The attitude and knowledge of pediatricians and family physicians toward COVID-19 vaccination in children: A cross-sectional study

ABSTRACT

COVID-19 vaccines to children are expected to reduce the transmission of the disease to high-risk groups and achieve herd immunity in younger populations. A positive attitude toward COVID-19 vaccination in children among healthcare workers (HCWs) is predicted to reduce parents’ hesitancy to vaccinate their children. This study aimed to assess the knowledge and attitude of pediatricians and family physicians toward COVID-19 vaccination in children. A total of 112 pediatricians and 96 family physicians (specialists and residents) were interviewed to assess the level of knowledge, attitude, and perceived safety of COVID-19 vaccines for children. Physicians willing to receive regular COVID-19 vaccination (analogous to the influenza vaccine) had significantly higher knowledge and attitude scores (P < .05). Multivariate analysis indicated that a higher knowledge score and having at least five years of experience as a specialist were significantly associated with a positive attitude among pediatricians or family physicians (P < .05). Pfizer/BioNTech was the preferred COVID-19 vaccine in children among physicians of both groups (>67%). Around 71% of physicians believed COVID-19 vaccines for children do not cause or worsen any health condition. Educational and training programs that increase the knowledge of physicians about COVID-19 vaccines and their safety in children are recommended to inform a more positive attitude.

Introduction

During the COVID-19 pandemic, several measures were in effect to slow down the spread of the disease and prevent the straining of the healthcare systems. At the beginning of the pandemic, the primary methods were non-pharmaceutical interventions (NPIs), which included physical distancing, travel restrictions, stay-at-home recommendations, and the closure of public and educational institutions.^1–3 Evidence from several countries has shown that these measures could be effective in reducing the incidence and prevalence of COVID-19.^4–6 However, it was quickly realized that sustaining NPIs for extended periods of time is practically impossible to achieve and is associated with dire consequences on the economy, education systems, and mental health.^7,8 Mass public vaccination was thus considered the most effective strategy to control the COVID-19 pandemic and was later recommended by the World Health Organization (WHO) and adopted by the majority of countries worldwide.^9,10

Although evidence supports that COVID-19 vaccine is effective and safe in children, an overview of the epidemiology of the majority of COVID-19 variants discovered to date indicates that children and adolescents usually develop milder symptoms compared to adults affected with the same viral strain.¹¹ Nonetheless, the administration of COVID-19 vaccine to children was advocated by the WHO and other international and local public health authorities.^12,13 This was justified by the notion that vaccinating children will protect those with the risk of developing severe disease. Moreover, this measure is predicted to reduce SARS-CoV-2 transmission to adults and reduce the need for the closure of educational institutions in the event of any new wave.^12,14 In Jordan, by the 3^rd of January of 2023, 47.26 individuals per 100-population were vaccinated with at least one dose of a COVID-19 vaccine while only 6.69 individuals per 100 population received a booster dose.¹⁵ The same dataset showed that COVID-19 vaccine was not administered to any child in the age range of 5 to 12 years old.¹⁶

A few studies explored the acceptance of the public to vaccinate children,^17–19 with the majority of these studies demonstrating a high degree of hesitancy among the participants. The major reasons behind the above finding were the perceptions that (a) COVID-19 does not affect children, and (b) COVID-19 vaccines are generally unsafe.^16,20

A review of relevant literature shows that several factors were associated with a more positive attitude toward COVID-19 vaccination in children. These factors included a higher degree of knowledge of COVID-19 disease and its variants and the presence of a positive attitude toward the safety of vaccines in general.²¹ It is interesting to note that the way these factors affect the attitude of Health Care Workers (HCWs) including physicians, nurses, and paramedical staff, toward COVID-19 vaccines in children remains inconclusive, making it a rich area for investigation. In this context, studies have shown that vaccine hesitancy among HCWs will have a negative effect on vaccine recommendation by the physicians themselves.^21–24 Likewise, a study performed by Alsulaiman et al. showed that the trust of HCWs in vaccines positively affected the decision of the parents to vaccinate their children.¹⁶

The success of any COVID-19 vaccination program for children depends on many factors. One important factor is the effective communication of evidence that demonstrates vaccine efficiency and safety to parents and other caregivers.^25,26 This requires that physicians who are likely to be consulted on vaccines by parents, such as family medicine physicians and pediatricians, are well informed of vaccines in general, and the COVID-19 vaccine in particular.

A number of studies indicated that Health Care Workers (HCWs) may display a low rate of COVID-19 vaccine acceptance.^27–29 Several reasons could interpret these findings. For example, Kukreti et al. suggested that a general perception of a low health risk associated with COVID-19 infection explains the low acceptance rate among HCWs reported in their investigation.²⁸

Attitude toward COVID-19 vaccine could be affected by the level of relevant knowledge about COVID-19 vaccine. Kotecha and colleagues demonstrated that HCWs with less than 5-years work of experience and those with lower levels of knowledge of COVID-19 were more likely to express a negative attitude toward the vaccine.²⁷

One important factor that may contribute to vaccine hesitancy among HCWs is the fear of side effects.³⁰ Indeed, HCWs reported that the fear of short and long-term adverse events of COVID-19 vaccine was a major reason for vaccine denial.^31,32 HCWs also reported that the fear of side effects was one of the factors behind their decision of not recommending the COVID-19 vaccine for their patients.³¹ In fact, antivaccination campaigns, conspiracy theories and misconceptions about the side effects of the vaccine, including a presumed negative effect on fertility, have all contributed to vaccine hesitancy worldwide.^33–35

Based on the above, it is essential to evaluate physicians’ perception, knowledge and attitude toward COVID-19 vaccine for children prior to the initiation of any vaccination program. Such an evaluation will reveal any gaps in the knowledge of targeted physician groups. The results of such an evaluation are expected to aid public health policymakers in designing appropriate training programs to mend any knowledge gaps prior to the implementation of any vaccination program.

This study was cross-sectional in design and used structured interviews to assess the attitude and knowledge of COVID-19 vaccine for children in a sample of family physicians and pediatricians in Jordan. Considering that fear of side effects was found in relevant literature to be one of the major contributing factors to vaccine hesitancy among all community sectors including HCWs, this study also assessed the concerns of surveyed HCWs of any potential side effects of COVID-19 vaccine in children.

Materials and methods

Study design and participants

This study was cross-sectional in design. Jordan witnessed four waves of COVID-19, and the study was performed during the fourth wave between the months of January and March of 2022.³⁶ At the time the research team started to collect data, it was estimated that 14,069 individuals have passed away due to COVID-19 according to official statements issued by the Ministry of Health in Jordan.^36,37 The study was first approved by the Institutional Review Board of Jordan University of Science and Technology (Protocol ID: 20220527). The target population was pediatricians and family physicians registered under Jordanian Medical Association. Relevant literature indicated that 85% of surveyed pediatricians and 64.4% of surveyed family physicians recommended the COVID-19 vaccine for their patients.^38,39 These proportions were entered into EpiCalc 2000 software (version 1.02)⁴⁰ (http://www.brixtonhealth.com/epicalc.html) to estimate a minimum sample size for each group at a level of significance of 0.05 and a power of 80%. A minimum sample size of 68 physicians in each group was calculated under the assumptions above.

The Jordan Medical Association database was queried for specialists or residents in pediatrics or family medicine. A random sample was identified using registration ID number of the specialists or residents. A total of 150 pediatric specialists or residents and another 150 family physicians or residents were invited to participate in the study.

Physicians who agreed to participate in the study were later interviewed by two senior medical students from JUST. In order to minimize data collection errors and assure the collection of non-biased data, the two students above were trained on face-to-face interviewing by experienced research coordinators prior to data collection. The interviews took place at the workplace of each participant, either in hospitals or in primary care centers. Specifically, interviews were conducted in the personal office of the physician or in general meeting rooms which normally host departmental meetings. The interviewer started the meeting with the physician with a statement indicating that the study aims to assess the attitude and knowledge of COVID-19 vaccination in children and that the study findings may help inform public health policy in Jordan. It also stressed that participation is voluntary and confidential. The participants were then requested to sign a consent form prior to collecting the response of the participant to each of the survey statements. The physicians who did not accept the invitation of the research team to attend the interview and complete the survey listed several reasons including the presence of a large number of scheduled patient visits on the day of the interview or being overwhelmed with administrative duties.

Study instrument

A structured questionnaire was developed by reviewing relevant literature.^{13,15,16,41–45} The questionnaire was initially assessed and reviewed by the research team, then it was piloted to test the questionnaire under survey conditions. Pilot responders to the questionnaire were not members of the research team and were not included in the final analysis presented in this report.

The questionnaire consisted of five sections. The first section collected data related to the general characteristics of the study participants, including the gender, marital status, specialty, job title, and years of experience of the participants in their current job title (only if they were specialists). Years of experience were calculated starting from the day the physician obtained the relevant Jordanian board in Pediatrics or Family Medicine. This was followed by a statement that queried if the participant had any children. The final statement of this section queried the willingness of the participant to receive a COVID-19 vaccine on a regular basis (analogous to the influenza vaccine). The last two statements of this section required a yes/no answer from the participant.

The second section of the questionnaire assessed the level of knowledge of the participant regarding some pertinent issues related to COVID-19 vaccination in children. This section consisted of seven statements. The statements covered areas of COVID-19 vaccination that had clear, evidence-based answers in relevant literature.^13,44–46 All the statements of this section required a yes/no answer from the participant. A total knowledge score was computed for this part of the questionnaire. A score of 1 point was added to the total score upon the selection of an answer for that specific statement that agrees with the consensus of the relevant literature. This section had a possible maximum score of seven points.

The third section of the questionnaire assessed the attitude of the participants toward COVID-19 vaccination in children. This section included four statements that also required a yes/no answer from the participants. A total attitude score was also computed for this section. In this calculation, an answer which reflected a positive attitude was awarded 1 point out of a maximum score of 4 points. A positive attitude was defined as an answer to a surveyed statement which would reflect the tendency of the physician to recommend the vaccine for their pediatric patients.

The fourth section consisted of one statement only, which requested the participant to select his/her recommendation of a COVID-19 vaccine type to be administered to children. Available options included Pfizer/BioNTech, Sinopharm, AstraZeneca, Moderna, or Johnson & Johnson’s Janssen (J&J/Janssen). Participants were allowed to select more than one of the five listed vaccines. An additional sixth option (I don’t recommend any of the listed vaccines) was also listed in the questionnaire. In the interview, it was emphasized that participants can either select a vaccine or more from the list or state that they did not recommend any vaccine.

The fifth and last section included one single statement which requested the participant to select his perception of potential side effects which could occur in children upon their vaccination against COVID-19. The options were seven in number and included cardiac problems, respiratory problems including asthma, allergies, attention deficit hyperactivity syndrome (ADHD), autism, infertility, or ‘no serious side effects.

Statistical analysis

Data from the questionnaire were entered into Microsoft Excel spreadsheets. Data was then transferred and analyzed using Statistical Package for Social Science (SPSS®) version 28.

Pearson’s Chi-squared test was used to test for the presence of statistically significant differences in gender, job title, experience, marital status, having children of their own, and the willingness to regularly receive a COVID-19 vaccine among pediatricians or family physicians. A Pearson’s Chi-squared test was also used to assess for the presence of differences in responses to each knowledge or attitude statement between pediatricians or family physicians.

Following the calculation of knowledge or attitude score of each participant, the distribution of these scores was tested for its normality using the Kolmogorov-Smirnov goodness of fit test. The variable “years of experience” was treated as a categorical variable of two options (five or more years, less than five). The association of the knowledge or attitude scores with the characteristics of the participants (specialty, gender, years of experience categories, marital status, having children, or willingness for regular vaccination) was tested using a Mann-Whitney U test., while the association of the above scores with the job title of the participant was tested using Kruskal-Wallis H test.

Binary logistic regression was used to test the effect of knowledge score or the years of experience category on the attitude score of the participants. In this analysis, the attitude score was first converted into a binary variable (positive or negative) by considering a score of two or above to be synonymous with a positive attitude while a score of less than two synonymous with a negative attitude. In all the analyses, statistical significance was considered at a P-value < .05.

Results

Characteristics of the study participants

The response rate among pediatricians was 75% (Table 1) while the response rate among family physicians was 64% (Table 1). These indicate an overall response rate of 69%.

Table 1.

General characteristics of study participants.

Variable	Pediatricians n = 112	Family physicians n = 96	P valuea
	n (%)	n (%)
Gender			.97
Male	44 (39.3)	38 (39.6)
Female	68 (60.7)	58 (60.4)
Job Title			<.001
Resident	47 (42.0)	66 (68.8)
Specialist in academia	49 (43.8)	13 (13.5)
Specialist in the private sector	16 (14.3)	17 (17.7)
Experience as a specialistb			.03
Less than 5 Years	25 (35.2)	25 (55.6)
5 years or more	46 (64.8)	20 (44.4)
Marital Status			.83
Single	36 (32.1)	32 (33.3)
Married	75 (67.0)	64 (66.7)
Missing	1 (0.9%)	0
Have Children			.62
Yes	65 (58.0)	59 (61.5)
No	47 (42.0)	37 (38.5)
Willingness to regularly receive COVID-19 vaccine			.80
Yes	93 (83.0)	81 (84.4)
No	19 (16.0)	15 (15.6)

Data are presented as the n (percentage).

^aP-values were calculated using Pearson’s chi-squared test.

^bn (for pediatric specialists) = 71, n (for family medicine specialists) = 45.

No significant differences in gender distribution between pediatricians or family physicians were observed (P > .05). Most of the participants were females in both groups (60.7% among pediatricians and 60.4% among family physicians). More than half of participating pediatricians or family physicians had children (58.0% and 61.5%, respectively).

Specialists in the academic sector constituted the biggest percentage of pediatricians (43.8%), while residents were the most highly represented group among family physicians (68.8%). Participating pediatric specialists were more experienced, with 64.8% of them having an experience of five years or more compared to only 44.4% among family physicians. The majority of both pediatricians (83.0%) or family physicians (84.4%) were willing to regularly receive a COVID-19 vaccine analogous to the vaccine administered against influenza virus.

Knowledge and attitude of study participants toward COVID-19 vaccination in children

Differences in the responses between pediatricians or family physicians to each of the knowledge or attitude statements are displayed in Table 2. There was a significantly higher percentage of pediatricians than family physicians who agreed that COVID-19 vaccine is safe to administer with other childhood vaccines or that COVID-19 vaccines could be safely administered in children previously infected with the SARS-CoV-2 virus (P < .05).

Table 2.

Frequency table for the knowledge and attitude assessment items of the questionnaire.

Question	Total N = 208	Pediatricians N = 112	Family physicians N = 96	P Valuea
	n (%)	n (%)	n (%)
Knowledge Assessment Items
COVID-19 vaccine is safe to administer with other childhood vaccines (MMR, OPV, IPV, BCG, DPT)*				.04
Yes	65 (31.3)	42 (37.5)	23 (24.0)
No	143 (68.8)	70 (62.5)	73 (76.0)
Children previously infected with SARS-CoV-2 can safely receive COVID-19 vaccine:				.04
Yes	107 (51.4)	65 (58.0)	42 (43.8)
No	101 (48.6)	47 (42.0)	54 (56.3)
Pfizer/BioNTech was approved by WHO** for use in children above 5 years of age				.98
Yes	141 (67.8)	76 (67.9)	65 (67.7)
No	67 (32.2)	31 (27.7)	36 (37.5)
Moderna COVID-19 vaccine was approved by WHO for use in children above 5 years of age				.47
Yes	16 (7.7)	10 (8.9)	6 (6.3)
No	192 (92.3)	102 (91.1)	90 (93.8)
Most of SARS-CoV-2 variants produce a less severe disease in children than in adults:				.23
Yes	28 (13.5)	18 (16.1)	10 (10.4)
No	180 (86.5)	94 (83.9)	86 (89.6)
There is no evidence that vaccination against COVID-19 in children increases their risk of Infertility in the future.				.07
Yes	197 (94.7)	109 (97.3)	88 (91.7)
No	11 (5.3)	3 (2.7)	8 (8.3)
WHO recommends vaccination against COVID-19 in children 5 years old and above				.65
Yes	178 (85.58)	97 (86.61)	81 (84.38)
No	30 (14.42)	15 (13.39)	15 (15.63)
Attitude Assessment Items
The government should mandate that children of all age groups receive the COVID-19 vaccine				<.001
Yes	90 (43.3)	58 (51.8)	32 (33.3)
No	118 (56.7)	54 (48.2)	64 (66.7)
I would give the COVID-19 vaccine to my children regardless of their age				.60
Yes	121 (58.2)	67 (59.8)	54 (56.3)
No	87 (41.8)	45 (40.2)	42 (43.8)
The benefit of protecting against SARS-COV-2 infection in children outweighs the risks of COVID-19 vaccine				.61
Yes	153 (73.6)	84 (75.0)	69 (71.9)
No	55 (26.4)	28 (25.0)	27 (28.1)
I recommend that children of all age groups receive the COVID-19 vaccine.				.63
Yes	42 (20.2)	24 (21.4)	18 (18.8)
No	166 (79.8)	88 (78.6)	78 (81.3)

Data are presented as the n (percentage).

^aP-values were calculated using Pearson’s chi-squared test.

*MMR: Measles, Mumps, and Rubella, OPV: Oral polio vaccine, IPV: inactivated polio vaccine, BCG: Bacillus Calmette – Guérin, DPT: Diphtheria, Tetanus, and Pertussis.

**WHO: World Health Organization.

Association of the characteristics of the pediatricians or family physicians with their knowledge score

A knowledge score was calculated for both study groups (pediatricians or family physicians). Overall, pediatricians had a higher knowledge score than family physicians, although this difference did not reach statistical significance (P = .10) (Table 3). A higher knowledge score was associated with willingness to receive COVID-19 vaccine or an experience of five years or more as a specialist (P < .05) (Table 3). Moreover, specialists in the private sector had significantly higher knowledge scores than specialists in academia or residents (P < .05) (Table 3).

Table 3.

Association between knowledge score and the characteristics of the participants.

	Overall			Pediatricians			Family physicians
	N	Mean Rank	Test statistic (P value)a	n	Mean Rank	Test statistic (P value)	n	Mean Rank	Test statistic (P value)
Specialty				-			-
Pediatrics	112	110.699	4683.00
Family medicine	96	7.28	(.10)
Gender
Male	82	109.73	4737.00	44	58.98	1387.00	38	51.29	996.00
Female	126	101.10	(.30)	68	54.90	(.51)	58	46.67	(.42)
Willingness to regularly receive COVID-19 vaccine
Yes	174	113.34	1419.00	93	61.90	381.50	81	52.02	322.50
No	34	59.24	(<.001)	19	30.08	(<.001)	15	29.50	(<.001)
Job Title
Resident	113	99.03	14.73 (<.001)	47	51.33	13.67 (.001)	66	48.68	6.52 (.04)
Specialist in academia	62	95.35		49	52.58		13	33. 62
Specialist in the private sector	33	140.42		16	83.69		17	59.18
Experience as a specialist
<5 Years	50	49.80	1215.00	25	28.88	397.00	25	21.54	213.50
≥5 Years	66	65.09	(.01)	46	39.87	(0.03)	20	24.83	(.40)
Marital Status
Single	68	102.87	4649.00	36	53.47	1259.00	32	50.05	974.50
Married	139	104.55	(.85)	75	57.21	(.56)	64	47.73	(.69)
Having Children
Yes	124	106.04	5017.00	65	58.82	1377.00	59	47.95	1059.00
No	84	102.23	(.65)	47	53.30	(.37)	37	49.38	(.80)

^aP values were calculated using Mann – Whitney U test for binary variables, and Kruskal – Wallis H test for multinomial variables (Job title).

Association of the characteristics of the pediatricians or family physicians with their attitude score

Pediatricians had an overall higher attitude score than family physicians (P = .11, not significant) (Table 4). A more positive attitude in pediatricians or family physicians was associated with the willingness of the participants to regularly receive a COVID-19 vaccine (P < .05) (Table 4). A more negative attitude was associated with an experience of less than five years as a specialist in Pediatrics. The association above was not significant among family physicians (P = .41) (Table 4). Finally, it was observed that specialists in the private sector had a significantly higher attitude score than residents or specialists in academic institutions (P < .05) (Table 4).

Table 4.

Association between attitude score and the characteristics of the participants.

	Overall			Pediatricians			Family physicians
	N	Mean Rank	Test statistic (P value)a	n	Mean Rank	Test statistic (P value)	n	Mean Rank	Test statistic (P value)
Specialty				-			-
Pediatrics	112	110.49	4705.00
Family Medicine	96	97.51	(.11)
Gender
Male	82	106.91	4968.50	44	59.11	1381.00	38	48.43	1099.50
Female	126	102.93	(.63)	68	54.81	(.48)	58	48.54	(.99)
Willingness for regular vaccination
Yes	174	114.99	1133.50	93	62.37	338.00	81	53.17	229.50
No	34	50.84	(<.001)	19	27.79	(<.001)	15	23.30	(<.001)
Job Title
Resident	113	103.74	8.32 (.02)	47	57.52	10.00 (<.01)	66	48.59	1.76 (.41)
Specialist in academia	62	92.77		49	48.68		13	40.81
Specialist in the private	33	129.14		16	77.44		17	54.03
Experience as a specialist
<5 Years	50	46.40	1045.00	25	26.08	327.00	25	20.50	187.50
≥5 Years	66	67.67	(<.001)	46	41.39	(.001)	20	26.13	(.14)
Marital Status
Single	68	108.32	4432.00	36	55.00	1413.00	32	54.22	841.00
Married	139	101.88	(.46)	75	56.48	(.82)	64	45.64	(.14)
Having Children
Yes	124	99.96	4644.50	65	54.74	1413.00	59	45.75	929.00
No	84	111.21	(.18)	47	58.94	(.49)	37	52.89	(.21)

^aP values were calculated using Mann – Whitney U test for binary variables, and Kruskal – Wallis H test for multinomial variables (Job title).

The association between the knowledge of the participants and years of experience with their attitude toward COVID-19 vaccination in children

We wanted to determine whether a better knowledge score and/or longer experience positively impacted the attitude of the surveyed physicians. Data were analyzed using binary logistic regression with attitude as an outcome variable (positive or negative attitude). It was demonstrated that the odds of having a positive attitude increased with an increasing knowledge score (OR = 1.99; CI = 1.43–2.78; P < .001) (Table 5). This relationship was significant upon stratifying the participants into pediatricians or family physicians (P < .05) (Table 5).

Table 5.

Binary logistic regression of factors affecting positive attitude toward COVID-19 vaccine in children.

	Overall		Pediatricians		Family Physicians
Variable	Odds ratio [95%CIa]	P valueb	Odds ratio [95%CI]	P value	Odds ratio [95%CI]	P value
Knowledge Score	1.99 [1.43 – 2.78]	<0.001	1.62 [1.17-2.27]	0.01	3.20 [1.51-6.81]	0.001
Experience (≥5 years vs <5)	2.26 [0.95 – 5.40]	0.07	9.92 [1.21-81.09]	0.02	0.97 [0.21-4.54]	0.97

^aCI: Confidence interval.

^bP-values were calculated using logistic regression analysis.

It was also demonstrated that having an experience of five years or more increases the likelihood of a positive attitude 10-fold in pediatricians (OR = 9.92; CI = 1.21–81.09; P = .02) (Table 5). This relationship, however, was not significant for the overall population or for family physicians only.

Recommended type of COVID-19 vaccine for children

It was found in this analysis that around 14.4% of the participants discouraged all of the listed COVID-19 vaccines (Table 6). More than 60% of the participants recommended Pfizer/BioNtech vaccine, followed by Sinopharm (Table 6). J&J/Jassen was the least recommended type of vaccine by pediatricians or family physicians.

Table 6.

The recommended COVID-19 vaccine for use in children.

Type of vaccine	Total N = 208	Pediatricians n = 112	Family physicians n = 96
	n (%)	n (%)	n (%)
Pfizer/BioNTech	141 (67.8)	76 (67.9)	65 (67.7)
Sinopharm	63 (30.3)	34 (30.4)	29 (30.2)
AstraZeneca	12 (5.8)	8 (7.1)	4 (4.2)
Moderna	16 (7.7)	10 (8.9)	6 (6.3)
(J&J/Janssen)	1 (0.5)	1 (0.9)	0
None of them	30 (14.4)	15 (13.4)	15 (15.6)

Data are presented as n (percentage).

Perceived side effects of COVID-19 vaccines in children

It was demonstrated that around three quarters of the participants in either group believed that COVID-19 vaccines would not produce any side effects in children (Figure 1).

Figure 1.

The perception of the study participants toward any potential side effects associated with COVID-19 vaccination in children (total percentages are shown in black, percentages in pediatricians are shown in gray, percentages in family physicians are shown in white. *ADHD: Attention-Deficit/Hyperactivity Disorder.

Out of six potential side-effect categories listed in the questionnaire, cardiac problems were the most frequently selected category by both groups (Figure 1). This was followed by respiratory problems and then allergies (Figure 1). Attention Deficit Hyperactivity Syndrome (ADHD) was the least frequently selected side effect category by pediatricians or family physicians (Figure 1).

Discussion

Available literature indicates that several vaccines developed against COVID-19 were effective against SARS-CoV-2 infection and have succeeded in preventing severe disease states that require hospitalization and/or ICU admission.⁴⁷ A few health authorities raised some concerns regarding the benefits of these vaccines in protecting against the new emerging variants of SARS-CoV-2. However, recent data showed that this tentative problem could be overcome via booster doses of COVID-19 vaccines.⁴⁸ This strategy provided extra protection against the new emerging variants of SARS-CoV-2 compared to the primary vaccine series alone.⁴⁸

Many countries worldwide have prioritized the vaccination for community members at a higher risk of severe disease, including the elderly and patients with comorbidities, in addition to individuals working in the healthcare sector.^49–51 Children are generally at a lower risk of hospitalization from SARS-CoV-2 infection and thus were not a priority for receiving the vaccine.⁵² Nonetheless, epidemiological data describing the trend of the emerging variants of SARS-CoV-2 demonstrated that some of these variants were more likely to infect children than the parent viral strain.⁵³ This observation entails that children could become natural reservoirs of the SARS-CoV-2 virus or any of its variants and help in its dissemination to higher-risk community members.^16,54 Moreover, the population structure of many regions worldwide, including the Middle East, shows that children and young adults constitute the largest percentage of the population.⁵⁵ Consequently, COVID-19 vaccination in children would be a prerequisite to achieve a vaccine coverage percentage that could theoretically provide herd immunity for the population in question.⁵⁶

Given the above, the United States Centers for Disease Control and Prevention (US CDC) now recommends COVID-19 vaccination for children six months and older.¹³ Specifically, Pfizer-BioNTech COVID-19 vaccine was approved for its use as a primary vaccine series and a booster dose for children as young as five-year-old.^13,46 On the other hand, Moderna vaccine was approved as a primary series vaccine and as a booster dose for children older than six. There is no recommendation for a booster dose of any vaccine in children of the age group of six months to four years. However, this age group can receive the Pfizer-BioNTech or the Moderna vaccine.¹³

Despite CDC statements, recommendations to vaccinate against COVID-19 in children vary by country. Jordan, for example, has recently passed legislation allowing the vaccination of children older than five years old.¹⁶ Recent estimates, however, show that the majority of children of this age group are not yet vaccinated.⁵⁷ In fact, the rate of vaccination in children is very low in most of the countries of the region.⁵⁵ Given that children and young adults constitute the majority of the population in these countries, the low rate of vaccination in children could impede the efforts of reaching herd immunity.¹⁶

Given that low rate of vaccination in children could potentially hinder the efforts of the public health authorities to control COVID-19, several investigations assessed the attitude and perceptions of the general public or the parents toward the use of COVID-19 vaccines in children.^56,58 Previous reports supported that the knowledge and attitude of HCWs, in general and physicians in particular, can have a substantial impact on the level of confidence of the patients toward vaccines, including the decision to receive the vaccine themselves or vaccinate their children.^59–62 Hence, in this report, we describe the determinants of knowledge and attitude of a random sample of pediatricians and family physicians in Jordan toward COVID-19 vaccination in children.

This report showed that the level of knowledge of COVID-19 vaccination for children among sampled pediatricians or family physicians was correlated with their experience. Specifically, pediatric or family medicine specialists with five years or more of experience had a significantly higher level of knowledge compared to those with less experience.⁶³ Furthermore, physicians of both specialties who were working in the private sector had a significantly higher knowledge score than their peers. In Jordan, a considerable percentage of physicians move to the private sector after accumulating experience in the military or public health sectors.⁶⁴ Considering the effect of years of experience on the level of knowledge of the participants, this could explain why specialists working in the private sector had significantly better knowledge scores. Intriguingly, this investigation also demonstrated that physicians of either specialty who reported their willingness to regularly receive COVID-19 vaccine had significantly higher knowledge scores. This finding is in line with results obtained in other studies, which revealed that a knowledge deficit, in general, is associated with a greater degree of hesitancy toward COVID-19 vaccines.^65–67

Interestingly, declaring willingness to regularly receive a COVID-19 vaccine was also positively correlated with a more positive attitude toward COVID-19 vaccination for children. Poon et al. showed that family physicians who were vaccinated were more likely to recommend COVID-19 vaccine for their patients.³⁹ Within the same lines, Khatatbeh et al. found that a positive COVID-19 vaccination history correlated with the willingness of the parents to have their children receive the COVID-19 vaccine.⁵⁵ In this report, COVID-19 vaccination was a mandatory prerequisite to practice medicine at the time of data collection. The research team hence explored physicians’ intention to regularly receive COVID-19 vaccine instead of collecting data regarding COVID-19 vaccination history of the participating physicians.

Multivariate analysis of the knowledge and attitude data collected in this report showed that the knowledge score among pediatricians or family physicians was the most significant factor in predicting a positive attitude toward COVID-19 vaccination for children. Moreover, a five-year or more experience among pediatricians was significantly associated with a more positive attitude.

In general terms, physicians’ viewpoints and attitudes toward vaccinations are favorable.^68,69 In the specific case of the COVID-19 vaccine, a global scale study which included a representative sample from 23 countries demonstrated that vaccine acceptance was significantly higher among HCWs compared to the general population.⁶⁹ A survey-based study conducted on 693 general practitioners (GPs) working in the private sector of France indicated that GPs may have a disparity in their vaccination practice toward their patients or children as compared to themselves.⁷⁰ In the above study, the disparity in opinion was more pronounced upon the consideration of the newest vaccines such as the Human Papilloma Virus vaccine.⁷⁰

In line with the findings of the above study, Sertkaya et al. found that having children of their own significantly affected the attitude of physicians toward vaccination.⁷¹ In their study above, physicians with children were more likely to recommend Influenza vaccine than physicians without children.⁷¹

Considering that the COVID-19 vaccine is a newly developed prevention modality⁷² and the fact that the introduction of COVID-19 vaccination programs was surrounded with many conspiracy theories regarding their safety,⁷³ we evaluated whether having children of their own may modify physicians’ viewpoints or attitude toward COVID-19 vaccination in children. In this report, it was demonstrated using univariate and multivariate statistical models that having children did not affect attitude or knowledge of sampled physicians. A larger sample size may provide different findings.

Several studies reported that better knowledge of COVID-19 vaccine among HCWs was associated with a more positive attitude. For example, a study conducted on a sample of HCWs at a tertiary care center in India concluded that poor knowledge about the COVID-19 vaccine contributed significantly to vaccine hesitancy among surveyed participants.²⁷ Taken together, these findings emphasize the need for targeted educational programs among physicians of different specialties in order to increase the rate of COVID-19 vaccination in children groups.

Generally, safety concerns and the perception that children are not at risk of severe disease are the most commonly reported reasons for COVID-19 vaccine hesitancy.^74–76 However, despite that the majority of physicians from both groups agreed that administration of COVID-19 vaccine would not result in any major side effect in children, 15% of the surveyed participants discouraged the vaccination of children with any of the available COVID-19 vaccines. The majority of physicians trusted the Pfizer/BioNTech vaccine. This was consistent with the findings of Abdullah et al. who also showed that Pfizer/BioNTech was the preferred vaccine among the Jordanian population.⁷⁷

Pediatricians or family physicians are not the only HCWs approached for consultation by the parents regarding the effectiveness and/or safety profile of vaccinating children against COVID-19. Other HCW groups including nurses, general practitioners, or pharmacists are sometimes also approached for consultation. The viewpoints of these groups were not surveyed in this report. This was one limitation of this investigation. Another limitation was the small sample size. Future research that employs a mix of qualitative and quantitative methodology and/or open-ended questions that investigate the reasons behind vaccine hesitancy is recommended.

Conclusion

This report was amongst the first to reveal that the level of knowledge in a random sample of pediatricians or family physicians was the most significant factor contributing to their attitude toward COVID-19 vaccination for children. This finding represents a trigger for health managers and stakeholders to plan targeted educational and training programs for physicians and HCWs on the benefits of vaccinating children with COVID-19 vaccine. The implementation of such programs is expected to increase the acceptance of parents to vaccinate their children. Presumably, a higher rate of COVID-19 vaccination in children could decrease COVID-19 specific death rates via a reduction in the transmission of the virus to the elderly and/or other high-risk groups.

Funding Statement

Qatar National Library provided Funding for open access publishing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data are available from the corresponding author upon reasonable request.