Achieving high uptake rates among primary school children has been challenging in most countries including the Philippines where only 38.2% of children aged 5–11 years completed the primary vaccine series.4,11 In this study, we found that the key social and behavioral drivers of COVID-19 pediatric vaccination were protection against COVID-19 disease, government regulations and healthcare worker recommendations, with non-vaccination driven by vaccine safety and child age and preference to be vaccinated. Regardless of the child’s COVID-19 vaccination status, the DOH remained the leading source of information, with local authorities, health centers, and healthcare workers also important sources of vaccination.
In this study, only a quarter of caregivers (26.2%) had at least one child vaccinated against COVID-19, with protection against infection being a driver of vaccine acceptance. Findings were similar in other countries where it was commonly perceived that COVID-19 vaccines reduce disease severity for children, particularly for those with underlying health conditions.17–22 Most of these caregivers expressed high vaccine confidence (79%), high perceived benefit (81.1%) and need of vaccination for their children (78.3%). Their motivations and perceptions on vaccination may be attributed to the effective information dissemination from the DOH, LGU/health centers and HCWs, and mass media outlets including television, radio, and newspaper. In other countries, health advisories and information shared by government agencies and HCWs are also relied upon as credible sources.17–19,23,24 To comply with restrictions and regulations by the government and institutions, caregivers had their children vaccinated to facilitate their return to school, enable travel, and engage in social activities.17,22 HCWs can also influence decision making on vaccination due to their credibility and their ability to foster trusting relationships with caregivers through empathy and understanding.25,26
We found that caregivers belonging to the 30–45 year-old age group were three times more likely to have a child vaccinated compared to parents 18–29 years. Since children aged 5 to 11 years were eligible for COVID-19 vaccination in the Philippines, it was likely that their caregivers were slightly older and more aware of the benefits of vaccination. Similar to other studies, these age groups of primary caregivers had higher intention to vaccinate their children against COVID-19 compared to young adult caregivers.27–31 Caregivers perceive their younger children to be more prone to the side effects of vaccination.31–33 Moreover, younger caregivers were more likely to critically appraise vaccines, carefully considering various factors before making an informed decision.34 Although careful appraisal of the benefits and risks of vaccines does not inherently lead to vaccine hesitancy, there is a need for further research on how different demographics engage with, interpret, and evaluate vaccination information. In addition, perceived need for vaccines was a factor of vaccination uptake. High perceived need was found to be an enabler in this study, while low perceived need was a barrier, albeit insignificant. Recent research has highlighted the impact of low complacency, defined as the belief that COVID-19 vaccination is unnecessary, as a powerful influence on parental decisions regarding uptake of COVID-19 vaccination for their children.35 Furthermore, significant associations between complacency and vaccine hesitancy were identified in another study.36
Vaccine safety and fear of side effects was a major concern amongst parents of unvaccinated children (72.3%). A significant proportion of caregivers expressed low vaccine confidence (35.7%). This distrust may still be related to the Dengvaxia controversy in 2017, which led to public panic, anxiety, and diminished confidence in Dengvaxia and other vaccines, including routine childhood and COVID-19 vaccines.37,38 Safety concerns including fear of potential side effects such as fever, headache, muscle pain, fatigue, fertility issues, myocarditis, and even death were commonly reported as reasons for parental hesitancy to have their child vaccinated against COVID-19.12,22,39–41
Additionally, children not wanting to get vaccinated and children being sick were also frequent reasons for non-vaccination in this study. In other countries, respect for child’s autonomy and presence of comorbidities in children were considered in parental decision-making regarding vaccination, which can lead to vaccine hesitancy.19,22,32,42 Further, a notable proportion showed low perceived need, probably attributable to low perceived threat to COVID-19, low perceived risk for children, and non-requirement of vaccination to schools.12,43–45 Vaccinated caregivers may also no longer perceive vaccination as a necessity for their children since they themselves have already received the vaccines. These perceptions may also be an impact of mass media outlets, which were among the leading sources of information for these caregivers. Due to the proliferation of misinformation, there is an urgent need to combat fake news and promote accurate and reliable information on vaccines.
The findings of this study have several implications for improving delivery of pediatric COVID-19 vaccines. In particular, health promotion and education materials need to focus on the benefits of COVID-19 vaccines. This can be done by incorporating real-life stories and narratives instead of focusing solely on COVID-19 facts and statistics.46 Such information may positively influence the perceived need of caregivers to vaccinate their children. To address the distrust in vaccine safety/fear of side effects, enhancing risk communication focusing on the benefits and risks of vaccination through ongoing capacity training of HCWs, peer educators, and community leaders. Furthermore, strategies to improve health service delivery may include flexible opening hours, especially for working parents, and coadministration of pediatric COVID-19 vaccines with other childhood vaccines.29
Some limitations were identified in this study. Non-selection of all regions in the Philippines due to logistical constraints may have affected the national representativeness of the study. Additional data on sociodemographic characteristics of caregivers, including the number of children aged 5–11 years in the household, and verified data on the COVID-19 vaccination status of each child in the household would have enriched the study findings. Social desirability bias may have impacted parental reporting as researchers assisted the respondents to answer the questions face to face.