi-Hoffnung L.
      • Greenberg D.
      • Dalal I.
      • Livni G.
      • Chapnick G.
      • Grossman Z.
      The burden of COVID-19 in children and its prevention by vaccination: A joint statement of the Israeli pediatric association and the Israeli Society for pediatric infectious diseases.
      ). Evidence has been accumulated about an increase in the diagnosis of MIS-C syndrome, linked to the Omicron wave (
      • CDC
      Health department-reported cases of multisystem inflammatory syndrome in children (MIS-C).
      ).
      Importantly, children and adolescents play a significant role in coronavirus transmission (
      • Stein M.
      • Ashkenazi-Hoffnung L.
      • Greenberg D.
      • Dalal I.
      • Livni G.
      • Chapnick G.
      • Grossman Z.
      The burden of COVID-19 in children and its prevention by vaccination: A joint statement of the Israeli pediatric association and the Israeli Society for pediatric infectious diseases.
      ). A Centers for Disease Control and Prevention (CDC) analysis demonstrated that Pfizer vaccine given to children aged 5–11 years would prevent serious COVID-19 illness, including hospitalizations, intensive care unit admissions and MIS-C morbidity (
      • CDC
      Pediatric COVID-19 vaccines: CDC's recommendations for Pfizer-BioNTech COVID-19 vaccine primary series in children 5–11 years old.
      ). In addition to the efficacy of the mRNA COVID-19 vaccine in preventing symptomatic disease, it is effective in preventing asymptomatic infection and in reducing infectibility, even of the Delta variant (
      • Stein M.
      • Ashkenazi-Hoffnung L.
      • Greenberg D.
      • Dalal I.
      • Livni G.
      • Chapnick G.
      • Grossman Z.
      The burden of COVID-19 in children and its prevention by vaccination: A joint statement of the Israeli pediatric association and the Israeli Society for pediatric infectious diseases.
      ). Moreover, large-scale studies reported an excellent safety profile for children aged 5 to 11 years and for children aged 12 years and older (
      • Hause A.M.
      • Baggs J.
      • Marquez P.
      • Myers T.R.
      • Gee J.
      • Su J.R.
      • Shay D.K.
      COVID-19 vaccine safety in children aged 5-11 years - United States, November 3-December 19, 2021.
      ;
      • Stein M.
      • Ashkenazi-Hoffnung L.
      • Greenberg D.
      • Dalal I.
      • Livni G.
      • Chapnick G.
      • Grossman Z.
      The burden of COVID-19 in children and its prevention by vaccination: A joint statement of the Israeli pediatric association and the Israeli Society for pediatric infectious diseases.
      ). According to the most updated meta-analysis, based on 44 studies including 317,055 parents, lower overall intention of parents to vaccinate their children against the COVID-19 is related to the perception of a very low risk of severe COVID-19 in children and the fact that children are often asymptomatic carriers (
      • Galanis P.
      • Vraka I.
      • Siskou O.
      • Konstantakopoulou O.
      • Katsiroumpa A.
      • Kaitelidou D.
      Willingness, refusal and influential factors of parents to vaccinate their children against the COVID-19: A systematic review and meta-analysis.
      ).
      Despite the health and economic benefits of the COVID-19 vaccination for children, parents are hesitant about vaccinating their children. Studies report several causes for vaccine hesitancy or refusal. Individual characteristics such as education, age, sex, ethnicity, and parents' occupation related to healthcare are reported (
      • Goldman R.D.
      • Yan T.D.
      • Seiler M.
      • Parra Cotanda C.
      • Brown J.C.
      • Klein E.J.
      • Staubli G.
      Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.
      ;
      • Pan F.
      • Zhao H.
      • Nicholas S.
      • Maitland E.
      • Liu R.
      • Hou Q.
      Parents’ decisions to vaccinate children against COVID-19: A scoping review.
      ). Some parents object on religious or personal grounds; others have socioeconomic barriers, such as low income or multiple children (
      • Gust D.A.
      • Strine T.W.
      • Maurice E.
      • Smith P.
      • Yusuf H.
      • Wilkinson M.
      • Schwartz B.
      Underimmunization among children: Effects of vaccine safety concerns on immunization status.
      ;
      • Pan F.
      • Zhao H.
      • Nicholas S.
      • Maitland E.
      • Liu R.
      • Hou Q.
      Parents’ decisions to vaccinate children against COVID-19: A scoping review.
      ). Another important factor is willingness to vaccinate family members against other diseases (
      • Pan F.
      • Zhao H.
      • Nicholas S.
      • Maitland E.
      • Liu R.
      • Hou Q.
      Parents’ decisions to vaccinate children against COVID-19: A scoping review.
      ). Two beliefs that predict decisions not to vaccinate in general are that vaccines are unsafe and can have long-term negative health effects (
      • Flynn M.
      • Ogden J.
      Predicting uptake of MMR vaccination: A prospective questionnaire study.
      ;
      • Gust D.A.
      • Strine T.W.
      • Maurice E.
      • Smith P.
      • Yusuf H.
      • Wilkinson M.
      • Schwartz B.
      Underimmunization among children: Effects of vaccine safety concerns on immunization status.
      ).
      Kumar et al. utilized a social ecological framework to examine influenza vaccine uptake during the 2009 H1N1 pandemic (
      • Kumar S.
      • Quinn S.C.
      • Kim K.H.
      • Musa D.
      • Hilyard K.M.
      • Freimuth V.S.
      The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the United States.
      ). The Social Ecological Model for health promotion explains health outcomes by both individual and social environmental factors (
      • Kumar S.
      • Quinn S.C.
      • Kim K.H.
      • Musa D.
      • Hilyard K.M.
      • Freimuth V.S.
      The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the United States.
      ;
      • Mcleroy K.R.
      • Bibeau D.
      • Steckler A.
      • Glanz K.
      An ecological perspective on health promotion programs.
      ). According to this model the behavior is determined by five factors: intrapersonal, interpersonal, institutional, community and public policy factors (
      • Kumar S.
      • Quinn S.C.
      • Kim K.H.
      • Musa D.
      • Hilyard K.M.
      • Freimuth V.S.
      The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the United States.
      ;
      • Mcleroy K.R.
      • Bibeau D.
      • Steckler A.
      • Glanz K.
      An ecological perspective on health promotion programs.
      ). The intrapersonal level measures knowledge, attitudes and beliefs, including history of past vaccinations, perceived risk from the disease, trust in the government's handling of the pandemic and perceived presence in the priority group. The interpersonal factors assess the influence of social networks and number of family members and friends who took the vaccine; the community level factors include beliefs about the presence of the disease and the perceived risk to the community. Institutional factors address the presence of regular health providers and the amount of information given by the authorities while policy level includes having health insurance and being in the priority group for immunization (
      • Kumar S.
      • Quinn S.C.
      • Kim K.H.
      • Musa D.
      • Hilyard K.M.
      • Freimuth V.S.
      The social ecological model as a framework for determinants of 2009 H1N1 influenza vaccine uptake in the United States.
      ).
      Vaccination refusal and the belief that vaccines may be harmful are more severe when addressing the COVID-19 vaccine. Many parents express concerns regarding the safety of a rapidly-developed vaccine (
      • Goldman R.D.
      • Yan T.D.
      • Seiler M.
      • Parra Cotanda C.
      • Brown J.C.
      • Klein E.J.
      • Staubli G.
      Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.
      ;
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • Escudero D.
      • Hernandez-Diaz S.
      • Wyszynski D.F.
      • Wu J.W.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: Results of a survey in 16 countries.
      ;
      • Walker K.K.
      • Head K.J.
      • Owens H.
      • Zimet G.D.
      A qualitative study exploring the relationship between mothers’ vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months.
      ) with internet and social media playing an important role in parents' doubts about vaccine safety and declining vaccination rates (
      • Downs J.S.
      • Bruine De Bruin W.
      • Fischhoff B.
      Parents’ vaccination comprehension and decisions.
      ;
      • Puri N.
      • Coomes E.A.
      • Haghbayan H.
      • Gunaratne K.
      Social media and vaccine hesitancy: New updates for the era of COVID-19 and globalized infectious diseases.
      ;
      • Wilson S.L.
      • Wiysonge C.
      Social media and vaccine hesitancy.
      ). These platforms have a potential for spreading harmful disinformation across networks which may be propagated via the contemporary anti-vaccination movements (
      • Hussain A.
      • Ali S.
      • Ahmed M.
      • Hussain S.
      The anti-vaccination movement: A regression in modern medicine.
      ;
      • Puri N.
      • Coomes E.A.
      • Haghbayan H.
      • Gunaratne K.
      Social media and vaccine hesitancy: New updates for the era of COVID-19 and globalized infectious diseases.
      ).
      Whether children are vaccinated mainly depends on their parents; therefore, it is important to understand parents' decisions concerning vaccination for their children against COVID-19. Understanding the reasons for the parents' refusal may help to prepare and implement public health interventions to increase rates of children's vaccination. Therefore, the aim of the study was to examine the views of parents of children aged 5–18 regarding their vaccination beliefs and to identify factors associated with the parents' intention to vaccinate their children against Covid-19.

      Methods

      Participants and study design

      Israeli Jewish parents (n = 138) of children aged 5–18 were invited to participate in this cross-sectional study. Parents who did not speak Hebrew or parents of children with chronic diseases (clear clinical indications for Covid-19 vaccination) were not included in the sample.

      Sample size

      The sample size calculation was based on a study from Saudi Arabia (
      • Temsah M.H.
      • Alhuzaimi A.N.
      • Aljamaan F.
      • Bahkali F.
      • Al-Eyadhy A.
      • Alrabiaah A.
      • Alhasan K.
      Parental attitudes and hesitancy about COVID-19 vs. routine childhood vaccinations: A national survey.
      ). In this study, among parents who were hesitant toward routine vaccination, the proportion of willing to vaccinate the child against COVID-19 was 25%; among parents who were not hesitant toward routine vaccination, the proportion of willing to vaccinate the child against COVID-19 was 66%. Thus the total sample size calculation is 20 participants in every group (40 participants in total). On the other hand, the proportion of parents whose children are not vaccinated up-to-date in Israel is ∼6–10% (
      • Stein-Zamir C.
      • Israeli A.
      Age-appropriate versus up-to-date coverage of routine childhood vaccinations among young children in Israel.
      ). We decided that collecting data on a three-fold larger number of participants as a variable of hesitancy toward routine vaccination was important to account of in relation to willingness to vaccinate against Covid-19 (
      • Goldman R.D.
      • Yan T.D.
      • Seiler M.
      • Parra Cotanda C.
      • Brown J.C.
      • Klein E.J.
      • Staubli G.
      Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.
      ). Thus total sample size calculation in this study as we decided should be 120 participants in total. We assumed that as some missing data is expected, we would collect data on 130–140 parents.

      Tools

      Demographic characteristics

      Age of parent (used as a continuous variable); Gender of parent (female; male); Family status (married/in relationship; single/divorced); Number of children aged 5–18 in the family (used as a continuous variable); Education (school only; Bachelor's degree; Master's degree and above); Level of religiosity (secular [nonobservant]) or traditional [observes some religious commandments]; religious [observes all religious commandments]); Profession (being in the field of health care [physician, dentist, pharmacist, physical therapist, nurse, dietician, psychologist etc.); Socio-Economic Status (SES), based on reported income (Low [less than an average wages in the economy]; Medium [about average]; High [higher than average]).

      History of previous child vaccination

      Parents were asked whether they vaccinated their child/children according to the routine immunizations program of the Ministry of Health (no or not all vaccinations; yes).

      Intention to vaccinate child with COVID-19 vaccine

      Parents were asked to report their child/children's vaccination status (already vaccinated against COVID-19; is about to get the vaccine soon; will not because recently got sick and “was not vaccinated and will not be vaccinated”. Based on this question, the dichotomic variable “Intention” was created (yes - for those whose child/children had already been vaccinated or would be vaccinated soon vs. no - for those child/children had not been vaccinated and would not be vaccinated).
      Attitudes toward COVID-19 vaccine for children were measured using a 19-items tool addressing different aspects of vaccination and created by Levi (
      • Levi L.
      Attitudes of parents toward vaccination of their children (Hebrew).
      ). Items were rated on a 4-point Likert-type scale (1 = do not agree at all; 4 = strongly agree). The scoring for items number 3, 4 and 9 (Table 4) was reversed. Mean attitude score was calculated, while the higher score represented more positive views. The reliability of this tool in the previous study (
      • Levi L.
      Attitudes of parents toward vaccination of their children (Hebrew).
      ) was high (Cronbach's Alpha method = 0.88) and in this study Cronbach's Alpha is 0.89. These tools assessed the intrapersonal and community levels.

      Social influence

      Six items assessed the influence of family, friends, coworkers, media, social networks, and religious leaders on attitudes toward the COVID-19 vaccine (
      • Levi L.
      Attitudes of parents toward vaccination of their children (Hebrew).
      ) representing the intrapersonal level. Items were rated on a 4-point Likert-type scale (1 = do not agree at all; 4 = strongly agree). Mean social influence score was constructed, while the higher score represented higher social influence on attitudes toward COVID-19 vaccination of children. The reliability of this tool in this study was high (Cronbach's Alpha =0.83).

      The reasons for indecision and rejection of COVID-19 vaccine

      Eleven items addressing possible reasons for indecision and rejection of COVID-19 vaccine were based on a study carried out by Akarsu et al. (
      • Akarsu B.
      • Canbay Özdemir D.
      • Ayhan Baser D.
      • Aksoy H.
      • Fidancı İ.
      • Cankurtaran M.
      While studies on COVID-19 vaccine is ongoing, the public’s thoughts and attitudes to the future COVID-19 vaccine.
      ). Items were rated on a 4-point Likert-type scale (1 = do not agree at all; 4 = strongly agree) but following a modest sample size were categorized to agree/disagree. The aim of this tool was to obtain information on specific causes for indecision/rejection and was not used to calculate a score. This tool included questions assessing both intrapersonal and community levels.
      No questions addressed the policy and institutional levels (having health insurance and a regular healthcare provider and being in the priority group for vaccination) as all children in Israel are insured and are perceived as being in a priority group.

      Procedure

      The pilot included four parents: two Israeli-born parents (one male and one female) and two parents (one male and one female) immigrants from Former Soviet Union. These parents answered the questionnaire and supplied their feedback on clarity of the questions. No suggestions for repair were reported.
      The data was collected using the snowball method from December 2021 till January 2022. Parents were recruited to participate through social media and asked to forward the link to other parents. The response to the questionnaire was completely anonymous and voluntary, no compensation or reward was given to the participants. Parents could decide whether or not they would like to answer the specific questions: the questionnaire allowed the respondents to continue the survey without answering if they chose not to.

      Statistical analysis

      Descriptive statistics were used to examine distribution of the variables. A Chi-square test was used to examine the association between the demographic characteristics and intention to vaccinate a child/children with COVID-19 vaccine. Association between demographic variables and a mean attitude score was checked with a t-test for independent samples. The difference between parents who intended to vaccinate the child/children and those who did not intend in every item of the attitude questionnaire was assessed by the Mann-Whitney U non-parametric test. Spearman correlation was used to evaluate relationships involving ordinal variables: sources of influence on attitudes toward COVID-19 vaccine. Logistic regression was used to explore the antecedents of intention not to vaccinate a child with COVID-19 vaccine. Independent variables included parental age, gender, SES, profession, religiosity, adherence to the routine vaccination program of Ministry of Health and a social influence score. Nagelkerke R2 value was used to analyze the contribution of all independent variables to the variability of the dependent variable. Before including independent variables in the multivariable analysis, correlations between the variables were checked with Kendall's Tau coefficient. Following high correlation between education and profession, education was not included in multivariable model. For all analyses performed, a p <.05 for a two-tailed test was considered statistically significant. Analyses were carried out with the SPSS version 25.0 statistical package (SPSS, Inc., Chicago, IL).

      Ethical approval

      The study received approval from the Ethical Board of the Department of Nursing, (Ashkelon Academic College). The survey was anonymous; no identifying data were collected. The questionnaire was delivered through Google Forms. After an introduction that explained the study objectives, participants were asked to confirm and agreed to participate.

      Results

      Participants

      The study population included 138 parents; with mean age of 39 years (SD = 8.6 years); 55 (40%) of them worked in the healthcare sector, and 83 (60%) were from non-medical professions. Half of the parents had two children younger than 18 years old in both groups.
      The proportion of secular/traditional parents was higher among healthcare workers vs. others (72.7% vs. 60.2%, not significant). The distribution of family income was similar in both groups. The proportion of highly educated parents holding MA or PhD degrees was significantly higher among healthcare workers than others (44.2% vs. 16.9%, p =.001). Additional demographic characteristics are shown in Table 1.
      Table 1Demographic characteristics of the study population.
      Demographic characteristicsHealthcare workersOtherTotal
      n = 55n = 83n = 138
      Age (years)
       Mean (SD)39.0 (8.1)38.8 (8.9)38.9 (8.6)
       Median (Interquartile Range [IQR])38.0 [32.0–46.0]39.0 [30.0–46.0]39.0 [32.0–46.0]
      Gender (%)
       Female70.956.162.0
       Male29.143.938.0
      Family status “married or living with a partner”(%)86.789.187.7
      Number of children < 18 years old (median [IQR])2.0 [1.8–3.0]2.0 [1.0–3.0]2.0 [1.0–3.0]
      Level of religiosity (%)
       Secular/ Traditional
      group of Secular/Traditional includes 81% secular and 19% traditional parents.
      72.760.265.2
       Religious/ Orthodox
      group of Religious/Orthodox includes 88% religious and 12% orthodox parents.
      27.339.834.8
      Socio-Economic Status (%)
       Income <average wage in the economy25.527.726.8
       Income about the average41.841.041.3
       Income >average wage in the economy32.731.331.9
      Education (%)
      p <.05
       School7.727.319.4
       Bachelor's degree48.155.852.7
       Master's degree/ PhD44.216.927.9
      low asterisk group of Secular/Traditional includes 81% secular and 19% traditional parents.
      low asterisklow asterisk group of Religious/Orthodox includes 88% religious and 12% orthodox parents.
      low asterisklow asterisklow asterisk p <.05

      Intention not to vaccinate child

      More than a quarter (26.6%) of parents reported that they did not intend to vaccinate their child/children with the COVID-19 vaccine. These parents were less educated (the proportion of those having only primary school education was 27.3% vs. 16.7% among others); they were less involved in the healthcare sector (33.3% vs. 42.2%), less religious (proportion of secular/traditional parents among them was 80.6% vs. 59.8%, p =.026). Among these parents, 47.2% did not vaccinate their child/children according to the routine vaccination program of the Ministry of Health (vs. 18.6% among others) (p =.001).
      Other background characteristics (age, gender, family status) did not contribute to the differences between the two groups.
      In the univariate analysis, lower religiosity and nonadherence to the routine vaccination program were associated with the intention not to vaccinate a child with COVID-19 vaccine (OR = 2.79, 95% CI: 1.12–6.96 for secular/traditional vs. religious parents and OR = 3.91, 95% CI: 1.72–8.89 for parents who do not follow the Ministry of Health program for routine vaccination vs. others, respectively). The social influence score was negatively associated with the intention not to vaccinate: elevation of one point in social influence score was associated with 2.5 fold decrease in odds for not vaccinating the child/children (OR = 0.40, 95% CI: 0.20–0.80) (Table 2).
      Table 2Analysis of Intention To Not Vaccinate Child With COVID-19 Vaccine: Results of the Logistic Regression Model.
      Parents` CharacteristicsOdds for not vaccinating the child with COVID-19 vaccine
      Univariate AnalysisMultivariable Analysis
      Odds Ratio (OR)95% CIOdds Ratio (OR)95% CI
      Age0.990.94–1.040.990.94–1.04
      Gender (female vs. male)0.810.37–1.761.480.55–4.03
      Socio-Economic Status (low vs. medium/high)1.840.81–4.171.800.69–4.70
      Number of children aged <18 years (1,2 vs. 3+)1.101.01–1.191.070.96–1.19
      Religiosity (secular/traditional vs. religious)2.791.12–6.961.320.39–4.45
      Profession (work unrelated to healthcare field vs. health professionals)1.460.66–3.231.560.61–3.96
      Vaccination according to Ministry of Health Program

      (no vs. yes)
      3.911.72–8.904.821.83–12.71
      Social Influence Score0.400.20–0.800.310.13–0.73
      In bold: p <.05.
      Multivariable analysis (Table 2) reveals that parents who do not vaccinate their child/children according to the Ministry of Health program for routine vaccination have almost five-fold significant odds not to vaccinate a child with the COVID-19 vaccine (OR = 4.82, 95% CI: 1.83–12.71) independently of other parental characteristics. Other parental demographic characteristics were not associated with the intention not to vaccinate after mutual adjustment.

      Social influence and intention not to vaccinate child with COVID-19 vaccine

      Correlation between all sources of influence on attitudes toward the COVID-19 vaccine was positive and significant. The highest Spearman coefficients exceeded to 0.7 (p <.0001) for correlation between influence of family and friends, 0.6 (p <.0001) for the influence of friends and coworkers, and 0.6 (p <.0001) for the influence of friends and social media. Following the high correlation between the sources of influence and high reliability of the social influence questionnaire, the social influence score was constructed (as explained in the Methods), while the higher score represented higher social influence on attitudes toward COVID-19 vaccination of children. The score was distributed between 1 and 4 with a mean = 1.9 (SD = 0.6) and a median = 2.0 (IQR 1.5–2.3).
      The mean social influence score was higher among parents who intended to vaccinate their child (2.0 vs. 1.7, p =.008). Studying the specific sources of social influences, the difference in the median social influence score between parents who intend to vaccinate a child and those who do not intend was significant for influence of the family, coworkers and media on attitude toward children's vaccination. The mean social influence score was higher among religious parents vs. secular/traditional (2.2 vs. 1.7, p <.0001). The mean social influence score was significantly higher among religious parents for every source, except for social media. Multivariable analysis (Table 2) revealed that the social influence score was negatively associated with the intention not to vaccinate: elevation of one point in the social influence score was associated with three-fold decrease in odds for not vaccinating the child/children (OR = 0.31, 95% CI: 0.13–0.73). After adding to the model social influence score, lower religiosity was no longer significantly associated with the intention not to vaccinate, which may represent a phenomenon of full mediation of the association between religiosity and intention not to vaccinate by social influence. SES, profession, age, and gender were not significantly associated with odds of not vaccinating a child with COVID-19 vaccine. This model explained 26% of variance in intention not to vaccinate the child/children.

      The reasons for indecision and rejection of COVID-19 vaccine

      As shown in Table 3, among the whole sample of parents, 63.8% reported fear of the side effects of the vaccine, 57.7% thought that there was not enough information about this vaccine for children, 54.0% had doubts about vaccinations in general, and 43.5% reported that their hesitation was associated with the fact that the vaccine was too new.
      Table 3The Reasons for Refusal to Vaccinate Children Against COVID-19 (N = 138).
      The reasonsStrongly disagreeDisagreeAgreeStrongly Agree
      % of total population
      Vaccines to be produced for the COVID 19 virus can cause COVID-19 infection.35.054.08.82.2
      I am afraid of the side effects of the vaccine.14.521.742.821.0
      COVID-19 virus is a biological weapon and I think that the vaccine will serve those who produced this virus.44.042.59.73.7
      I don't think it can be reliable as it is the vaccine is too new.22.534.129.713.8
      I don't think that the vaccines produced for corona virus can be effective.29.240.921.98.0
      I don't think I have enough information about the COVID-19 vaccine12.429.933.624.1
      The COVID-19 infection is exaggerated, it is not a risky disease, so no vaccine is needed34.642.616.26.6
      I prefer other ways of protection.24.132.131.412.4
      I will not vaccinate my child as he already had COVID-19 virus.34.647.413.54.5
      I am waiting for vaccination until the child is a little older31.939.322.26.7
      In general, I have doubts about vaccinations.19.027.032.121.9
      Among parents who did not intend to vaccinate a child with the COVID-19 vaccine, 92% worried about possible side effects of the vaccine; 89% reported that their hesitation was associated with the fact that the vaccine was too new, 69% did not believe in its effectiveness, 92% thought that there was not enough information about this vaccine for children, 66% preferred to wait until the child was older, 28% believed that vaccination might cause COVID-19 and 31% thought that as SARS-Cov-2 was invented as a biologic weapon, and the vaccine might serve those who created the virus.

      Parents' views on COVID-19 vaccination of children

      The mean attitude score toward vaccination was distributed between 1 and 4 with a mean = 2.6 (SD = 0.7) and a median = 2.7 (IQR 2.0–3.1). Comparative analysis by intention to vaccinate children revealed interesting findings. As shown in Table 4, among parents who reported their intention not to vaccinate, the mean attitude score was significantly lower in comparison with those who reported intention to vaccinate (mean attitude score 1.7 vs. 2.9, p <.0001 (Table 4). Only the item“COVID-19 vaccine for children may be accompanied by mild side effects such as fever, restlessness” was ranked similarly by both groups. The maximal difference was in two items reflecting the importance of COVID-19 vaccine on individual and social levels: “COVID-19 vaccine for children is important for the protection of my children, but also important for the health of those around my children” and “Vaccinating children against corona will reduce the duration and severity of the disease if my child gets sick”.
      Table 4Difference in Specific Items Of Attitude Toward Vaccination Score Between Parents Who Intend to Vaccinate and Those Who Do Not Intend Vaccinate.
      Number of ItemAttitude toward COVID-19 vaccination questionnaireIntend to vaccinateDo not Intend vaccinatep value of Mann–Whitney U test
      Mean (SD)Mean (SD)
      Overall attitude score2.9 (0.6)1.7 (0.4)<0.0001
      1COVID-19 vaccine is safe for children2.9 (0.8)1.6 (0.6)<0.0001
      2COVID-19 vaccine for children may be accompanied by mild side effects such as fever, restlessness2.7 (0.8)2.5 (1.0)0.562
      3
      coding of items 3, 4 and 9 was reversed.
      I am afraid of the side effects of vaccine2.4 (0.8)1.4 (0.6)<0.0001
      4
      coding of items 3, 4 and 9 was reversed.
      The likelihood of side effects appearing as a result of the COVID-19 vaccine is a reason to avoid it3.0 (0.8)1.7 (0.7)<0.0001
      5COVID-19 vaccine passed safety tests before being marketed for use3.1 (0.7)1.7 (0.7)<0.0001
      6I trust the COVID-19 vaccine for children2.9 (0.8)1.4 (0.5)<0.0001
      7Vaccines are one of the safest medical tools3.1 (0.7)2.4 (0.8)<0.0001
      8Vaccines are an effective and safe tool developed and checked during medical studies3.2 (0.6)2.5 (0.8)<0.0001
      9
      coding of items 3, 4 and 9 was reversed.
      COVID-19 vaccine was too quickly approved as a result of demand and funding2.1 (0.7)1.8 (0.8)<0.0001
      10Despite the speed of approval of a vaccine against Corona, it has passed all the required tests2.9 (0.7)1.6 (0.6)<0.0001
      11COVID-19 vaccine for children is very safe and I am not afraid of harm as a result of using it2.7 (0.8)1.3 (0.5)<0.0001
      12I trust the production process of the COVID-19 vaccine for children2.9 (0.7)1.5 (0.6)<0.0001
      13Even if my child develops a local side effect (redness, pain, swelling) I will know the COVID-19 is safe2.8 (0.7)1.5 (0.7)<0.0001
      14Even if my child develops general side effects (fever, restlessness, vomiting, muscle aches and headaches) I will know the COVID-19 is safe2.8 (0.7)1.4 (0.6)<0.0001
      15Long-term side effects as a result of COVID-19are rare3.1 (0.7)2.0 (0.8)<0.0001
      16The children's vaccination against COVID-19will end the outbreak of an epidemic2.6 (0.9)1.5 (0.6)<0.0001
      17Vaccinating children against the coronavirus is important for protection of the child against COVID-193.1 (0.8)1.8 (0.8)<0.0001
      18COVID-19 vaccine for children is important for the protection of my children, but also important for the health of those around my children3.2 (0.7)1.6 (0.8)<0.0001
      19Vaccinating children against corona will reduce the duration and severity of the disease if my child gets sick3.2 (0.8)1.6 (0.8)<0.0001
      low asterisk coding of items 3, 4 and 9 was reversed.
      Parents who vaccinated their children in the past according to the national program for routine vaccination demonstrated more positive attitudes toward COVID-19 vaccination of children (M = 2.7 vs. M = 2.1, p <.0001). None of parental demographic characteristics were significantly associated with the attitude scores toward COVID-19 vaccine.

      Discussion

      The study aimed at examining parental attitudes toward COVID-19 vaccination of children aged 5–18, the concerns about vaccination and the intention to vaccinate children. In our sample of Israeli Jewish parents, about a quarter reported that they do not intend to vaccinate their children. This percentage is smaller than the proportion reported in an Israeli study from October 2021, in which 43% of parents claimed unwillingness to vaccinate their children against COVID-19 (
      • Shmueli L.
      How many parents are willing to vaccinate their children against Corona? (Hebrew)..
      ). The difference may be explained by the fact that in October, vaccination of children aged 5–11 was only a theoretical issue, while now, during the fifth wave of the pandemic with the advent of highly infectious Omicron variant of the coronavirus, almost 20% of this age group have already been vaccinated (
      • Ministry of Health
      Corona virus in Israel - general situation (Hebrew).
      ). In comparison, the rates of COVID-19 vaccine hesitancy among parents from Shandong and Zhejiang in China were 19.4 and 11.7% (
      • Xu Y.
      • Xu D.
      • Luo L.
      • Ma F.
      • Wang P.
      • Li H.
      • Zheng X.
      A cross-sectional survey on COVID-19 vaccine hesitancy among parents from Shandong vs. Zhejiang.
      ), in Italy 12.4% of parents reported vaccine hesitancy (
      • Bianco A.
      • Della Polla G.
      • Angelillo S.
      • Pelullo C.P.
      • Licata F.
      • Angelillo I.F.
      Parental COVID-19 vaccine hesitancy: A cross-sectional survey in Italy.
      ), in Saudi Arabia 32% of parents reported that they would not vaccinate a child (
      • Temsah M.H.
      • Alhuzaimi A.N.
      • Aljamaan F.
      • Bahkali F.
      • Al-Eyadhy A.
      • Alrabiaah A.
      • Alhasan K.
      Parental attitudes and hesitancy about COVID-19 vs. routine childhood vaccinations: A national survey.
      ).
      The parents' tendency not to vaccinate was mainly related to intrapersonal factors, such as uncertainty and fear of risks associated with introduction of a new vaccine. This was reflected in the rankings of statements that refer to reliability of information about vaccination's influence on children, it's possible side effects and effectiveness. The same reasons for COVID-19 vaccine hesitancy or rejection among adults were found in the systematic review of 209 studies published worldwide (
      • Cascini F.
      • Pantovic A.
      • Al-Ajlouni Y.
      • Failla G.
      • Ricciardi W.
      Attitudes, acceptance and hesitancy among the general population worldwide to receive the COVID-19 vaccines and their contributing factors: A systematic review.
      ).
      After taking into account age, gender, SES, profession and adherence to national routine vaccination program for children (but not the social influence score), the probability of vaccine rejection was significantly higher in our study among parents who were secular or traditional vs. religious. According to Jewish religious principles, a person has a duty to prevent harm to himself and his environment. In light of this orientation, religious and rabbinical organizations support vaccination in general, including childhood vaccination (
      • Keshet Y.
      • Popper-Giveon A.
      “I took the trouble to make inquiries, so I refuse to accept your instructions”: Religious authority and vaccine hesitancy among ultra-orthodox Jewish mothers in Israel.
      ). On the other hand, the religious community in Israel is not monolithic but includes ultra-orthodox communities which tend to extreme segregation from the secular world in general and, in particular, from the rest of Israeli society (
      • Okun B.S.
      Religiosity and fertility: Jews in Israel.
      ) vs. national-religious community which promotes contact with the outside world while maintaining Jewish culture and practices (
      • Be’ery G.
      • Heller E.
      • Cohen C.
      • Lebel Y.
      • Mozes H.
      • Neuman K.
      • Hermann T.
      The national-religious sector in Israel 2014 main findings.
      ). In addition, heterogeneity exists within these religious communities in beliefs or practices (particularly in health-related issues). Thus, lower children's routine vaccination coverage was reported in ultra-orthodox communities of Jerusalem in comparison with other Jewish population groups (
      • Stein-Zamir C.
      • Israeli A.
      Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks, Jerusalem, Israel.
      ). Ultra-Orthodox Jews comprise 13% of the total Israeli population; this community is very young (58% of this population ages 0–19, compared to 30% among Jews who are not ultra-Orthodox) (
      • Malach G.
      • Cahaner L.
      2018 statistical report on ultra-orthodox society in Israel.
      ), making the issue of children` vaccination extremely important. The ultra-orthodox community needs special attention of public health practitioners and considering these needs brings results. Thus a task force was created by the Ministry of Health with the aim of increasing the compliance of the ultra-orthodox community with COVID-19 vaccination. The task force brought together trusted physicians and rabbinic leaders, and succeeded to address the concern about possible side-effects on fertility, which was the main barrier among young ultra-Orthodox women (
      • Rosen B.
      • Waitzberg R.
      • Israeli A.
      • Hartal M.
      • Davidovitch N.
      Addressing vaccine hesitancy and access barriers to achieve persistent progress in Israel’s COVID-19 vaccination program.
      ;
      • Schroeder H.
      • Numa R.
      • Shapiro E.
      Promoting a culturally adapted policy to deal with the COVID-19 crisis in the Haredi population in Israel.
      ). In this study the ultra-orthodox community was not well represented (only 4% of parents in the sample defined themselves as ultra-orthodox). Thus, religious parents in our sample represent the national-religious community, which is more open to new trends and to what the world has to offer (
      • Be’ery G.
      • Heller E.
      • Cohen C.
      • Lebel Y.
      • Mozes H.
      • Neuman K.
      • Hermann T.
      The national-religious sector in Israel 2014 main findings.
      ). This religious community is less studied concerning vaccine hesitancy, probably because it is not at high risk for vaccination hesitancy as is the ultra-orthodox community.
      Seeking the consultation of the religious leader (Rabbi) is highly acceptable in Jewish religious communities. For example, 63–77% of religious parents of sick children reported approaching their Rabbi to get medical advice (
      • Shuper A.
      • Zeharia A.
      • Balter-Seri J.
      • Steier D.
      • Mimouni M.
      The paediatrician and the rabbi.
      ). In this study the mean influence score for Rabbi or community leader as having influence on attitude toward children's vaccination was significantly higher than among secular/traditional parents representing a strong intrapersonal factor among this community. Taking into account effort which had been made by public health professionals to enlist the support of religious leaders to vaccination program, this finding may at least partially explain the difference between religious and secular parents in our study in intention not to vaccinate, which was higher among the secular parents.
      In general, religious groups in Israel are characterized by a strong sense of commitment to the community. For the religious person, affiliation to a religious community is considered a key mechanism in promoting well-being since it provides people with a social identity and a sense of belonging, and also allows access to essential information, social activities, and social support (
      • Russo-Netzer P.
      • Bergman Y.S.
      Prioritizing patterns and life satisfaction among ultra-orthodox Jews: The moderating role of the sense of community.
      ). That may explain why after we included social influence in the multivariable analysis, religiosity was no longer significantly associated with intention not to vaccinate a child. Healthcare policy makers should take these cultural aspects and tendencies into account when planning programs to increase population adherence to vaccination programs in general and the COVID-19 vaccination campaign in particular. Social influences are a primary factor in the adoption of health behaviors (
      • Smith K.P.
      • Christakis N.A.
      Social networks and health.
      ). Compliance with diet, adherence to preventive screening recommendations, and maintenance of exercise routines all can depend on having contact with friends and family who also engage in these behaviors. Being a part of religious community was previously found as a protective factor against overall mortality: after accounting for individual and area SES, men and women living in religiously affiliated neighborhoods had lower mortality rates than those living in unaffiliated areas (
      • Jaffe D.H.
      • Eisenbach Z.
      • Neumark Y.D.
      • Manor O.
      Does living in a religiously affiliated neighborhood lower mortality?.
      ).The authors believe that the link between affiliation to a religious community and better health outcomes goes through promotion of healthy behaviors and attitudes, reduction of stress, and the formation of strong social bonds, all of which are strongly related to physical and mental wellbeing (
      • Jaffe D.H.
      • Eisenbach Z.
      • Neumark Y.D.
      • Manor O.
      Does living in a religiously affiliated neighborhood lower mortality?.
      ).
      Adherence to Ministry of Health vaccination program for children was found to be another important factor significantly associated with the intention to vaccinate against COVID-19, while parents who were adherent to the routine vaccination program were also the ones who intended to vaccinate their child/children with the COVID-19 vaccine. This finding supports the previous evidence that parents tend to make the decision to vaccinate their children with a newly developed vaccine based upon attitudes and perceptions toward established vaccines (
      • Hetherington E.
      • Edwards S.A.
      • MacDonald S.E.
      • Racine N.
      • Madigan S.
      • McDonald S.
      • Tough S.
      SARS-CoV-2 vaccination intentions among mothers of children aged 9 to 12 years: A survey of the all our families cohort.
      ;
      • Humble R.M.
      • Sell H.
      • Dubé E.
      • MacDonald N.E.
      • Robinson J.
      • Driedger S.M.
      • MacDonald S.E.
      Canadian parents’ perceptions of COVID-19 vaccination and intention to vaccinate their children: Results from a cross-sectional national survey.
      ;
      • Lackner C.L.
      • Wang C.H.
      Demographic, psychological, and experiential correlates of SARS-CoV-2 vaccination intentions in a sample of Canadian families.
      ). Correspondingly, (
      • Goldman R.D.
      • Yan T.D.
      • Seiler M.
      • Parra Cotanda C.
      • Brown J.C.
      • Klein E.J.
      • Staubli G.
      Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.
      ) and (
      • Temsah M.H.
      • Alhuzaimi A.N.
      • Aljamaan F.
      • Bahkali F.
      • Al-Eyadhy A.
      • Alrabiaah A.
      • Alhasan K.
      Parental attitudes and hesitancy about COVID-19 vs. routine childhood vaccinations: A national survey.
      ) reported that parents whose children were up-to-date on their scheduled vaccines were more willing to vaccinate their children against COVID-19.
      In this study, healthcare workers were not statistically different from other parents in their intention to vaccinate children with COVID-19 vaccine or in their attitudes toward the COVID-19 vaccination. Healthcare workers would be expected to have more positive attitudes toward primary prevention strategies such as vaccination than the general population. An Italian study showed that physicians expressed higher willingness to receive vaccination against COVID-19 (
      • Di Giuseppe G.
      • Pelullo C.P.
      • Della Polla G.
      • Montemurro M.V.
      • Napolitano F.
      • Pavia M.
      • Angelillo I.F.
      Surveying willingness toward SARS-CoV-2 vaccination of healthcare workers in Italy.
      ). There is evidence that shows a disappointing trend of vaccine hesitancy among healthcare workers; in a Chinese study of 1332 doctors and nurses who had at least one child under the age of 18, only 44.5% reported that they would likely or very likely have their children under the age of 18 years take the COVID-19 vaccination (
      • Wang Z.
      • She R.
      • Chen X.
      • Li L.
      • Li L.
      • Huang Z.
      • Lau J.T.F.
      Parental acceptability of COVID-19 vaccination for children under the age of 18 years among Chinese doctors and nurses: A cross-sectional online survey.
      ). The acceptance rate of Covid-19 vaccine among the general population (81.65%) was higher than that among healthcare workers (65.65%) (
      • Wang Q.
      • Yang L.
      • Jin H.
      • Lin L.
      Vaccination against COVID-19: A systematic review and meta-analysis of acceptability and its predictors.
      ). Healthcare workers have a high rate of COVID-19 vaccination hesitancy: 4.3 to 72% (average = 22.5% across all studies with 76,471 participants worldwide) (
      • Biswas N.
      • Mustapha T.
      • Khubchandani J.
      • Price J.H.
      The nature and extent of COVID-19 vaccination hesitancy in healthcare workers.
      ). The majority of the studies found concerns about vaccine safety, efficacy, and potential side effects as top reasons for COVID-19 vaccination hesitancy among healthcare workers. As healthcare workers should be role models for disease prevention and they play important roles in reducing the burden of the pandemic, special communication and education strategies should be built specifically for this important population.

      Practice implications

      This study adds new and important information, which is needed for healthcare professionals in Israel and other countries in their effort to reach high anti-COVID-19 vaccination coverage. Thus, this study found that interpersonal factors such as vaccination in the past as part of routine government immunization programs and positive attitudes toward vaccines in general and new COVID-19 vaccines in particular, predict a tendency to vaccinate children during the pandemic. Public health practitioners should address vaccine hesitancy in relation to routine vaccines. There are recommended approaches which can be used, such as motivational interviewing techniques to provide public health practitioners tools for work with vaccine-hesitant parents (
      • MacDonald N.
      • Desai S.
      • Gerstein B.
      Working with vaccine-hesitant parents: An update.
      ;
      • Velan B.
      Vaccine hesitancy as self-determination: An Israeli perspective.
      ).
      Additionally, our study emphasized the importance of acknowledging and targeting those parental beliefs and attitudes which highly related to parental intention not to vaccinate against Covid-19, in particular the concerns and uncertainty about the necessity of the vaccine, its side effects and reliability have been emphasized. This study draw attention to cultural-religious characteristics as playing an important role in shaping public opinion regarding vaccines and the decision to vaccinate children. When planning campaigns to increase vaccination for children, a comprehensive explanation of scientific validity and the side effects of the new vaccine should be provided together with an explanation of the risks of developing the disease in children as well as infecting others who may be at risk for serious morbidity and mortality. Cultural-religious adjustments should be applied when planning and implementing interventions and campaigns of this kind.
      This study underlined the importance of different sources of influence as creating attitudes toward vaccination. Public health professionals should think about platforms which will make it possible to incorporate those parents who have vaccinated their children and have a positive attitude toward vaccination. It is important to provide the opportunity for these parents to share their opinions and even become “ambassadors” of vaccination in both their interpersonal relationships and social networks, since social influence has an important place in adopting a positive attitude toward vaccines. Rabbinical support of vaccination is crucial for increase in vaccination rates of children in religious communities.
      Special focus should be given in future studies to unravel the way to improve attitudes toward COVID-19 vaccination among healthcare workers. As previous studies showed, healthcare workers are worried about the same vaccine-related issues as other participants. As rates of COVID-19 vaccination hesitancy in this population are high worldwide, education and policy-based interventions should be urgently aimed at this group to ensure their vaccination with the available COVID-19 vaccines. High compliance for COVID-19 vaccination among healthcare workers is crucial for the general public health.

      Limitations

      The limitations in this study may be related to the study sample characteristics and selection bias. First, a snowball sample limits the generalizability of the study findings; thus, ultra-orthodox parents were not represented in the sample. Generally, 64% of ultra-orthodox community used the internet in 2020 (compared to 93% among other Jewish Israelis) (
      • Malach G.
      Two thirds of ultra-orthodox are online.
      ). Therefore, the recruitment of participants from ultra-orthodox community through the Internet may be limited. On another hand, the sample represented all SES levels and almost all main religious Israeli subgroups.
      Second, the relatively small sample size may affect the reliability of the findings, e.g. difference between healthcare workers and other participants could not reach statistical significance.
      Third, the sample represents only the Jewish Hebrew-speaking population. Future studies require an extension of the examination to additional populations that speak Arabic (Muslim or Christian Arabs), Russian (immigrants from Russia and Former Soviet Union countries) and Amharic (immigrants from Ethiopia).
      Finally, recall and social-desirability biases in relation to routine vaccination of the child could distort the findings. On the other hand, previous studies found that the history of child vaccination was accurately identified through maternal recall and concluded that it might be used to estimate the vaccination coverage (
      • Binyaruka P.
      • Borghi J.
      Validity of parental recalls to estimate vaccination coverage: Evidence from Tanzania.
      ;
      • Hu Y.
      • Chen Y.
      • Wang Y.
      • Liang H.
      Validity of maternal recall to assess vaccination coverage: Evidence from six districts in Zhejiang Province, China.
      ). The complete anonymity of this study decreases the possibility of a social-desirability bias (
      • Lelkes Y.
      • Krosnick J.A.
      • Marx D.M.
      • Judd C.M.
      • Park B.
      Complete anonymity compromises the accuracy of self-reports.
      ).

      Conclusions

      The study's findings highlight the importance of parents' attitudes regarding vaccines as a key to advancing children's immunization programs in routines and emergencies. Vaccination is a safe and effective tool in preventing COVID-19 in children, who may not only spread the virus in the population but also develop prolonged clinical symptoms (known as “long COVID”). Thus, every effort should be made to improve parental compliance with vaccination.

      CRediT authorship contribution statement

      Bella Savitsky: Resources, Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft. Rachel Shvartsur: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Ilya Kagan: Project administration, Supervision, Resources, Writing – review & editing.

      Conflict of interest statement

      All authors approve that they do not have any financial and personal relationships with other people, or organizations, that could inappropriately influence (bias) this research and this manuscript.

      Acknowledgements

      We would like to thank the students who studied in the Research Seminar course in the nursing department at Ashkelon Academic College: Anna Arutyunyan, Hagit Shvartzer Asaf, Anastasia Kulover, Miriam Schreiber, Emilia Cooper and Shoshan Margalit. We wish to thank Susan Holzman for her highly professional editing advice and her valuable and kind support on this project.

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