Navigating Parental Vaccine Hesitancy in Pahang, Malaysia: Insights into Childhood Vaccination Decisions
DOI:
https://doi.org/10.56294/hl2025877Keywords:
Childhood Vaccine, Immunization, PLS-SEM, Theory of Planned Behavior, Global Vaccine HesitancyAbstract
Introduction: vaccine hesitancy among parents is on the rise, with some opting for alternative vaccination schedules, selectively vaccinating their children, or rejecting vaccines altogether. Malaysia has reported 1600 cases of parents refusing to vaccinate their children, an increase from 1500 cases in 2015, with Pahang being one of the states experiencing the highest number of vaccine refusals.
Method: a quantitative approach was employed, utilizing surveys to collect and analyze data from 333 parents who have at least one child under the age of 16 in Pahang, Malaysia.
Results: the findings revealed that attitude and risk perception negatively influenced vaccine hesitancy, while other factors, such as subjective norms, perceived behavioral control, and safety perception, positively influenced childhood vaccine intention and negatively influenced vaccine hesitancy.
Conclusions: these results have important implications for public health initiatives aimed at reducing vaccine hesitancy in Malaysia. Understanding the factors that contribute to parents' decisions can help design targeted interventions that address misconceptions, improve risk perception, and encourage positive attitudes toward vaccination.
References
1. Quinn SC, Jamison AM, An J, Hancock GR, Freimuth VS. Measuring vaccine hesitancy, confidence, trust and flu vaccine uptake: Results of a national survey of White and African American adults. Vaccine. 2019;37(9):1168-1173. https://doi.org/10.1016/j.vaccine.2019.01.033
2. UNICEF. Immunization coverage. 2021 [cited 2025 Aug 3]. Available from: https://www.who.int/news-room/fact-sheets/detail/immunizationcoverage
3. Vaithilingam S, Hwang LA, Nair M, Ng JWJ, Ahmed P, Musa KI. COVID-19 vaccine hesitancy and its drivers: An empirical study of the vaccine hesitant group in Malaysia. PLoS One. 2023;18(3): e0282520. https://doi.org/10.1371/journal.pone.0282520
4. Mat Daud MRH, Yaacob NA, Ibrahim MI, Wan Muhammad WAR. Five-year trend of measles and its associated factors in Pahang, Malaysia: a population-based study. Int J Environ Res Public Health. 2022;19(13):8017. https://doi.org/10.3390/ijerph19138017
5. Farhana SN. Puzzled by parents' anti-vaccine stand. New Straits Times. 2017.
6. Fernandes N, Costa D, Costa D, Keating J, Arantes J. Predicting COVID-19 vaccination intention: The determinants of vaccine hesitancy. Vaccines. 2021;9(10):1161. https://doi.org/10.3390/vaccines9101161
7. Lazarus JV, Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, El-Mohandes A. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2021;27(2):225-228. https://doi.org/10.1101/2020.08.23.20180307
8. Henrich J, Heine SJ, Norenzayan A. The weirdest people in the world? Behav Brain Sci. 2010;33(2-3):61-83. https://doi.org/10.31219/osf.io/ufjya
9. Sallam M. COVID-19 vaccine hesitancy worldwide: A concise systematic review of vaccine acceptance rates. Vaccines. 2021;9(2):160. https://doi.org/10.3390/vaccines9020160
10. Betsch C, Schmid P, Heinemeier D, Korn L, Holtmann C, Böhm R. Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination. PLoS One. 2018;13(12): e0208601. https://doi.org/10.31234/osf.io/ytb7w
11. Ajzen I, Fishbein M. Attitude-behavior relations: A theoretical analysis and review of empirical research. Psychol Bull. 1977;84(5):888-918. https://doi.org/10.1037//0033-2909.84.5.888
12. Fan CW, Chen IH, Ko NY, Yen CF, Lin CY, Griffiths MD, Pakpour AH. Extended theory of planned behavior in explaining the intention to COVID-19 vaccination uptake among mainland Chinese university students: an online survey study. Hum Vaccin Immunother. 2021;17(10):3413-3420. https://doi.org/10.1080/21645515.2021.1933687
13. Wolff K. COVID-19 vaccination intentions: the theory of planned behavior, optimistic bias, and anticipated regret. Front Psychol. 2021; 12:648289. https://doi.org/10.3389/fpsyg.2021.648289
14. Shmueli L. Predicting intention to receive COVID-19 vaccine among the general population using the health belief model and the theory of planned behavior model. BMC Public Health. 2021; 21:804. https://doi.org/10.1186/s12889-021-10816-7
15. Patwary MM, Bardhan M, Disha AS, Hasan M, Haque MZ, Sultana R, Sallam M. Determinants of COVID-19 vaccine acceptance among the adult population of Bangladesh using the health belief model and the theory of planned behavior model. Vaccines. 2021;9(12):1393. https://doi.org/10.3390/vaccines9121393
16. Husain F, Shahnawaz MG, Khan NH, Parveen H, Savani K. Intention to get COVID-19 vaccines: Exploring the role of attitudes, subjective norms, perceived behavioral control, belief in COVID-19 misinformation, and vaccine confidence in Northern India. Hum Vaccin Immunother. 2021;17(11):3941-3953. https://doi.org/10.1080/21645515.2021.1967039
17. Akbar MB, Singh L, Deshpande S, Amoncar N. COVID-19 vaccine perceptions among South Asian communities in the UK: An application of the theory of planned behavior. Health Mark Q. 2023;40(3):271-288. https://doi.org/10.1080/07359683.2022.2092325
18. Caso D, Capasso M, Fabbricatore R, Conner M. Understanding the psychosocial determinants of Italian parents’ intentions not to vaccinate their children: an extended theory of planned behaviour model. Psychol Health. 2022;37(9):1111-1131. https://doi.org/10.1080/08870446.2021.1936522
19. Catalano HP, Knowlden AP, Birch DA, Leeper JD, Paschal AM, Usdan SL. Using the theory of planned behavior to predict HPV vaccination intentions of college men. J Am Coll Health. 2017;65(3):197-207. https://doi.org/10.1080/07448481.2016.1269771
20. Myers LB, Goodwin R. Determinants of adults' intention to vaccinate against pandemic swine flu. BMC Public Health. 2011; 11:15. https://doi.org/10.1186/1471-2458-11-15
21. Sallam M, Dababseh D, Eid H, Al-Mahzoum K, Al-Haidar A, Taim D, Mahafzah A. High rates of COVID-19 vaccine hesitancy and its association with conspiracy beliefs: a study in Jordan and Kuwait among other Arab countries. Vaccines. 2021;9(1):42. https://doi.org/10.3390/vaccines9010042
22. Guidry JP, Laestadius LI, Vraga EK, Miller CA, Perrin PB, Burton CW, Carlyle KE. Willingness to get the COVID-19 vaccine with and without emergency use authorization. Am J Infect Control. 2021;49(2):137-142. https://doi.org/10.1016/j.ajic.2020.11.018
23. Lau L, Lau Y, Lau YH. Prevalence and correlates of influenza vaccination among non-institutionalized elderly people: an exploratory cross-sectional survey. Int J Nurs Stud. 2019;46(6):768-777. https://doi.org/10.1016/j.ijnurstu.2008.12.006
24. Strelitz B, Gritton J, Klein EJ, Bradford MC, Follmer K, Zerr DM, Opel DJ. Parental vaccine hesitancy and acceptance of seasonal influenza vaccine in the pediatric emergency department. Vaccine. 2015;33(15):1802-1807. https://doi.org/10.1016/j.vaccine.2015.02.034
25. Daugherty JD, Blake SC, Grosholz JM, Omer SB, Polivka-West L, Howard DH. Influenza vaccination rates and beliefs about vaccination among nursing home employees. Am J Infect Control. 2015;43(2):100-106.https://doi.org/10.1016/j.ajic.2014.08.021
26. Van den Dool C, Van Strien AM, Looijmans-Van Den Akker I, Bonten MJM, Sanders EAM, Hak E. Attitude of Dutch hospital personnel towards influenza vaccination. Vaccine. 2008;26(10):1297-1302 https://doi.org/10.1016/j.vaccine.2007.12.045.
27. Akbar MB, Singh L, Deshpande S, Amoncar N. COVID-19 vaccine perceptions among South Asian communities in the UK: An application of the theory of planned behavior. Health Mark Q. 2023;40(3):271-288. https://doi.org/10.1080/07359683.2022.2092325
28. Greyson D, Dubé È, Fisher WA, Cook J, Sadarangani M, Bettinger JA. Understanding influenza vaccination during pregnancy in Canada: attitudes, norms, intentions, and vaccine uptake. Health Educ Behav. 2021;48(5):680-689. https://doi.org/10.1177/10901981211001863
29. Zulkifli SN, Minhat HS, Lim PY. Driving factors of parental vaccine hesitancy towards COVID-19 vaccines for children in Petaling District, Malaysia. Malays J Public Health Med. 2024;24(1):239-248.
30. Fisher CB, Gray A, Sheck I. COVID-19 pediatric vaccine hesitancy among racially diverse parents in the United States. Vaccines. 2021;10(1):31. https://doi.org/10.3390/vaccines10010031
31. Agarwal V. A/H1N1 vaccine intentions in college students: An application of the theory of planned behavior. J Am Coll Health. 2014;62(6):416-424. https://doi.org/10.1080/07448481.2014.917650
32. Hilyard KM, Quinn SC, Kim KH, Musa D, Freimuth VS. Determinants of parental acceptance of the H1N1 vaccine. Health Educ Behav. 2014;41(3):307-314. https://doi.org/10.1177/1090198113515244
33. Liu X, Zhou Y, Wang Z. Preference access of users' cancer risk perception using disease-specific online medical inquiry texts. Inf Process Manag. 2022;59(1):102737. https://doi.org/10.1016/j.ipm.2021.102737
34. Link E. Information avoidance during health crises: Predictors of avoiding information about the COVID-19 pandemic among German news consumers. Inf Process Manag. 2021;58(6):102714. https://doi.org/10.1016/j.ipm.2021.102714
35. Wismans A, Thurik R, Baptista R, Dejardin M, Janssen F, Franken I. Psychological characteristics and the mediating role of the 5C Model in explaining students’ COVID-19 vaccination intention. PLoS One. 2021;16(8):e0255382. https://doi.org/10.1371/journal.pone.0255382
36. Youn S. Teenagers' perceptions of online privacy and coping behaviors: A risk–benefit appraisal approach. J Broadcast Electron Media. 2005;49(1):86-110. https://doi.org/10.1207/s15506878jobem4901_6
37. Carcelen AC, Prosperi C, Mutembo S, Chongwe G, Mwansa FD, Ndubani P, Truelove SA. COVID-19 vaccine hesitancy in Zambia: A glimpse at the possible challenges ahead for COVID-19 vaccination rollout in sub-Saharan Africa. Hum Vaccin Immunother. 2022;18(1):1-6. https://doi.org/10.1080/21645515.2021.1948784
38. Joshi A, Kaur M, Kaur R, Grover A, Nash D, El-Mohandes A. Predictors of COVID-19 vaccine acceptance, intention, and hesitancy: A scoping review. Front Public Health. 2021; 9:698111. https://doi.org/10.3389/fpubh.2021.698111
39. Karlsson LC, Soveri A, Lewandowsky S, Karlsson L, Karlsson H, Nolvi S, Antfolk J. Fearing the disease or the vaccine: The case of COVID-19. Pers Individ Dif. 2021; 172:110590. https://doi.org/10.31234/osf.io/7n3gt
40. Fadhel FH. Vaccine hesitancy and acceptance: An examination of predictive factors in COVID-19 vaccination in Saudi Arabia. Health Promot Int. 2023;38(4): daab209. https://doi.org/10.1093/heapro/daab209
41. Verger P, Scronias D, Dauby N, Adedzi KA, Gobert C, Bergeat M, Dubé E. Attitudes of healthcare workers towards COVID-19 vaccination: a survey in France and French-speaking parts of Belgium and Canada. Euro Surveill. 2021;26(3):2002047. https://doi.org/10.2807/1560-7917.es.2021.26.3.2002047
42. Featherstone JD, Bell RA, Ruiz JB. Relationship of people’s sources of health information and political ideology with acceptance of conspiratorial beliefs about vaccines. Vaccine. 2019;37(23):2993-2997. https://doi.org/10.1016/j.vaccine.2019.04.063
43. Syan SK, Gohari MR, Levitt EE, Belisario K, Gillard J, DeJesus J, MacKillop J. COVID-19 vaccine perceptions and differences by sex, age, and education in 1,367 community adults in Ontario. Front Public Health. 2021; 9:719665. https://doi.org/10.3389/fpubh.2021.719665
44. Ryan M, Marlow LA, Forster A. Countering vaccine hesitancy among pregnant women in England: the case of Boostrix-IPV. Int J Environ Res Public Health. 2020;17(14):4984. https://doi.org/10.3390/ijerph17144984
45. Sarathchandra D, Navin MC, Largent MA, McCright AM. A survey instrument for measuring vaccine acceptance. Prev Med. 2018; 109:1-7. https://doi.org/10.1016/j.ypmed.2018.01.006
46. Zhang Q, Zhang R, Wu W, Liu Y, Zhou Y. Impact of social media news on COVID-19 vaccine hesitancy and vaccination behavior. Telemat Inform. 2023; 80:101983. https://doi.org/10.1016/j.tele.2023.101983
47. Liu Z, Yang JZ. In the wake of scandals: how media use and social trust influence risk perception and vaccination intention among Chinese parents. Health Commun. 2021;36(10):1188-1199. https://doi.org/10.1080/10410236.2020.1748834
48. Zhou L, Ampon-Wireko S, Xu X, Quansah PE, Larnyo E. Media attention and vaccine hesitancy: Examining the mediating effects of fear of COVID-19 and the moderating role of trust in leadership. PLoS One. 2022;17(2): e0263610. https://doi.org/10.1371/journal.pone.0263610
49. Gefen D, Rigdon EE, Straub D. Editor's comments: An update and extension to SEM guidelines for administrative and social science research. MIS Q. 2011;35(2): iii-xiv.
50. Ringle C, Da Silva D, Bido D. Structural equation modeling with the SmartPLS. Braz J Mark. 2015;13(2).
51. Hair JF, Risher JJ, Sarstedt M, Ringle CM. When to use and how to report the results of PLS-SEM. Eur Bus Rev. 2019;31(1):2-24. https://doi.org/10.1108/ebr-11-2018-0203
52. MacKenzie SB, Podsakoff PM. Common method bias in marketing: Causes, mechanisms, and procedural remedies. J Retail. 2012;88(4):542-555. https://doi.org/10.1016/j.jretai.2012.08.001
53. Ngah AH, Ramayah T, Ali MH, Khan MI. Halal transportation adoption among pharmaceuticals and cosmetics manufacturers. J Islam Mark. 2020;11(6):1619-1639. https://doi.org/10.1108/jima-10-2018-0193
54. Lindell MK, Whitney DJ. Accounting for common method variance in cross-sectional research designs. J Appl Psychol. 2001;86(1):114. https://doi.org/10.1037//0021-9010.86.1.114
55. Schwarzinger M, Watson V, Arwidson P, Alla F, Luchini S. COVID-19 vaccine hesitancy in a representative working-age population in France: A survey experiment based on vaccine characteristics. Lancet Public Health. 2021;6(4): e210-e221. https://doi.org/10.1016/s2468-2667(21)00012-8
56. Myers R. Classical and modern regression with applications. 2nd ed. Boston, MA: Duxbury; 1990.
57. Kleinbaum DG, Kupper LL, Muller KE. Applied regression analysis and other multivariate methods. 2nd ed. Boston: PWS–Kent; 1988.
58. Kleinbaum DG, Kupper LL, Muller KE, Nizam A. Applied regression analysis and other multivariable methods. Boston, MA: Cengage Learning; 2014.
59. Kaps M, Lamberson WR. Biostatistics for animal science. Wallingford: CABI; 2017.
60. Hair JF Jr, Matthews LM, Matthews RL, Sarstedt M. PLS-SEM or CB-SEM: updated guidelines on which method to use. Int J Multivar Data Anal. 2017;1(2):107-123. https://doi.org/10.1504/ijmda.2017.087624
61. Chin WW. Commentary: Issues and opinion on structural equation modeling. MIS Q. 1998;22(1): vii-xvi.
62. Sharif Nia H, Allen KA, Arslan G, Kaur H, She L, Khoshnavay Fomani F, Gorgulu O, Sivarajan Froelicher E. The predictive role of parental attitudes toward COVID-19 vaccines and child vulnerability: A multi-country study on the relationship between parental vaccine hesitancy and financial well-being. Front Public Health. 2023; 11:1085197. https://doi.org/10.3389/fpubh.2023.1085197
63. Li JB, Lau EYH, Chan DKC. What makes Hong Kong parents hesitant to vaccinate their children against COVID-19? Testing health belief model and theory of planned behavior in a large-scale survey. 2022. https://doi.org/10.31234/osf.io/9vh4p
64. Abd Rahman NAS, Ju SY, Razali JR, Hamdan NH, Ridzuan MR, Kong LK. Post-COVID-19 Malaysian parents’ views on children’s vaccination: subjective norms analysis. Int J Eval Res Educ. 2024;13(5):2801.
65. Dou K, Yang J, Wang LX, Li JB. The theory of planned behavior explains males’ and females’ intentions to receive COVID-19 vaccines differently. Hum Vaccin Immunother. 2022;18(5):2086393. https://doi.org/10.1080/21645515.2022.2086393
66. Dawson K, Gyurcsik N, Culos-Reed N, Brawley L. Perceived control: a construct that bridges theories of motivated behavior. In: Roberts G, editor. Advances in motivation in sport and exercise. Champaign (IL): Human Kinetics; 2001. p. 321–357.
67. Ridzuan MR, Abd Rahman NAS, Manas NHN, Rabun MN, Yew JS. A descriptive study on the Malaysian parents' HPV vaccination intentions. J Acad. 2022;10(1):132–140.
68. Caserotti M, Girardi P, Rubaltelli E, Tasso A, Lotto L, Gavaruzzi T. Associations of COVID-19 risk perception with vaccine hesitancy over time for Italian residents. Soc Sci Med. 2021; 272:113688. https://doi.org/10.1016/j.socscimed.2021.113688
69. Wang B, Zhong X, Fu H, He M, Hu R. COVID-19 vaccine hesitancy and GAD: The role of risk perception and vaccination status. Front Public Health. 2022; 10:994330. https://doi.org/10.3389/fpubh.2022.994330
70. Martinelli M, Veltri GA. Shared understandings of vaccine hesitancy: How perceived risk and trust in vaccination frame individuals’ vaccine acceptance. PLoS One. 2022;17(10): e0276519. https://doi.org/10.1371/journal.pone.0276519
71. Osman R, Ridzuan MR, Amira N, Abd Rahman S, Yusof NM. Prevalence of Human Papillomavirus (HPV) vaccine interest among female university students in Kuantan, Pahang. 2022.
72. Obohwemu K, Christie-de Jong F, Ling J. Parental childhood vaccine hesitancy and predicting uptake of vaccinations: a systematic review. Prim Health Care Res Dev. 2022;23: e68.
73. Martinelli M, Veltri GA. Do cognitive styles affect vaccine hesitancy? A dual-process cognitive framework for vaccine hesitancy and the role of risk perceptions. Soc Sci Med. 2021; 289:114403. https://doi.org/10.1016/j.socscimed.2021.114403
74. Wagner AL, Huang Z, Ren J, Laffoon M, Ji M, Pinckney LC, Zikmund-Fisher BJ. Vaccine hesitancy and concerns about vaccine safety and effectiveness in Shanghai, China. Am J Prev Med. 2021;60(1 Suppl 1):S77-S86. https://doi.org/10.1016/j.amepre.2020.09.003
75. Liao Q, Lam WWT, Cowling BJ, Fielding R. Psychosocial influences on parental decision-making regarding vaccination against seasonal influenza for young children in Hong Kong: a longitudinal study, 2012–2013. Int J Behav Med. 2016; 23:621-634. https://doi.org/10.1007/s12529-016-9551-1
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Nur Hidayahtul Nabihah Manas, Mohd Rozaimy Ridzuan, Noor Amira Syazwani Abd Rahman, Muhammad Redzuan Osman, Muhammad Iqbal (Author)
This work is licensed under a Creative Commons Attribution 4.0 International License.
The article is distributed under the Creative Commons Attribution 4.0 License. Unless otherwise stated, associated published material is distributed under the same licence.
