Confidence in the efficacy of routine vaccines after the COVID-19 pandemic: a cross-sectional web-based study

Abstract

Background

There is limited data that assessed the changes in public confidence in routine childhood and adult vaccines after Corona Virus Disease-2019 (COVID-19) pandemic. We, therefore, assessed these changes and the reasons; if any; for these changes and measured the impact of COVID-19 on peoples’ thoughts regarding routine vaccinations in Saudi Arabia.

Methods

We undertook a cross-sectional online study in Saudi Arabia from November 2023 to April 2024. Participation was voluntary for those above 18 years and lived in Saudi Arabia. The study tool was an online self-administered questionnaire. Data gathered were analyzed using the SPSS version 25 software.

Results

A total of 1217 Saudi Arabian participants were enrolled. Among the total participants, only 32.4% (n = 394) participants were males. Most of the participants (55%, n = 679) were from the western region and were married (56.9%, n = 693). Most participants (71%, n = 873) revealed that the routine vaccination plays an important role in protecting them and their children from infectious diseases. The confidence in routine vaccination after the COVID-19 pandemic didn’t change among 59% (n = 723), decreased in 22% (n = 261) and increased in 19% (n = 238) of the participants. The most common reason for the change in participants’ confidence (68%, n = 743) in routine vaccination after the COVID-19 pandemic was the fear of the impact of COVID-19 vaccine on the immune system or the body’s ability to respond correctly to routine vaccines.

Conclusions

We have showed that there is little change in the confidence of routine vaccination among people in Saudi Arabia compared to before the COVID-19 pandemic. Our study could shed light on the potential challenges and opportunities for promoting vaccine acceptance and uptake in a post-pandemic era.

Introduction

The Coronavirus Disease-2019 (COVID-19) pandemic has had a profound impact on global health systems, economies, and societies. While the development and deployment of COVID-19 vaccines were critical in combating the virus, the pandemic also had unintended consequences for other public health initiatives [1]. However, some adverse reactions and side effects to the COVID-19 vaccines have been reported in Saudi Arabia [2–4]. As the world grappled with the pandemic, it is crucial to examine the broader implications of the crisis on public confidence in routine vaccines [1]. Routine vaccines such as measles, mumps, rubella, polio, and hepatitis, have long been a cornerstone of public health initiatives [5] may include vaccines that use the whole organism, either inactivated or live attenuated, only sub-unit vaccines or only the organism genetic material which is used to synthesize some proteins that induce immunity in people [6].

Even before the pandemic, vaccine hesitancy – the refusal or reluctance to receive vaccinations – was already a major public health concern [7, 8]. Defined as a complex behavior influenced by factors like trust issues, complacency, and convenience, vaccine hesitancy continues to pose a significant threat to global health [8]. The World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) use diphtheria, tetanus, and pertussis (DTP) vaccine coverage as a global marker for immunization rates [9]. Unfortunately, data shows a worrying trend in 2019, before the pandemic, where 18.4 million children missed out on routine vaccinations globally [9] which increased to 24.4 million during the pandemic in 2021 and remained elevated at 20.5 million in 2022. Measles vaccination rates also paint a concerning picture [9]. Although first-dose coverage increased to 83% in 2022 compared to 81% in 2021, it still falls short of the 86% achieved in 2019 [9]. As a result, an estimated 21.9 million children missed out on the routine measles vaccination in their first year of life in 2022 [9]. Therefore, these unvaccinated children are at increased risk of measles during potential outbreaks, which can have severe morbidity and mortality [9]. In a study including 55 countries that tracked global trends in vaccine trust between 2015 and 2022, opinions regarding the value of vaccinations for children declined in 46 of those countries, with significant increases in Mexico and India [4]. Continued observation of vaccine confidence in China is imperative to comprehend the pandemics’ long-term effects [4]. In the Eastern Province of Saudi Arabia, it was shown that at least one child in every three missed routine vaccinations during the pandemic [10]. While a significant number of parents (approximately 33.1%) delayed or avoided vaccination, most fortunately continued to adhere to childhood immunization schedules [10].

There is limited data that assessed the changes in public confidence regarding routine vaccines after the COVID-19 pandemic both globally and in Saudi Arabia. Thus, a mixed picture of vaccination confidence is presented globally and locally [4, 11–16]. Opinions regarding the value and safety of the Human Papilloma Virus (HPV) and MMR vaccinations declined during the COVID-19 pandemic with significant changes across several regions with different socioeconomic categories. In the UK, vaccine confidence significantly decreased during the pandemic [16]. Almost 25% of respondents said that their faith in vaccines had decreased since the pandemic started [4]. Also, at the beginning of the COVID-19, quarantine in Saudi Arabia, a cross-sectional study in Jeddah city assessed the percentage of children who had a delay in their routine vaccination [17]. The study revealed that most respondents (65.8%) reported a delay in their child receiving vaccination during the quarantine. The most common reasons for the delay were fear of being infected, unavailability of appointments, and the difficulty to access the healthcare centers [17]. Another cross-sectional study measured the changes in the confidence level regarding routine vaccination (children and adults) after the COVID-19 pandemic among Saudi residents. Subjects who were confident that influenza vaccination is safe were 4.5 times more likely to receive it, while those who were certain that it is successful in preventing influenza and its complications were 3.6 times more likely to receive the vaccine [15]. We therefore assessed the changes in the confidence in routine vaccination after the COVID-19 pandemic. We also assessed the reasons, if any; for these changes and the impact of the COVID-19 pandemic on peoples’ thoughts regarding routine vaccinations. By examining attitudes, beliefs, and concerns related to routine vaccines, we shed light on the potential challenges and opportunities for promoting vaccine acceptance and uptake in the post COVID-19-pandemic era.

Subjects and methods

Study design and settings

We undertook a cross-sectional survey that was conducted among residents from different regions in Saudi Arabia during the period from November 2023 to March 2024 to assess the confidence level regarding routine vaccination (children and adults) after the COVID-19 pandemic. A self-administered online survey was employed using Google Forms. The survey link was distributed randomly on several social media platforms such as Telegram, Twitter, and WhatsApp groups, with a brief description of the study’s aim, and the participation was voluntary. The survey included residents of both genders, 18 years old and above. Participation was not permitted by those under 18 years old. The study protocol was approved by the ethics committee at Taif University (approval number 45–081).

Sample size calculation

The sample size was calculated using the following sample size equation: n = z2 x p (1 − p)/e2 where: “n” is the sample size, “z” (1.96) is the z-score associated with a level of confidence (95%), p is the sample proportion, expressed as a decimal, “e” (0.05) is the margin of error, expressed as a decimal. The calculated sample size was 385 participants.

Study instrument

The study tool was a self-administered questionnaire designed after consulting previously published literature [7, 18–20]. Given that Arabic is the participants’ predominant language in Saudi Arabia, we administered the questions in Arabic for the best possible understanding. The final revised questionnaire contained four sections and a total of 31 questions. Section one (fourteen questions) was concerned with the demographic data where participants were asked to provide information about their gender, age, social status, nationality, residence, educational level, employment, income, number of children, COVID-19 vaccination status, and other demographics. Section two (twelve questions) measured the participants’ attitude on routine vaccines e.g., the importance of routine vaccination, refusal to get their children vaccinated in the past, and source and confidence in the sources of information about routine vaccines…etc. The third section (two questions) measured the participants’ confidence in routine vaccines’ efficacy, safety, manufacture, literature, information sources, and future intentions regarding routine vaccination. The fourth section (three questions) measured the participants’ change in confidence and efficacy of different childhood and adult vaccines after the COVID-19 pandemic.

Questionnaire validity and reliability

The questionnaire was developed specifically for our study by consulting previous literature [7, 18–20] and was face and content validated via feedback from four experts in the field. Also, a pilot study was conducted on 28 individuals to assure the clarity and avoid any confusing questions. The results of the pilot sample were not included in the final analysis. In addition, the questionnaire was validated by testing the attitude items for reliability using Cronbach alpha that was > 0.75.

Statistical analysis

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software, version 25 (IBM Corporation, NY, USA). Descriptive statistics included the calculation of frequencies and percentages. The Chi-square test with cross tabulation was used to test the relationship between categorical variables. A P-value of < 0.05 was considered significant.

Results

Demographic and clinical characteristics of the study participants

A total of 1217 participants were included in our study. Of them, 823 (67.6%) were females, 704 (57.8%) had an age ranging from 18 to 30 years, 679 (55.8%) were from the Western region of Saudi Arabia and 1131 (92.9%) were Saudi citizens. As shown in Table 1, most of the participants (n = 953; 78.3%) were university students/having a diploma or a bachelor’s degree and 784 (64.4%) were not employed. The majority (n = 734; 60.3%) had a monthly income < 5000 SAR and 693 (56.9%) were married. About 39% had no children, while 302 (24.8%) had four or more children. Almost one third of (n = 384; 33.2%) of the participants had children who were two years old and younger during the COVID-19 pandemic while the remaining did not. Only 110 (9%) of the participants were employed in the healthcare sector and 770 (63.3%) of them received three doses of the COVID-19 vaccine. Almost half of the participants (n = 562; 46.2%) had a child who received all his/her routine vaccines on time during the COVID-19 pandemic, and only 69 (5.7%) delayed their children’s vaccination. Of those who had delayed their children’s vaccination during the pandemic, 167 (13.7%) delayed it for less than three months, while only 36 (3%) delayed it for more than 12 months (Table 1).

Table 1.

Demographic and clinical characteristics of the study participants

Questions	Category	Frequency (%)
Gender	Female	823 (67.6)
	Male	394 (32.4)
Age	18–30	704 (57.8)
	31–40	226 (17.6)
	41–50	175 (14.4)
	51–60	91 (7.5)
	> 60	21 (1.7)
Region	Southern	91 (7.5)
	Eastern	125 (10.3)
	Northern	35 (2.9)
	Western	679 (55.8)
	Central	287 (23.6)
Nationality	Saudi	1131 (92.9)
	Non-Saudi	86 (7.1)
Qualification	Secondary school or below	152 (12.5)
	University student Diploma/bachelor’s degree	953 (78.3)
	Master/ Ph. D	112 (9.2)
Employment Status	Government sector	248 (20.4)
	Private sector	154 (12.7)
	Not currently employed	784 (64.4)
	Volunteer	31 (2.5)
Monthly Income	< 5000 SAR	734 (60.3)
	5000–10,000 SAR	218 (17.9)
	> 10,000 SAR	265 (21.8)
Marital Status	Single	468 (38.5)
	Married	693 (56.9)
	Divorced/ Widowed	56 (4.6)
Total of Children	None	473 (38.9)
	One	153 (12.6)
	Two	166 (13.6)
	Three	123 (10.1)
	Four and more	302 (24.8)
Number of children who were two years old and younger during COVID-19	None	813 (66.8)
	One	292 (24.0)
	Two	78 (6.4)
	Three	14 (1.2)
	Missing	20 (1.6)
Employed in the healthcare sector	No	1107 (91.0)
	Yes	110 (9.0)
Number of COVID-19 vaccine doses	None	29 (2.4)
	One dose	32 (2.6)
	Two doses	339 (27.9)
	Three doses	770 (63.3)
	Four doses	47 (3.9)
Ensuring child/children at vaccination age receive routine vaccinations on time during the COVID-19 pandemic	Not applicable/ Not sure/ I do not remember	510 (41.9)
	Not applicable, my child is not two years yet or not at the vaccination age	76 (6.2)
	No, I have delayed my child’s vaccines due to COVID-19 pandemic	69 (5.7)
	Yes, my child had received all his/her vaccines on time	562 (46.2)
Duration of the delay for children not receiving routine vaccination on time	Not applicable	907 (74.5)
	Less than three months	167 (13.7)
	Three - six months	74 (6.1)
	Six - Twelve months	33 (2.7)
	More than twelve months	36 (3.0)

The participant’s perspective on routine vaccines

A total of 987 (81.1%) of the participants strongly agreed/agreed that routine vaccination plays a key role in their children’s health and prevention of diseases while only 84 (6.9%) of them strongly disagreed (Table 2). The importance of routine vaccination in child health and disease prevention was significantly associated with monthly income (p = 0.039), total number of children (p = 0.019), number of children who were two years or younger during the COVID-19 pandemic (p < 0.001), number of COVID-19 vaccine doses (p < 0.001), receiving the children routine vaccinations on time during the COVID-19 (p = 0.015) and duration of delay in receiving routine vaccinations beyond the scheduled time (p < 0.001).

Table 2.

The participant’s perspectives on routine vaccines

Questions	Response N (%)					P- value
	SD*	D*	N*	A*	SA*	Gender	Age	RA**	N**	EL**	ES**	MI**	MS**	NC**	CB**	HE**	VD**	RV**	DT**
Routine vaccinations (such as polio, pneumococci, hepatitis B, DTP, MMR) play a key role in your children’s health and in preventing diseases.	84 (6.9)	38 (3.1)	108 (8.9)	114 (9.4)	873 (71.7)	0.534	0.150	0.087	0.089	0.422	0.659	0.039	0.063	0.019	< 0.001	0.082	< 0.001	0.015	< 0.001
The COVID-19 pandemic has affected the public’s perception and understanding of the importance of routine vaccinations	160 (13.1)	86 (7.1)	295 (24.2)	157 (12.9)	519 (42.6)	0.161	0.770	0.413	0.730	0.344	0.483	0.280	0.101	0.056	0.006	0.777	0.014	0.014	0.036
Routine vaccinations must be received by individuals by mandatory laws.	160 (13.1)	99 (8.1)	234 (19.2)	142 (11.7)	582 (47.8)	0.570	0.194	0.645	0.205	0.633	0.626	0.059	0.005	0.093	0.675	0.704	< 0.001	0.003	0.006
Routine vaccination certificate must be a requirement for accessing some public facilities (such as schools or hospitals).	192 (15.8)	83 (6.8)	201 (16.5)	159 (13.1)	582 (47.8)	0.605	0.019	0.021	0.039	0.419	0.170	< 0.001	0.018	0.025	0.327	0.267	0.001	0.017	< 0.001
The government should increase awareness about routine vaccinations after the COVID-19 pandemic.	68 (5.6)	62 (5.1)	195 (16)	184 (15.1)	708 (58.2)	0.146	0.431	0.127	0.342	0.712	0.333	0.150	0.371	0.362	0.575	0.727	< 0.001	0.502	< 0.001
I have negative beliefs about the side effects or harmful events of routine vaccinations before the COVID-19 pandemic.	396 (32.5)	168 (13.8)	272 (22.4)	134 (11)	247 (20.3)	0.163	0.024	0.293	0.734	0.498	0.274	0.106	< 0.001	0.001	0.726	0.714	0.248	0.003	0.087
It is necessary for parents to ensure that their children receive the recommended vaccinations.	61 (5.0)	40 (3.3)	133 (10.9)	118 (9.7)	865 (71.1)	0.524	0.649	0.159	0.656	0.803	0.932	0.037	0.024	0.637	0.015	0.007	< 0.001	0.332	< 0.001
I will recommend routine vaccinations to friends, family, and colleagues after the COVID-19 pandemic.	101 (8.3)	77 (6.3)	232 (19.1)	146 (12)	661 (54.3)	0.662	0.080	0.499	0.871	0.477	0.189	0.021	0.001	0.056	0.902	0.421	< 0.001	< 0.001	0.045

*SD, strongly disagree. D, Disagree. N, Neutral. A, Agree. SA, strongly agree

** RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status. NC, Total number of children. CB, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, Duration of vaccine delay by months

Most of the participants (n = 676; 55.5%) strongly agreed/agreed that the COVID-19 pandemic had affected the public’s perception and understanding of the importance of routine vaccinations, while 160 (13.1%) strongly disagreed. This was significantly associated with number of children who were two years or younger during the COVID-19 pandemic (p = 0.006), number of COVID-19 vaccine doses (p = 0.014), receiving the routine vaccines on time during the pandemic (p = 0.014) and duration of delay in receiving routine vaccinations beyond the scheduled time (p = 0.036, Table 2).

Most of the participants (n = 724; 59.5%) strongly agreed/agreed that routine vaccinations must be received by individuals by mandatory laws, while only 160 (13.1%) of them strongly disagreed. This was significantly associated with marital status (p = 0.005), number of COVID-19 vaccine doses (p = 0.001), receiving routine vaccinations on time during the pandemic (p = 0.003) and duration of delay in receiving routine vaccinations beyond the scheduled time (p = 0.006; Table 2).

Most of the participants (n = 741; 60.9%) strongly agreed/agreed that routine vaccinations must be a requirement for accessing certain public facilities (such as schools or hospitals), while 15.8% of them strongly disagreed. This was significantly associated with age (p = 0.019), residency area (p = 0.021), nationality (p = 0.039), monthly income (p < 0.001), marital status (p = 0.018), total number of children (p = 0.025), number of COVID-19 vaccine doses (p = 0.001), receiving routine vaccinations on time during the pandemic (p = 0.017) and duration of delay in receiving routine vaccinations beyond the scheduled time (p < 0.001; Table 2).

Almost two-thirds of the participants (n = 892; 63.3%) strongly agreed that the government should increase awareness about routine vaccinations after the COVID-19 pandemic. This was significantly associated with the number of COVID-19 vaccine doses (p < 0.001) and duration of delay in receiving their child’s routine vaccinations beyond the scheduled time (p < 0.001).

Only 31.4% (n = 406) of the participants strongly agreed/agreed that they have negative beliefs about the side effects of routine vaccination before pandemic. This was significantly associated with marital status (p < 0.001), total number of children (p = 0.001) and receiving routine vaccinations on time during the COVID-19 pandemic (p = 0.003; Table 2).

Most of the participants (n = 1083; 80.8%) strongly agreed/agreed that the parents must ensure that their children receive the recommended vaccination. This was significantly associated with monthly income (p = 0.037), marital status (p = 0.024), number of children who were two years or younger during the COVID-19 pandemic (p = 0.015), healthcare sector employment (p = 0.007), number of COVID-19 vaccine doses (p < 0.001) and duration of delay in receiving routine vaccinations beyond the scheduled time (p < 0.001; Table 2).

Two thirds of the participants (n = 807; 66.3%) strongly agreed/agreed that they will recommend routine vaccinations to friends, family, and colleagues after the COVID-19, while only 101 (8.3%) strongly disagreed. This was significantly associated with monthly income (p = 0.021), marital status (p = 0.001), number of COVID-19 vaccine doses (p < 0.001), receiving routine vaccinations on time during the COVID-19 pandemic (p < 0.001), and duration of delay in receiving routine vaccinations beyond the scheduled time (p = 0.045; Table 2).

The participant’s awareness about routine vaccines

As shown in Table 3, more than one third of the participants received the seasonal influenza vaccine in 2023 or the year before. A significant relationship was found between receiving the seasonal influenza vaccine and the participant’s gender (p < 0.001), age (p = 0.001), residency (p = 0.007), educational level (p = 0.004), employment status (p = 0.001), monthly income (p < 0.001), marital status (p < 0.001), total number of children (p < 0.001) and number of children who were two years or younger during the COVID-19 pandemic (p = 0.03). Similarly, a significant relationship was found between receiving the seasonal influenza vaccine and being a healthcare sector employee (p < 0.001), number of COVID-19 vaccine doses received (p < 0.001) and the having the child/children receiving their routine vaccinations on time during the COVID-19 pandemic (p = 0.005).

Table 3.

The participant’s awareness towards routine vaccines

Questions	Response N (%)			P- value
	Yes	No	I don’t know	Gender	Age	RA*	N *	EL*	ES*	MI*	MS*	NC*	CB*	HE*	VD*	RV*	DT*
Have you received the seasonal influenza vaccine this year or last year?	454 (37.3)	595 (48.9)	168 (13.8)	< 0.001	0.001	0.007	0.149	0.004	0.001	< 0.001	< 0.001	0.002	0.030	< 0.001	< 0.001	0.005	0.140
Did you refuse any routine vaccinations for your child in the past?	69 (5.7)	928 (76.3)	220 (18.1)	0.001	< 0.001	0.044	0.052	0.067	0.008	< 0.001	< 0.001	< 0.001	< 0.001	0.088	< 0.001	< 0.001	< 0.001
Are you aware of any rumors or misconceptions that have appeared during the COVID-19 pandemic regarding COVID-19 vaccination?	823 (67.6)	180 (14.8)	214 (17.6)	0.092	0.041	0.018	0.842	0.099	0.232	< 0.001	0.217	0.892	0.864	0.066	0.423	0.087	0.586

* RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status. NC, Total number of children. CB, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, Duration of vaccine delay by months

Only 69 (5.7%) of the participants refused vaccinating their child/children with routine vaccines in the past. A significant relationship was found between refusing any routine vaccinations for the child in the past and participants’ gender (p = 0.001), age (p < 0.001), residency area (p = 0.004), employment status (p = 0.008), monthly income (p < 0.001), marital status (p < 0.001), and total number of children (p < 0.001). Also, refusing a routine vaccinations for the child in the past was significantly associated with number of children who were two years or younger during the COVID-19 pandemic (p < 0.001), number of COVID-19 vaccine doses received (p < 0.001), and having a child/children at vaccination age who received their routine vaccinations on time during the COVID-19 pandemic (p < 0.001) and having a child who had a delay in receiving routine vaccinations beyond the scheduled time (p < 0.001).

About two thirds of the participants (n = 823; 67.6) were aware of rumors or misconceptions about COVID-19 vaccines. The awareness of any rumors or misconceptions that appeared during the COVID-19 pandemic regarding COVID-19 vaccination was significantly associated with the participants’ age (p = 0.004), residence area (p = 0.018) and monthly income (p < 0.001; Table 3).

The participant’s trust in various sources regarding the efficacy and efficiency of routine immunizations

Table 4 shows that the participant’s trust in healthcare specialists regarding the effectiveness and efficiency of routine vaccinations was very high (n = 1091; 89.6%) and was significantly associated with their number of COVID-19 vaccine doses (p < 0.001), having a child/children at vaccination age who received their routine vaccinations on time during the COVID-19 pandemic (p = 0.032) and delay duration in receiving routine vaccinations beyond the scheduled time for a certain period (p = 0.004). The participants had an average trust (n = 723; 59.4%) in books regarding the effectiveness and efficiency of routine vaccinations that was significantly associated with their age (p = 0.044) and residence (p = 0.014). On the other hand, the participants trust in social media was low (335; 27.5%) that was significantly associated with their gender (p = 0.034). In addition, the participants trust in family and friends was below average (n = 509; 41.8%) and this was significantly associated with participants’ education level (p = 0.028), monthly income (p = 0.004), and the number of COVID-19 vaccine doses (p = 0.042; Table 4).

Table 4.

The participant’s trust of diverse sources about the effectiveness and efficiency of routine vaccinations

Question	Response N (%)		P- value
	Yes	No	Gender	Age	RA*	N *	EL*	ES*	MI*	MS*	NC*	CB*	HE*	VD*	RV*	DT*
Healthcare specialist	1091 (89.6)	126 (10.4)	0.574	0.982	0.136	0.061	0.111	0.303	0.484	0.063	0.512	0.481	0.597	< 0.001	0.032	0.004
Books	723 (59.4)	494 (40.6)	0.082	0.044	0.014	0.373	0.129	0.206	0.974	0.557	0.493	0.816	0.119	0.319	0.620	0.183
Social media/Internet	335 (27.5)	882 (72.5)	0.034	0.126	0.128	0.560	0.279	0.510	0.177	0.102	0.186	0.544	0.950	0.153	0.064	0.660
Family and friends	509 (41.8)	708 (58.2)	0.552	0.200	0.454	0.492	0.028	0.732	0.004	0.902	0.734	0.292	0.223	0.042	0.250	0.244

*RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status, NC, Total number of children. CB, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, Duration of vaccine delay by months

Participant’s confidence in routine vaccinations after the COVID-19 pandemic

As shown in Tables 5 and 871 (71.5%) of the participants had very high/high confidence in the effectiveness of routine vaccines in preventing the respective diseases. This was significantly associated with the participants’ monthly income (p = 0.003), marital status (p = 0.005), number of COVID-19 vaccine doses (p < 0.001), having the child/children at vaccination age receiving their routine vaccinations on time during the COVID-19 pandemic (p = 0.017) and the duration of delay in receiving routine vaccinations beyond the scheduled time (p < 0.001). Also, the participants confidence in the safety of routine vaccinations was very high/high among 824 (67.7%) of the participants and this was significantly associated with their employment status (p = 0.032), marital status (p = 0.018), number of COVID-19 vaccine doses (p < 0.001), having their child/children at vaccination age receiving their routine vaccinations on time during the COVID-19 pandemic (p = 0.041) and duration of delay in receiving routine vaccinations beyond the scheduled (p < 0.001; Table 5).

Table 5.

The participant’s confidence in routine vaccination after COVID-19 pandemic

Questions	Response N %					P-value
	VLC*	LC	MC	HC	VHC	Gender	Age	RA**	N**	EL**	ES**	MI**	MS**	NC**	CB**	HE**	VD**	RV**	DT**
Your confidence in the effectiveness of routine vaccinations in preventing diseases?	30 (2.5)	47 (3.9)	269 (22.1)	334 (27.4)	537 (44.1)	0.240	0.677	0.304	0.218	0.437	0.074	0.003	0.005	0.018	0.174	0.182	< 0.001	0.017	< 0.001
Your confidence in safety of routine vaccinations?	37 (3.0)	69 (5.7)	287 (23.6)	327 (26.9)	497 (40.8)	0.386	0.202	0.144	0.065	0.363	0.032	0.081	0.018	0.104	0.156	0.591	< 0.001	0.041	< 0.001
Your confidence in the safety of the routine vaccines manufacturing process?	44 (3.6)	92 (7.6)	306 (25.1)	321 (26.4)	454 (37.3)	0.420	0.571	0.680	0.095	0.702	0.153	0.200	0.143	0.520	0.188	0.427	< 0.001	0.035	< 0.001
Your confidence in scientific studies that support the effectiveness of routine Vaccinations?	38 (3.1)	83 (6.8)	280 (23.0)	353 (29.0)	463 (38.0)	0.070	0.534	0.380	0.048	0.928	0.107	0.120	0.051	0.154	0.435	0.551	< 0.001	0.024	< 0.001
Your confidence in healthcare providers' recommendations for routine vaccinations?	37 (3.0)	76 (6.2)	248 (20.4)	353 (29.6)	496 (40.8)	0.393	0.491	0.310	0.077	0.237	0.191	0.157	0.050	0.030	0.076	0.704	< 0.001	0.075	< 0.001
Your confidence in the health authorities responsible for monitoring and licensing vaccinations	35 (2.9)	44 (3.6)	185 (15.2)	325 (26.7)	628 (51.6)	0.597	0.610	0.270	0.077	0.080	0.667	0.163	0.043	0.145	0.143	0.364	0.019	0.411	< 0.001
Your confidence in the health authorities responsible for monitoring and licensing	33 (2.7)	48 (3.9)	178 (14.6)	318 (26.1)	640 (52.6)	0.196	0.501	0.300	0.202	0.058	0.944	0.357	0.011	0.360	0.037	0.208	0.003	0.340	0.001
Your confidence in the Ministry of Health for providing recommendations regarding who should receive licensed vaccinations?	31 (2.5)	41 (3.4)	181 (23.7)	289 (23.7)	675 (55.5)	0.712	0.595	0.058	0.288	0.078	0.969	0.155	0.007	0.283	0.075	0.525	< 0.001	0.113	0.014

*VLC, very low confidence. LC, Low confidence. MC, Medium confidence. HC, High confidence. VHC, Veery high confidence

**RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status, NC, Total number of children. CB, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, if you have a child who delayed receiving one of his/ her routine vaccinations beyond the scheduled time, how long was the delay

The confidence in the safety of the routine vaccines manufacturing process was very high/high among almost two thirds of the participants’ (n = 775; 63.7%) and this was significantly associated with the number of COVID-19 vaccine doses (p < 0.001), having their child/children at vaccination age receiving their routine vaccinations on time during the COVID-19 pandemic (p = 0.035) and duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p < 0.001). Also, the confidence in scientific studies that support the effectiveness of routine vaccinations was very high/high among two thirds of the participants (n = 816; 67%). This was significantly associated with the participants’ nationality (p = 0.048), the number of COVID-19 vaccine doses (p < 0.001), having their child/children at vaccination age receiving their routine vaccinations on time during the COVID-19 pandemic (p = 0.024) and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p < 0.001; Table 5).

The confidence in healthcare providers’ recommendations of routine vaccinations was 70.4% (n = 849) among the participants and this was significantly associated with the participants’ total number of children (p = 0.03), the number of COVID-19 vaccine doses (p < 0.001) and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p < 0.001). Also, the confidence in the healthcare authorities responsible for monitoring and licensing routine vaccine was very high/high among 78.3% (n = 953) participants. This was significantly associated with the participants’ marital status (p = 0.043), the number of COVID-19 vaccine doses (p = 0.019) and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p < 0.001; Table 5).

The confidence in the healthcare authorities on monitoring and licensing vaccinations as a monitoring authority of the safety of recommended childhood vaccinations was very high/high among 78.7% (n = 958) of the participants. This was significantly associated with the participants’ marital status (p = 0.011), number of children who were two years or younger during the COVID-19 pandemic (p = 0.037), the number of COVID-19 vaccine doses (p = 0.003) and duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p < 0.001). Also, confidence in the Ministry of Health to provide recommendations regarding who should receive licensed vaccinations was very high/high among 79.2% (n = 964) of the participants. This confidence was significantly associated with the participants’ marital status (p = 0.007), the number of COVID-19 vaccine doses (p < 0.001) and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p = 0.014; Table 5).

The intended steps individuals plan to take regarding routine vaccinations post the COVID-19 pandemic

As shown in Table 6, most of the participants were proactive in following vaccination schedules with 75.9% (n = 924) affirming their continuation of vaccination schedules. This was significantly associated with age (p = 0.001), employment status (p = 0.030), monthly income (p < 0.001), total number of children (p < 0.001), number of children who were two years or younger during the COVID-19 pandemic (p < 0.001), number of COVID-19 vaccine doses (p = 0.035), ensuring routine vaccinations for children (p < 0.001), and the duration of delay in receiving routine vaccinations beyond the scheduled time (p = 0.036). Also, a significant portion of the participants (n = 957; 78.6%), actively sought more information about routine vaccinations from reliable sources compared to (260; 21.4%) who did not. In this regard, only employment status (p = 0.012) emerged as a significant factor. This suggests that one’s occupational circumstances may play a role in their proactive information-seeking behavior about vaccinations. In addition, discussions with healthcare providers about routine vaccinations were also prevalent among the participants with 76.4% (n = 930) engaging in such discussions. This was only significantly influenced by the area of residency (p = 0.001) pointing to geographical differences in the propensity to engage in conversations with healthcare professionals about vaccinations. Furthermore, encouraging others to get vaccinated was reported by 70.4% (n = 857) of the participants. This was significantly associated with several factors including marital status (p = 0.006), total number of children (p = 0.020), number of COVID-19 vaccine doses (p < 0.001), ensuring that the child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic (p = 0.031), and the duration of delay in receiving routine vaccinations beyond the scheduled time (p = 0.049). Finally, skepticism regarding the effectiveness of routine vaccinations was noted in about one-third of the participants (n = 401; 32.9%). This was significantly associated with age (p = 0.046), educational level (p = 0.005), monthly income (p = 0.007), number of children who were two years and younger during the COVID-19 pandemic (p = 0.014), and number of COVID-19 Vaccine doses (p = 0.014; Table 6).

Table 6.

The participant’s planned actions to take now on routine vaccinations after the COVID-19 pandemic

Question	Response N (%)		P- value
	Yes	No	Gender	Age	RA*	N *	EL*	ES*	MI*	MS*	NC*	CB*	HE*	VD*	RV*	DT*
Continuing to follow Vaccination schedules	924 (75.9)	293 (24.1)	0.902	0.001	0.597	0.854	0.514	0.030	< 0.001	< 0.001	< 0.001	< 0.001	0.561	0.035	< 0.001	0.036
Search for more information about routine vaccinations from reliable sources	957 (78.6)	260 (21.4)	0.979	0.572	0.251	0.233	0.209	0.012	0.099	0.494	0.145	0.214	0.393	0.147	0.553	0.932
Discussing routine vaccinations with healthcare providers	930 (76.4)	287 (23.6)	0.674	0.952	0.001	0.132	0.026	0.686	0.494	0.091	0.289	0.845	0.353	0.409	0.187	0.307
Encouraging others to get vaccinated	857 (70.4)	360 (29.6)	0.051	0.155	0.237	0.036	0.919	0.057	0.124	0.006	0.020	0.854	0.320	< 0.001	0.031	0.049
Doubting the effectiveness of routine vaccinations to a great extent	401 (32.9)	816 (67.1)	0.915	0.046	0.075	0.750	0.005	0.590	0.007	0.162	0.315	0.014	0.151	0.014	0.199	0.052

*RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status, NC, Total number of children. CB, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, if you have a child who delayed receiving one of his/ her routine vaccinations beyond the scheduled time, how long was the delay

The level of confidence in different routine vaccine types after COVID-19 pandemic

As shown in Table 7, we found only 16.8% (n = 205) of the participants strongly agreeing/agreeing with the confidence in the effectiveness of COVID-19 vaccines and about one-third of the participants (n = 429; 35.3%) were neutral in this regard. These data show a low confidence in COVID-19 vaccines. This was associated with gender (p = 0.002), age (p = 0.042), number of children (p < 0.001), number of COVID-19 vaccine doses (p = 0.005), routine vaccine (p = 0.021), and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p = 0.001). Also, only 26% (n = 317) of the participants strongly agree/agree that polio vaccines are effective, and more than half of the participants (n = 662; 54.4%) were neutral in this regard. This was significantly associated with gender (p < 0.001), number of children (p = 0.011), COVID-19 vaccine doses (p < 0.001). In addition, only 25.9% (n = 316) of the participants strongly agree/agree that DPT vaccines is effective after the COVID-19 pandemic and more than half (n = 660; 54.2%) of the participants were neutral in this regard. This was significantly associated with gender (p = 0.001), residency area (p < 0.001), employment status (p = 0.009), COVID-19 vaccine doses (p = 0.002), the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p = 0.002). Moreover, only 26.6% (n = 324) of the participants strongly/agree that they are confident in the effectiveness of MMR vaccines after the COVID-19 pandemic with 55.9% (n = 680) being neutral in this regard. This was significantly associated with gender (p = 0.014), residency area (p = 0.010), COVID-19 vaccine doses (p = 0.001), and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p = 0.046). Furthermore, 27.9% (n = 339) of the participants strongly agree/agree that they are confident in the effectiveness of hepatitis B vaccines after the COVID-19 pandemic with 53.8% (n = 655) being neutral in this regard. This was significantly associated with gender (p = 0.020), residency area (p = 0.008), healthcare sector employment (p = 0.038), and COVID-19 vaccine doses (p = 0.005). Finally, 26.5% (n = 323) of the participants strongly agree/agree that they are confident in the effectiveness of pneumococcal conjugate vaccine after the COVID-19 pandemic with 55.2% (n = 672) being neutral in this regard. This was significantly associated with gender (p = 0.003), residency area (p = 0.002), healthcare sector employment (p = 0.029), COVID-19 vaccine doses (p = < 0.001), and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p = 0.031; Table 7). These data show a low level of confidence in COVID-19 vaccines as compared to the other routine vaccines determined herein.

Table 7.

The extent of confidence in different routine vaccine types after COVID-19 pandemic

Question	Response N (%)					P- value
	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Gender	Age*	RA*	N *	EL*	ES*	MI*	NC*	CB*	HE*	VD*	RV*	DT*
COVID-19 vaccines	286 (23.5)	297 (24.4)	429 (35.3)	122 (10)	83 (6.8)	0.002	0.042	0.132	0.123	0.196	0.186	0.710	< 0.001	0.240	0.969	0.005	0.021	0.001
Polio vaccines	138 (11.3)	100 (8.2)	662 (54.4)	157 (12.9)	160 (13.1)	< 0.001	0.486	0.109	0.922	0.587	0.482	0.401	0.011	0.579	0.126	< 0.001	0.913	0.167
DPT vaccine (Diphtheria, Pertussis, Tetanus)	131 (10.8)	110 (9.0)	660 (54.2)	156 (12.8)	160 (13.1)	0.001	0.353	< 0.001	0.830	0.721	0.009	0.284	0.134	0.112	0.199	0.002	0.402	0.002
MMR vaccine (measles, mumps, rubella)	112 (9.2)	101 (8.3)	680 (55.9)	157 (12.9)	167 (13.7)	0.014	0.286	0.010	0.481	0.458	0.477	0.237	0.246	0.625	0.236	0.001	0.942	0.046
Hepatitis B vaccine	118 (9.7)	105 (8.6)	655 (53.8)	163 (13.4)	176 (14.5)	0.020	0.200	0.008	0.837	0.503	0.200	0.076	0.079	0.303	0.038	0.005	0.908	0.064
Pneumococcal Conjugate Vaccine (PCV)	122 (10)	100 (8.2)	672 (55.2)	161 (13.2)	162 (13.3)	0.003	0.146	0.002	0.726	0.321	0.265	0.209	0.360	0.221	0.029	< 0.001	0.694	0.031

*RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status, NC, Total number of children. CY, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, if you have a child who delayed in receiving one of his/ her routine vaccinations beyond the scheduled time, how long was the delay

Changes in the confidence in routine vaccines after the COVID-19 pandemic and the main reasons behind these changes

The participants were asked if their confidence in routine vaccines after COVID-19 pandemic was positively or negatively affected by the pandemic. We found that 59% (n = 723) of the participants had the same confidence level in routine vaccines as before the pandemic while 19% (n = 232) had an increased confidence and 22% (n = 261) reporting a decreased confidence after the pandemic. The participants were, also, asked about reasons for the change in their confidence level in routine vaccines after COVID-19 pandemic and the data are shown in Table 8. As shown, 60.7% (n = 656) of the participants indicated that the speed at which COVID-19 vaccines were developed was the main reason for the change in their confidence in routine vaccines. However, this was not significantly associated with any of the demographic and clinical characteristics of the study participants. We also found that 68.3% (n = 743) of the participants fear that the impact of the COVID-19 vaccine on the immune system or the body’s ability to respond correctly to routine vaccines as another reason for the change in their confidence in routine vaccines. This was significantly associated with gender (p = 0.027), age (p = 0.010), number of children (p = 0.001), and the duration of delay in receiving routine vaccinations beyond the scheduled time for any duration (p = 0.026). In addition, 56.8% (n = 617) of the participants had the reason for the change in their confidence in routine vaccines attributed to having misinformation or false information about the safety of vaccines, which was significantly associated with the number of COVID-19 vaccine doses (p = 0.022). On the other hand, only about a quarter (n = 275; 25.4%) of the participants had the reason attributed to a lack of trust in government or health authorities, which was significantly associated with gender (p = 0.004; Table 8).

Table 8.

The possible reasons for the change in the confidence in routine vaccines after COVID-19 pandemic

Question	Response N (%)		P- value
	Yes	No	Gender	Age*	RA*	N *	EL*	ES*	MI*	MS*	NC*	CB*	HE*	VD*	RV*	DT*
The speed at which COVID-19 vaccines were developed	656 (60.7)	425 (39.3)	0.323	0.871	0.285	0.735	0.244	0.953	0.277	0.986	0.659	0.406	0.621	0.139	0.365	0.918
Fear of the impact of the COVID-19 vaccine on the immune system or the body’s ability to respond correctly to routine vaccines.	743 (68.3)	345 (31.7)	0.027	0.010	0.203	0.269	0.294	0.432	0.231	0.205	0.001	0.077	0.743	0.362	0.287	0.026
Misinformation or false information about the safety of vaccines	617 (56.8)	469 (43.2)	0.406	0.114	0.092	0.768	0.041	0.252	0.043	0.621	0.610	0.328	0.848	0.022	0.394	0.770
Lack of trust in government or health authorities	275 (25.4)	806 (74.6)	0.004	0.794	0.136	0.754	0.073	0.882	0.099	0.103	0.215	0.065	0.298	0.552	0.243	0.439
Personal experience or witnessing negative reactions to vaccines.	612 (56.3)	475 (43.7)	0.129	0.225	0.362	0.956	0.055	0.327	0.224	0.786	0.799	0.347	0.710	0.663	0.493	0.213
Influence of anti-vaccine sentiments or vaccine hesitancy movements	480 (44.6)	596 (55.4)	0.537	0.242	0.163	0.490	0.038	0.459	0.161	0.589	0.759	0.048	0.285	0.525	0.543	0.964
Lack of information or understanding about vaccine development	590 (54.5)	493 (45.5)	0.220	0.268	0.097	0.756	0.174	0.269	0.172	0.904	0.481	0.564	0.996	0.151	0.761	0.583
Advice from friends or family	506 (46.7)	578 (53.3)	0.540	0.879	0.064	0.610	0.122	0.229	0.267	0.944	0.982	0.096	0.918	0.291	0.726	0.746

* RA, Residency area. N, Nationality. EL, Education level. ES, Employment status. MI, Monthly income. MS, Marital status, NC, Total number of children. CY, Number of children who were two years and younger during the COVID-19 pandemic. HE, Healthcare sector employment. VD, Number of COVID-19 vaccine doses. RV, have you ensured that your child/children at vaccination age receive their routine vaccinations on time during the COVID-19 pandemic? DT, if you have a child who delayed in receiving one of his/ her routine vaccinations beyond the scheduled time, how long was the delay

Discussion

We aimed to assess the participants’ changes in confidence towards routine vaccinations after the COVID-19 pandemic. We found that most of the participants had the same confidence level in routine vaccines’ effectiveness as before the pandemic with an almost equal percentage of participants who changed their mind either positively or negatively after the pandemic. Our study also demonstrated a favorable attitude of the participants towards routine vaccinations that was associated with participant’s demographic characteristics.

A study done in Saudi Arabia correlated the parents’ knowledge and views on vaccinations with gender, place of residency, and educational attainment [21]. We also showed that participants’ attitudes were associated with other demographic characteristics such as residence area and educational level. According to a recent study, women had a 1.45 (p < 0.05) higher likelihood than men of displaying positive attitudes [22] which was corroborated in our study.”

This study revealed that most of the participants (81.1%) strongly agreed/agreed that routine vaccination play a key role to their children health and prevention of infectious diseases. Another Saudi study showed that 93% of parents knew that routine vaccinations shield the children from infectious diseases and their consequences, 73.3% of parents felt they had a strong understanding of childhood immunizations, most parents concurred that vaccinations are safe and crucial for maintaining their children’s health, and they firmly believed that the advantages of vaccinations outweigh the risks [23]. It was also found that 94.4% of the parents strongly agreed/agreed that vaccinations given to children protect them from dangerous diseases [22].

Our study showed that 80% of the participants strongly agreed/agreed that it is necessary for parents to ensure that their children receive the recommended vaccinations. Similarly, a study performed among Jeddah residents found that 91% of parents believed that vaccinations keep their children healthy [22]. These findings align with an earlier report on the opinions of parents regarding vaccinations [24]. Similarly, most parents acknowledged the value of vaccination in preventing infectious diseases, according to another study that sought to determine their opinions regarding the HPV vaccine [25]. Similar findings were observed in several national and international studies [23, 26, 27].

We have shown a positive attitude by about 60% of the participants who strongly agreed/agreed that routine vaccinations should be received by individuals by mandatory laws. A similar finding was reported elsewhere, where 59% of the participants thought that regular childhood vaccinations needed to be administered on schedule, even in the face of the COVID-19 pandemic [28]. Regarding the COVID-19 pandemic and regular immunization, only 31.3% of our participants strongly agreed/agreed that they had negative beliefs about the side effects or harmful events of routine vaccinations before the COVID-19 pandemic with the participants’ age, place of residence, and monthly income substantially correlating with their awareness of any myths or misconceptions that surfaced throughout the pandemic. It has been reported that girls in the 18–29 age group who had better educational levels and lived in cities had higher odds of belonging to the low misunderstanding level [29].

In our study, the rate of receiving seasonal influenza vaccination this year or last year (37.3%) was found to be significantly associated gender, age, residence, educational level, employment status, monthly income, marital status, total number of children, and number of children under two years old during the COVID-19 pandemic. A previous Saudi report found that 56.6% of the participants aged 36 or older did not obtain the yearly influenza vaccine [30]. However, we had a lower rate of 48.9%.

Among the 1217 participants in our study, only 5.7% had refused any vaccinations for their child. According to a study performed among parents in Jeddah city, Saudi Arabia, there are still misunderstandings and worries about vaccinations, even though most parents support childhood immunization programs and acknowledge their advantages [22]. Vaccination hesitancy is common all over the world and varies in degree of concern depending on the nation [31]. Likewise, a study reported that social media misinformation, personal opinions and values, and a lack of trust in healthcare providers are some of the factors that contribute to vaccine hesitation [32].

We found several significant associations between participants’ trust in different sources of information regarding routine vaccinations and various demographic factors. Specifically, trust in healthcare specialists regarding routine vaccinations was very high (89.6%) and was associated with COVID-19 vaccine doses, timely vaccination of children during the pandemic, and delays in routine vaccinations for children and have the highest impact on participants trust. The trust in healthcare specialists may be influenced by experience of the participants with COVID-19 vaccination programs and the perceived effectiveness of routine vaccinations during the pandemic. The trust in books regarding routine vaccinations was also high (59.4%) and was associated with age and residence which may be influenced by age-related factors and geographical location. However, trust in family and friends was below average and was associated with education level, monthly income, and COVID-19 vaccine doses which may be influenced by socioeconomic status and personal experiences with vaccination. Finally, trust in social media regarding routine vaccinations was low (27.5%) and was only associated with gender suggesting that it may be influenced by gender-related factors and exposure to online information sources. Other studies have reported a significant influence of social media on vaccine hesitancy [33–35].

We have shown significant associations between the participants’ socioeconomic status, their experiences during the COVID-19 pandemic, and their confidence in routine vaccinations. Notably, higher monthly incomes and marital status were positively associated with confidence in vaccine effectiveness and safety. Other studies [21, 23] provided corroboration that highlighted the influence of socioeconomic factors on vaccination attitudes in Saudi Arabia, suggesting that individuals with better economic stability and social support tend to exhibit higher trust in vaccines.

The number of COVID-19 vaccine doses received emerged as a pivotal factor in enhancing confidence across various dimensions, from vaccine safety to the trustworthiness of health authorities. This echoes the broader literature indicating that positive experiences with healthcare systems, including vaccination, can reinforce trust in public health measures [36–38]. However, our study uniquely contributes to the understanding that delays in routine vaccinations for children during the pandemic significantly affected parents’ confidence, underscoring the critical role of maintaining vaccination schedules for sustaining public trust.

The associations observed in our study extend the findings of previous research within the Saudi context and underscore the importance of addressing vaccine hesitancy through targeted communication and support, particularly for populations experiencing socioeconomic vulnerabilities or disruptions in routine vaccination schedules due to the pandemic. These associations are substantiated by one report [39], where the safety concerns and misinformation about side effects significantly contributed to vaccine hesitancy among the Saudi Arabian population. That study used the WHO Vaccine Hesitancy Scale and highlighted that individuals with chronic diseases were notably less inclined to accept vaccination [39]. Similarly, another study [40], identified adverse side effects and doubts about vaccine safety as primary reasons for hesitancy in the rural Jazan region, emphasizing the need for targeted educational campaigns to address these misconceptions. These studies collectively suggest that a nuanced understanding of local and demographic-specific concerns about vaccines can significantly enhance the effectiveness of communication strategies aimed at reducing hesitancy [39, 40]. In addition, our results demonstrate a proactive approach towards routine vaccinations among the study participants, with a significant majority adhering to vaccination schedules and actively seeking information from reliable sources. Such behavior aligns with the global emphasis on vaccine literacy and the positive shift towards vaccine acceptance post-COVID-19 [41]. Our findings on the significance of socioeconomic factors, such as employment status and income, in influencing vaccination behaviors resonate with the patterns highlighted in other reports, where parental attitudes towards vaccines were closely linked to demographic characteristics and socioeconomic states [22, 23].

The engagement with healthcare providers and the inclination to encourage others to vaccinate shown in our study reflect a community-oriented perspective towards public health, which has been identified as a crucial element in vaccine advocacy [42]. Our study extends these observations by providing empirical evidence of these behaviors in the context of the COVID-19 pandemic, highlighting how experiences during the pandemic have potentially reinforced the value placed on routine vaccinations. Moreover, skepticism towards the effectiveness of routine vaccinations, although present, was not predominant, suggesting a generally positive attitude towards vaccines among the participants. A nuanced understanding of vaccine skepticism offers a critical perspective for public health strategies aiming to address vaccine hesitancy, reinforcing the need for targeted interventions that consider the complex interplay of individual experiences, socioeconomic factors, and the broader impact of the pandemic on public attitudes towards vaccinations [40].

More than half of the participants in our study had a neutral opinion on the confidence in the effectiveness of various vaccines with lower proportions having a high to very high confidence in routine vaccines with the lowest rates in COVID-19 vaccine confidence. Several factors were associated with these confidence levels, including gender, age, vaccination status during the COVID-19 pandemic, vaccination doses, residence, education level, and socioeconomic status. A recent study [16] found a decline in vaccine confidence scores following the COVID-19 pandemic irrespective of the participants’ gender, age, graduate status, ethnicity and religious belief. Despite abundant epidemiological evidence of the safety and effectiveness of COVID-19 vaccines, in our study, only 1 in 5 participants (19%) reported that their vaccine confidence had increased since the pandemic while most participants reported that their confidence remained unchanged (59%) or even decreased (22%). The decreased confidence in routine vaccines levels suggest a lack of trust or skepticism among respondents regarding the effectiveness of vaccines, which could be influenced by various factors e.g., gender, age, and socioeconomic status that may impact individuals’ perceptions of vaccine efficacy. Additionally, experiences during the COVID-19 pandemic, such as vaccination status and number of COVID-19 doses received, may also influence the confidence levels. Another study found the perceptions around the importance and safety of the MMR and HPV vaccines dropped over the pandemic period with notable backslides in specific countries and socio-demographic groups [43]. For example, there has been a significant change since the start of the pandemic in the association between vaccine confidence and age, with younger adults becoming less confident since 2019, while older groups remain at high vaccine confidence levels [43].

Our study has several strengths including the large number of participants and the scarcity of the existing data on this topic both locally and globally. To our knowledge, our study is one of very few studies conducted in Saudi Arabia to address the impact of COVID-19 and its vaccination on the community confidence in routine vaccination. The major limitation in our study is the use of social media and online surveys which may not always be acceptable to people resulting in refusal to participate. In addition, response rates cannot accurately be calculated since the denominator is unknown and reasons for low response rates cannot be explained [44]. Furthermore, these online tools may be prone to selection bias such as preventing certain demographic groups from participating such as older, illiterate individuals, or those who have no internet or social media access. In addition, participants may have difficulty accurately recalling past events or behaviors potentially introducing recall bias. However, Saudi Arabia is a high-income country, and internet and social media users represent 99% and approximately 80% of the population, respectively [45]. Thus, selection bias is unlikely present in our study and the surveyed participants does represent the Saudi population to a high extent. Also, another point to consider in interpreting the study findings is that routine vaccination may be defined differently in different countries.

In conclusion, our study found that the confidence in routine vaccination after the COVID-19 pandemic stayed the same among most of the participants and decreased or increased among comparable proportions of them. The most common reason behind the participant’s confidence changes in routine vaccination after the COVID-19 pandemic was the fear of the impact of COVID-19 vaccine on the immune system or the body’s ability to respond correctly to routine vaccines influenced by the influx of information about vaccines after the pandemic. Our study could shed light on the potential challenges and opportunities for promoting vaccine acceptance and uptake in the post-pandemic era.

Abbreviations

COVID-19

Corona Virus Disease-2019

DPT

Diphtheria, Pertussis and Tetanus

MMR

Mumps, Measles, and Rubella

SPSS

Statistical Package for Social Sciences

UNICIF

United Nations International Children’s Emergency Fund

WHO

World Health Organization

Author contributions

All authors contributed to the study conception and design and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This research was funded by Taif University, Saudi Arabia, Project No. (TU-DSPP-2024-135).

Data availability

The data sets used and/or analyzed during this study are available from the corresponding author on reasonable request.

Declarations

Ethical approval

The studies involving human participants were reviewed and approved by The Scientific Research Ethical Committee at Taif University (Approval No. 45–081).

Informed consent statement

Consent to participate in the study was obtained online at the beginning of the survey. The Scientific Research Ethical Committee at Taif University waived the requirement of written informed consent for participation.

Consent for publication

All authors participated in this manuscript and agreed for publication.

Competing interests

The authors declare no competing interests.