Structural equation modeling of factors influencing childhood vaccination in Saudi Arabia

Vaccines are a global health success story, saving millions of lives each year. However, barriers to acceptance, such as misinformation, safety concerns, and trust issues, persist among parents. This study aimed to explore factors influencing Saudi parents' decisions to vaccinate their children, focusing on attitudes, subjective norms, perceived behavioral control, and behavioral intentions.

A cross-sectional study was conducted in Jazan, Saudi Arabia, across 170 primary healthcare centers (PHCCs) in seven administrative sectors. A random sampling approach selected 10 PHCCs per sector. Saudi parents with children aged 0-6 years attending PHCCs were approached to complete an online questionnaire. Data were collected from December 2023 to February 2024 with a total sample size of n=1310. The inter-relationship in the Theory of Planned Behavior was examined based on the data collected. Structural Equation Modeling (SEM) was used to evaluate the direct relationship between the predictor variables: attitude, subjective norm, and parent perceived behavioral control, on a mediating variable: behavioral intention. Mediation analysis was further carried out to investigate the indirect relationship between the predictor variables and the parents' vaccination decision-making.

The largest proportion of participants was from the Central Sector (27.9%), and the majority were female (68.5%). Most participants were aged 31-40 years (49.8%), married (92.6%), had a university-level education (65.9%), and 66.6% of participants were employed. Approximately 96.3% of children had received vaccinations, and 95.4% were vaccinated. The SEM revealed significant influence of parental attitudes on behavioral intention (B = 0.18, p<0.05); significant influence of subjective norms on behavioral intention (B = 0.08,p<0.05), and negative significant influence of perceived behavioral control on behavioral intentions (B = -0.208, p<0.05). Behavioral intention partially mediated the relationships between the predictor variables and parents' vaccination decision-making. The model fit indices: P value 0.00, Root Mean Square Error of Approximation (RMSEA)= 0.058, Comparative Fit Index (CFI)= 0.866, Tucker Lewis index (TLI)= 0.911, demonstrate the model's overall fit to the data, which indicates a good model fit.

These findings highlight the influence of parental beliefs and social factors on vaccination decisions and emphasize the need for targeted interventions. Insights from this study can inform culturally and contextually relevant strategies to address vaccination hesitancy and strengthen trust in childhood vaccination programs in Saudi Arabia.