Parental coronavirus disease vaccine hesitancy for children in Bangladesh: a cross-sectional study

Ethics statements

The Institutional Review Board of Uttara Adhunik Medical College and Hospital approved this study (Approval number: UAMC-IRB-2021/09). Written informed consent both for participation and publication of data was obtained from all participants.

Study design and participants

This cross-sectional study was conducted in Bangladesh from October 10, 2021, to October 31, 2021. A margin of 2% error, a confidence level of 95%, and a response distribution of 50% were used to calculate the sample size to target fathers/mothers of 80 million children and obtain a minimum sample size of 2401 participants.^19,20 Approximately 3000 parents aged ≥18 years with children aged <18 years who permanently live in Bangladesh were conveniently invited to participate in an individualized interview session using a previously employed vaccine hesitancy questionnaire.^10,21,35 We received data from 2703 parents, as a result of a 10% refusal rate. However, 36 parents did not answer all the questions, thus were excluded. We also excluded 34 data points for the contradicting answers to the question. These exclusions meant that, only 2633 respondents were included in the final analysis.³⁵

Study questionnaire

In the first part of the questionnaire, participants were queried regarding parental vaccine hesitancy and perceived COVID-19 threat. First, parents were asked about the likelihood of vaccinating their youngest children. Parental vaccine hesitancy, the dependent variable and a vital outcome of the study, was measured using the question, “If a vaccine that would be effective against coronavirus disease among children was available, how likely are you to get your children vaccinated?” (response options: very likely, somewhat likely, not likely, and definitely not). Second, participants were asked two questions regarding the perceived COVID-19 threat: (1) “How likely is it that your children or a family member could get infected with coronavirus in the next year?” (response options: very likely, somewhat likely, not likely, and definitely not). (2) “How concerned are you that your children or a family member could get infected with coronavirus in the next year?” (response options: very concerned, concerned, slightly concerned, and not concerned at all).

The second part of the questionnaire included a wide array of sociodemographic questions for both children and parents. A set of structured questions assessed the child's health (healthy/disabled), age, and sex. Information on parents' sex, age, religion, current marital status, education, employment status, monthly household income (Bangladeshi taka), permanent address, and region of residence (north, south, and central zones in Bangladesh, including Dhaka), current residence type (own/rented/others), family type (nuclear or extended, number of children, current tobacco use status, religious practice habits, and political affiliation was collected. Additionally, parents were asked some additional COVID-19 vaccine-related questions: “Do you think the COVID-19 vaccine will be effective among Bangladeshi children?” (response options: no, yes, or skeptical), “Have you received or plan to receive the COVID-19 vaccine,” “Did you or your family member(s) test positive for COVID-19,” and “Have you lost any of your family member(s) to COVID-19?” The last three questions received dichotomous (yes or no) answers.

Sampling technique and data collection

Data was collected from all eight divisions of Bangladesh. A dual-stage cluster sampling technique was used to include potential samples for this study. We randomly chose marketplaces, shopping malls, waiting rooms of large hospitals, diagnostic centers, bus and rail stations, and residences and processed them as a cluster in the first stage. To obtain data from the parents of a child with a disability, we also visited randomly selected centers for disabled children. The list of given data collection sites was collected from the divisions' websites. In the second stage, we chose participants conveniently. Data from only the father or mother of a child were taken from a family with children to avoid repeating data.

Eight teams of two persons were created. A team member read the questions aloud to the interviewees individually. Acceptable options were asked and recorded in the question paper. Subsequently, the answers were checked and confirmed by the second team member. The coinvestigator reviewed the data collection sheets for completeness, accuracy, and internal consistency and secured them with the principal investigator. Individual face-to-face interviews were conducted to ensure the participants' privacy. All participants were informed of the voluntary nature of their participation, and the interviews were conducted in Bangla.

Statistical analysis

The crucial outcome of this study was vaccine hesitancy. We dichotomized the four responses to the vaccine hesitancy question as either a positive (very likely and somewhat likely) or a negative (not likely and definitely not) attitude towards the COVID-19 vaccine. The Fisher exact test was used for two nominal variables, and chi-square test was used for more than two nominal variables to assess vaccine hesitancy rates and draw comparisons between the groups. Binary logistic regression analyses were performed to identify the predictors of parental COVID-19 vaccine hesitancy and compute adjusted odds ratios (AORs) with a 95% confidence interval (CI). Factors significantly associated with vaccine hesitancy in the descriptive analysis were included in the regression model. A goodness-of-fit test for the adjusted logistic regression model was performed using the Hosmer-Lemeshow test. The significance level was set at p<0.05, and SPSS (version 22.0; IBM Corp; RRID: SCR_002865) was used to perform all data analyses.

Parents and children's characteristics

Overall, 2633 parents aged 34.97±7.87 years (mean±standard deviation) were included in the analysis, with 52.8% (1390) being women. In total, 396 (15%) parents of children with a physical disability were included. Among the children, 1372 (52.1%) were boys, and 1206 (45.8%) were in the 0–4-year-old group. Most parents (653, 24.8%) were in the 31–35-year-old group. Overall, 2358 (89.4%) parents were Muslim, 1791 (68%) were a nuclear family member, 1075 (40.8%) had two children, 1022 (38.8%) had a low education level, 756 (28.7%) were homemakers, and 833 (31.6%) had a low-middle household income. Among all participants, 1528 (58%) were from the village, 1323 (50%) were living in the central zone, including Dhaka, 1695 (64.4%) were tobacco non-users, 1797 (68.2%) were regular religious practitioners, and 1032 (39.2%) were politically neutral respondents. A total of 177 (6.3%) parents did not adhere to the regular government vaccination programs other than COVID-19, and 1458 (55.4%) remained skeptical about COVID-19 vaccine effectiveness for Bangladeshi children. Furthermore, 722 (27.4%) parents were either not vaccinated or did not receive the COVID-19 vaccine; however, 752 (28.6%) parents reported that they or their family members tested positive for COVID-19, and 151 (5.7%) lost a loved one to COVID-19. Details of the responses to the questions regarding the likelihood of children or family members' infection by COVID-19 and the level of concern about children or family members' disease in the next year are shown in Table 1.

Results of descriptive analysis

Overall, 42.8% of parents reported hesitancy towards the COVID-19 vaccine for their youngest child. Closer analysis revealed that 26.05% of parents were very likely, 31.18% were somewhat likely, and 36.31% were not likely to vaccinate their child. While only 6.46% were definitely not vaccinating their child against COVID-19 (Figure 1). The incidence of vaccine hesitancy was significantly high among the parents of 0–4-year-old children (53.8%; p=0.000), parents of girls (46.7%; p=0.000), young parents (54.5%; p=0.000), Muslims (45.4%; p=0.000), parents who received college education (53.2%; p=0.000), unemployed parents (73.7%; p=0.000), parents with a household income of <৳15 000 (50.2%; p=0.000), those who lived in their own house (45%; p=0.030), came from a village (45%; p=0.000), lived in the north zone (51.2%; p=0.000), tobacco users (47.7%; p=0.000), and parents politically affiliated with opposition parties (59.1%; p=0.000). Similarly, participants who did not vaccinate or will not vaccinate their child with regular vaccines (other than COVID-19) available under government programs (58.2%; p=0.000), those who did not believe in the effectiveness of the COVID-19 vaccine for Bangladeshi children (90%; p=0.000), and those who did not or will not receive the COVID-19 vaccine for themselves (88%; p=0.000) showed high vaccine hesitancy. Parents who were not likely to believe that their children or a family member could be infected with COVID-19 in the next year (71.7%; p=0.000) and those not concerned about their children or a family member getting COVID-19 in the next year (66.2%; p=0.000) showed high levels vaccine hesitancy (Table 1).

Figure 1. Likelihood of COVID-19 vaccine acceptance/refusal by Bangladeshi parents for children aged <18.

Results of regression analysis

Subgroups with statistically significant higher odds of vaccine hesitancy were found to be parents of children aged 0–4 years (AOR=5.87, 95% CI=2.91–11.85; p=0.000), parents aged 26–30 years (AOR=2.73, 95% CI=1.04–7.16; p=0.035), Muslims (AOR=24.27, 95% CI=2.36–248.74; p=0.007), unemployed parents (AOR=2.94, 95% CI=1.35–6.41; p=0.007), parents with a household income of <৳15 000 (AOR=1.49, 95% CI=0.962–1.84; p=0.009), those from a semi-urban area (AOR=1.61, 95% CI=1.09–2.38; p=0.016), lived in the north zone (AOR=3.71, 95% CI=2.37–5.82; p=0.000), did not vaccinate or will not vaccinate their child with regular vaccines (other than COVID-19) available under government programs (AOR=1.93, 95% CI=1.19–3.14; p=0.007), did not believe in the effectiveness of COVID-19 vaccine for Bangladeshi children (AOR=5.80, 95% CI=3.12–10.78; p=0.000), and did not or will not receive the COVID-19 vaccine for themselves (AOR=10.15, 95% CI=7.16–14.39; p=0.000).

Contrarily, participants who were non-tobacco users (AOR=0.71, 95% CI=0.53–0.96; p=0.025), appeared to be very likely to believe that their children or a family member could be infected with COVID-19 in the next year (AOR=0.21, 95% CI=0.97–0.44; p=0.000), and very concerned about their children or a family member contracting COVID-19 in the next year (AOR=0.34, 95% CI=0.21–0.58; p=0.000) had significantly lower odds of COVID-19 vaccine hesitancy (Table 2).

Strengths and limitations

This is the first study to reveal the rate of parental vaccine hesitancy for children in Bangladesh. This study included parents' data from all eight divisions of Bangladesh by randomly selected data collection sites; 52% women, 10% Hindu parents, and 1% other non-Muslim parents participated, providing a good representation of the population. Additionally, we conducted anonymous face-to-face interviews to reduce social desirability bias, minimize non-response, and maximize the quality of collected data. Data from parents of children with disabilities have also increased the generalizability of our findings.

Nevertheless, this study has several limitations. Previous studies have found that vaccine hesitancy is complicated, time and location vary, and adherence-specific matter depends on the perceived behavioral nature of the community.^31–33 We conducted this study when the COVID-19 detection rate in the community was significantly lower than it has been, which may have influenced the perceived threat of the disease and the vaccine hesitancy rate. This study did not measure social and traditional media influences, which may have confounded the results.³⁴ Lastly, our questionnaire did not include questions specific to attitudes, beliefs, or mistrust about the vaccine.

Underlying data

Open Science Framework: Parental coronavirus disease vaccine hesitancy for children in Bangladesh: a cross-sectional study. https://doi.org/10.17605/OSF.IO/43G5M³⁵

The project contains the following underlying data:

Extended data

Open Science Framework: Parental coronavirus disease vaccine hesitancy for children in Bangladesh: a cross-sectional study. https://doi.org/10.17605/OSF.IO/43G5M³⁵

The project contains the following extended data:

Reporting guidelines

Open Science Framework: Parental coronavirus disease vaccine hesitancy for children in Bangladesh: a cross-sectional study. https://doi.org/10.17605/OSF.IO/43G5M³⁵

This project contains the following reporting guidelines checklist:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).