Vaccine 35 (2017) 2955–2961

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Vaccine hesitancy among parents in a multi-ethnic country, Malaysia

Fatin Shaheera Mohd Azizi, Yueting Kew ⇑, Foong Ming Moy
Julius Centre University of Malaya, Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Vaccine hesitancy is a threat in combating vaccine-preventable diseases. It has been studied
Received 26 January 2017 extensively in the Western countries but not so among Asian countries.
Received in revised form 5 April 2017 Objectives: To assess the test-retest reliability of the Parent Attitudes about Childhood Vaccines (PACV)
Accepted 5 April 2017
questionnaire in Malay language; to determine the prevalence of vaccine hesitancy among parents and
Available online 20 April 2017
its associations with parents’ socio-demographic characteristics.
Methods: Forward and backward translation of PACV in Malay language was carried out. The reliability of
Keywords:
the Malay-PACV questionnaire was tested among parents with children. The same questionnaire was
Vaccine hesitancy
PACV
used to study vaccine hesitancy among parents in a tertiary hospital in Kuala Lumpur. Information per-
Parents taining to socio-demographic characteristics, sources of information regarding vaccination and vaccine
Multi-ethnic hesitancy were collected. Associations between vaccine hesitancy with socio-demographic factors were
Malaysia tested using Multivariable Logistic Regression.
Results: The Spearman correlation coefficient and Cronbach alpha for total PACV was 0.79 (p < 0.001) and
0.79 respectively. The intra-class correlation coefficients of the subscales ranged from 0.54 to 0.90
demonstrating fair to excellent reliability. A total of 63 (11.6%) parents were noted to be vaccine hesitant.
In the univariate analyses, vaccine hesitancy was associated with unemployed parents, parents who were
younger, had fewer children and non-Muslim. In the multivariate model, pregnant mothers expecting
their first child were four times more likely to be vaccine hesitant compared to those who already had
one or more children (aOR: 3.91, 95% CI: 1.74–8.79) and unemployed parents were also more likely to
be vaccine hesitant (aOR: 1.97, 95% CI: 1.08–3.59). The internet (65.6%) was the main source of informa-
tion on vaccination followed by brochures (56.9%).
Conclusion: The Malay-PACV questionnaire is reliable to be used. The prevalence of vaccine hesitancy
among the multi-ethnic Malaysians was comparable with other populations. Pregnant mothers expecting
their first child and unemployed parents were found to be more vaccine hesitant.
Ó 2017 Elsevier Ltd. All rights reserved.

1. Introduction
Vaccine hesitancy is defined as delay in acceptance or refusal of
vaccines despite availability of vaccination services [1]. It also
includes vaccine related beliefs and behaviors ranging from com-
plete refusal of all vaccines to complete vaccine acceptance [2].
Globally, vaccine hesitancy is a threat in combating vaccine-
preventable diseases [3–5]. Vaccine hesitancy has been studied
extensively in the Western countries and their prevalence ranged
from 8.9% to 28.2% [4,6–9]. However, there was a scarcity of such
information from the Asian countries, including Malaysia.
⇑ Corresponding author at: Julius Centre University of Malaya, Department of
Social & Preventive Medicine, Faculty of Medicine, University of Malaya, 50603
Kuala Lumpur, Malaysia.
E-mail address: yue_ting0214@hotmail.com (Y. Kew).
For the past decades, Malaysia has achieved more than 95%
immunization coverage among infants and young children [10].
However, the number of parents with children aged below two
years refusing vaccination increased from 470 cases in 2013 to
1292 cases in 2014. These numbers could have been larger as data
from the private health clinics were not included [11]. This issue
became more distinct with the re-emergence of diphtheria in June
2016 [12]. In order to maintain high immunization coverage, par-
ental understanding on the importance of vaccination and their
willingness to vaccinate children is important [13]. Hence, there
is an urgent need to study vaccine hesitancy among these parents.
To understand vaccine hesitancy, a valid and reliable tool is
required. Many of the studies on vaccine hesitancy were conducted
in qualitative design [14–17]. There were tools in quantitative
design but most of them were not widely used [16]. One of the
tools, Parent Attitudes About Childhood Vaccines (PACV) [18],
developed in English by Opel et al. was validated and widely used

http://dx.doi.org/10.1016/j.vaccine.2017.04.010
0264-410X/Ó 2017 Elsevier Ltd. All rights reserved.
2956 F.S. Mohd Azizi et al. / Vaccine 35 (2017) 2955–2961
in the United States [19]. The PACV contains 15 items with three
domains, which are (1) behavior, (2) safety and efficacy, and (3)
general attitudes. It has good internal consistency with Cronbach’s
alpha coefficients ranging from 0.74 to 0.84 [6] for the three
domains. The PACV’s validity was assessed by linking its scores
with the children’s immunization records. The results showed that
parents who were more vaccine hesitant (with higher PACV score)
had higher proportion of children being under-immunized [6,7].
Vaccine hesitancy has been reported extensively in the Western
countries but not so among Asian countries including Malaysia. It
is important to address the parents’ concerns and intervene at an
earlier stage to avoid further mushrooming of vaccine hesitant par-
ents. Therefore, a study was initiated to (1) translate the PACV
questionnaire into the Malay (national) language and to assess
its reliability among parents, (2) determine the prevalence of vac-
cine hesitancy among parents and (3) to determine the associa-
tions between parents’ socio-demographic background and
vaccine hesitancy.
2. Material and methods
This study was divided into two phases. Phase I was a cross-
sectional study to test the reliability of the Malay-PACV question-
naire and Phase II was also a cross-sectional study to understand
vaccine hesitancy among parents.
2.1. Phase I: Translation and test-retest of the Malay-PACV
questionnaire
PACV is a self-administered questionnaire that reads at a sixth-
grade level equivalent to primary six in Malaysia. It was translated
into the Malay language (national language of this multiethnic
country) using the forward and backward method. Two experi-
enced translators individually translated the PACV questionnaire
into the Malay version. Both translations were then reviewed and
reconciled to a single Malay version. Next, back translation into
English was conducted by two other bilingual translators blinded
to the original English version. The discrepancies that arose were
discussed and refined to ensure that the Malay version reflected
the meaning of the original PACV questionnaire. Before proceeding
with the reliability test, the Malay-PACV questionnaire was pre-
tested on ten employees at a tertiary institution in order to assess
its understandability and clarity of questions. The Malay PACV
questionnaire was finalized (Appendix A) after fine tuning with
the opinions gained.
Considering the PACV was valid in its original language (Eng-
lish) [6,7], hence, we only carried out the reliability testing via
test-retest method on the Malay-PACV questionnaire. The sample
in the reliability test was recruited through convenience sampling
among working adults from a public university and a primary
school. Inclusion criteria for participants were: (a) parents aged
18 years and above, (b) parents currently having at least a child
with age less than seven years old, or (c) mother who is currently
expecting a child. The Malay-PACV questionnaire was adminis-
tered twice to the participants in a one-week interval. One-week
interval was selected as a period of 2–14 days apart is considered
adequate for the interval to be long enough to reduce the effects
of memory but short enough to diminish the likelihood of system-
atic alterations [20].
2.2. Phase II: Understand vaccine hesitancy among parents
2.2.1. Setting and sample
The study was conducted in the Paediatrics and Antenatal
clinics of a tertiary hospital in Kuala Lumpur, the capital city of
Malaysia. The inclusion criteria were the same as listed in Phase
I. We excluded parents from foreign countries as they might not
be familiar with the vaccination schedule in Malaysia.
2.2.2. Ethical consideration
Approval was obtained from the Medical Research Ethics Com-
mittee (MREC) of University of Malaya Medical Centre, Kuala Lum-
pur, Malaysia (MRECID NO: 2016923-4278), the Department of
Paediatrics and Department of Obstetrics and Gynaecology of the
tertiary hospital. Participation in the study was voluntary. All data
collected was kept confidential, and no unique identifiable infor-
mation was collected. Participants did not receive any form of
remuneration for participation in this study.
2.2.3. Data collection
The study was conducted from November to December 2016.
Convenience sampling was carried out to recruit parents who vis-
ited the Paediatrics clinics and patients from the Antenatal clinics
during the study period. All eligible parents/patients were invited
to participate. After oral and written consents were obtained, par-
ticipants completed the PACV questionnaire, which also included
items regarding socio-demographic characteristics and sources of
information on vaccination. They were asked to consider all child-
hood vaccines in general when they answered the questionnaire.
2.2.4. PACV questionnaire
The PACV questionnaire in bilingual (English and Malay) was
used in the current study. The PACV contains 15 items in three
domains (behavior, safety and efficacy, and general attitudes). Con-
sistent with prior studies, items 1 and 2 were categorized under
the behavior domain; items 7–10 were grouped under the safety
and efficacy domain while items 3–6 and 11–15 in the general atti-
tude domain (Appendix A) [7]. Responses were assigned to a score
of 2 for hesitant responses, 1 for not sure responses and 0 for non-
hesitant responses. Item scores were summed to a total score rang-
ing from 0 to 30. For pregnant mothers who were currently expect-
ing their first child, their maximum total score was 26 as they were
unable to answer two behavior items, i.e. ‘‘Have you ever delayed
having your child get a shot for reasons other than illness or
allergy?” and ‘‘Have you ever decided not to have your child get
a shot for reasons other than illness or allergy?”. For parents with
children who answered ‘‘don’t know” in the above mentioned
behavior items were considered as missing data because this was
more likely to reflect poor recall rather than immunization hesi-
tancy, as suggested by other studies [6,8]. The total raw score
was converted to a 0–100 scale. The PACV scores were dichoto-
mized into two categories, i.e. non-hesitant (score < 50) and hesi-
tant (score  50) following previous literature [6–8].
2.3. Statistical analysis
Data was entered and analyzed using the SPSS software, version
23.0. Internal consistency was assessed using the Cronbach’s alpha.
Test-retest reliability was assessed using the Spearman’s correla-
tion coefficients (r) and the intra-class correlation coefficients
(ICC). Univariate analyses using X2 test were performed to deter-
mine the associations between vaccine hesitancy with socio-
demographic factors. The associations between vaccine hesitancy
and socio-demographic factors were further investigated using
the Multivariable Logistic Regression. All variables with p < 0.25
at univariate level were entered into the multivariate model. Odds
ratio (OR) and 95% confidence intervals (CI) were reported. Signif-
icant level was preset at 0.05.
 F.S. Mohd Azizi et al. / Vaccine 35 (2017) 2955–2961 2957

3. Results Table 2
Socio-demographic characteristics of study population (N = 545).

3.1. Phase I Socio-demographic characteristics N (%)

Age group (years)
One hundred and twenty-four participants answered the 20–29 147 (27.1)
Malay-PACV questionnaire (response rate, 89.2%) during the first 30–39 362 (66.8)
40–49 33 (6.1)
administration. Among the 124 participants, 90 (72.6%) returned
the questionnaires answered one week later. The participants Race
Malay 359 (65.9)
who answered both questionnaires were aged between 25 and
Chinese 107 (19.6)
55 years (mean 35.33 ± 5.45 years), predominantly Malays Indian 79 (14.5)
(83.3%) and females (75.6%). Mean scores for total, behavior, safety
Religion
and efficacy and general attitudes subscales obtained from the Islam 362 (66.4)
Malay-PACV are presented in Table 1. The Spearman correlation Buddha 80 (14.7)
coefficient and Cronbach alpha for total PACV scores were 0.79 Hindu 70 (12.8)
(p < 0.001) and 0.79 respectively. The ICCs of the subscales ranged Christian 33 (6.1)

from 0.54 to 0.90 demonstrating fair to excellent reliability Highest educational level
(Table 1). Secondary school and below 132 (24.2)
Diploma 163 (29.9)
Degree and above 250 (45.9)
Employment status
3.2. Phase II
Unemployed 117 (21.5)
Employed 427 (78.5)
A total of 650 questionnaires were distributed and 604 returned
Monthly household income
(response rate, 92%). Among the 604 returned questionnaires, 59 <RM2 000 59 (11.0)
were excluded as 45 questionnaires were incomplete, eight were RM 2000–RM 5000 270 (50.4)
foreigners and six were indigenous. Finally, 545 participants were RM 5000–RM 10,000 159 (29.7)
included in the data analysis. >RM 10,000 48 (9.0)
Majority of the participants were mothers (91.4%) with mean Marital status
age of 32.3 years old, about two thirds were of Malay ethnicity Married 542 (99.4)
Divorced 3 (0.6)
(65.9%) and Muslims (Islam) (66.4%) (Table 2). About half had
attended university or higher education (45.9%), 78.5% were Relationship with child
Mother 498 (91.4)
employed, about half had household income between RM 2000
Father 47 (8.6)
to RM 5000 and had one to two children.
Number of children
Although some parents considered themselves to be hesitant
Nonea 102 (18.7)
about childhood vaccination or not very confident with the recom- 1–2 313 (57.5)
mended vaccination schedule (Table 3), only 7.9% of them ever >2 130 (23.8)
delayed sending their children for vaccination and 3.2% of them a
Pregnant mothers currently expecting their first child.
had refused vaccines for their children.
The parents’ greatest concerns on vaccination were mainly the
side effects (40.0%); and the efficiency and safety of the vaccines
(22.2% being unsure and 37.4% being concerned). About two third
of the parents (69.4%) were either not sure or agreed that their From the PACV questionnaire, only 63 (11.6%) parents were
children were getting too many vaccine injections while more than noted to be vaccine hesitant (score 50). Compared to the non-
half of them (59.4%) were either unsure or agreed that their chil- vaccine hesitant group, unemployed parents, parents from younger
dren should get fewer vaccines at the same time. Nearly half of age group, non-Muslim and mothers expecting their first child
them (52.0%) showed uncertainty as well as agreeing that it was were significantly more vaccine hesitant (p < 0.05) (Table 4). Other
better for their children to develop immunity by getting sick even socio-demographic characteristics such as ethnicity, educational
though majority of them (88.8%) were aware of the severity of the level, household income and gender did not have any significant
vaccine preventable diseases. association with vaccine hesitancy.
Most parents agreed that they could trust the information they In the multivariate logistic regression analyses (Table 5), preg-
received about vaccination (85.1%). The internet was the most pop- nant mothers expecting their first child were about four times
ular source of information (65.6%), followed by brochures (56.9%), more likely to be vaccine hesitant compared to those who already
healthcare workers (49.4%) and TV (44.1%). However, their confi- had one or more children (aOR: 3.91, 95% CI: 1.74–8.79). Unem-
dence towards the children’s doctors was somewhat lower ployed parents were also more likely to be vaccine hesitant
(70.1%) even though most of them agreed that they were able to (aOR: 1.97, 95% CI: 1.08–3.59). Religion was not significantly asso-
discuss their concern about vaccines with their children’s doctors ciated with vaccine hesitancy in the multivariate model.
(88.4%).

Table 1
Test-retest reliability of the malay-parent attitudes about childhood vaccines (PACV) scores (n = 90).

PACV scores Mean ± SD ICC 95% CI

Test 1 Test 2
Total 7.17 ± 5.19 7.41 ± 5.06 0.91 0.86–0.94
Behavior 0.24 ± 0.79 0.49 ± 1.07 0.54 0.28–0.70
Safety and efficacy 3.62 ± 2.60 3.60 ± 2.52 0.89 0.83–0.93
General attitudes 3.51 ± 2.83 3.53 ± 2.71 0.90 0.84–0.93
2958 F.S. Mohd Azizi et al. / Vaccine 35 (2017) 2955–2961

Table 3 Table 4
Individual PACV statements and participants’ responses. Associations of socio-demographic characteristics and vaccine hesitancy.

Demographic data Vaccine hesitant group p-

valueb
Vaccine hesitant Non vaccine hesitant
n = 63, n (%) n = 482, n (%)
Age group (years)
20–29 30 (20.4) 117 (79.6)
30–39 32 (8.8) 330 (91.2)
40–49 1 (3.0) 32 (97.0) <0.001
Race
Malay 34 (9.5) 325 (90.5)
Chinese 16 (15.0) 91 (85.0)
Indian 13 (16.5) 66 (83.5) 0.101
Religion
Muslim 34 (9.4) 328 (90.6)
Non-Muslim 29 (15.8) 154 (84.2) 0.026
Employment status
Unemployed 20 (17.1) 97 (82.9)
Employed 43 (10.1) 384 (89.9) 0.035
Highest educational level
Secondary school 13 (9.8) 119 (90.2)
and below
Diploma 23 (14.1) 140 (85.9)
Degree and above 27 (10.8) 223 (89.2) 0.459
Monthly household income
<RM 2 000 10 (16.9) 49 (83.1)
RM 2 000–RM 5 30 (11.1) 240 (88.9)
000
RM 5 000–RM 14 (8.8) 145 (91.2)
10,000
>RM 10,000 5 (10.4) 43 (89.6) 0.402
Relationship with child
Mother 59 (11.8) 439 (88.2)
Father 4 (8.5) 43 (91.5) 0.494
Number of children
Nonea 26 (25.5) 76 (74.5)
1–2 27 (8.6) 286 (91.4)
>2 10 (7.7) 120 (92.3) <0.001

Bold values indicate significant difference between vaccine hesitant and non-vac-
cine hesitant groups (p  0.05).
a
Pregnant mothers currently expecting their first child.
b
Chi-square test. P value of 0.05 was considered significant for differences
between vaccine hesitant and non-vaccine hesitant groups.

8.9 to 28.2% [4,6–9]. This variation may be due to different study

a
Shaded responses indicated hesitancy.
4. Discussions
The internal consistency of the Malay-PACV was comparable
with the original PACV [6]. There were high correlation and good
ICC scores for the test-retest of Malay-PACV suggested that the
questionnaire was reliable and responses obtained from this ques-
tionnaire were stable. Hence, the Malay-PACV could serve as a tool
in the evaluation of vaccine hesitancy among parents in Malaysia
as the original PACV was already validated and widely used [6,7].
In our present study, only 11.6% of parents were found to be
vaccine hesitant. Our results concurred with other studies from
the West, with the prevalence of vaccine hesitancy ranging from
populations from different settings (i.e. community vs. hospital
or clinics, urban vs. rural areas, developed vs developing countries,
countries practicing different immunization schedule).
Ninety percent of our participants had never delayed or refused
vaccination for their children, consistent with another study con-
ducted in Malaysia [21]. However, self-reporting of delayed or
refused vaccination was reported in both studies. Hence, the actual
rates of delaying or refusing vaccination may be under-reported.
The main reasons for vaccine refusal in the United States were par-
ental perceptions and concerns about vaccine safety and the risk of
vaccine-preventable diseases [22,23]. Parental concerns on vacci-
nes reported in our study as well as another study from Malaysia
included side effects, religious concerns or beliefs that the disease
was not harmful [21]. The lack of understanding on vaccine pre-
ventable diseases may lead to parents declining vaccination for
their children or to let their children to have the disease run its nat-
ural course [24,25].
In the univariate analyses, vaccine hesitancy was found to be
associated with unemployed parents, parents who were younger,
had fewer children and non-Muslim. However, there were no asso-
ciations with ethnicity, educational level, monthly household
income and parental relationship with children. After adjusted
for religion, number of children and employment status in the mul-
tivariate model, only employment status and number of children
 F.S. Mohd Azizi et al. / Vaccine 35 (2017) 2955–2961 2959

Table 5
Odds Ratio (OR) of factors associated with vaccine hesitancy among parents.

Characteristics Number (n) Crude OR (95% CI) P-value Adjusted ORc (95% CI) P-value
Gender
Male 47 1.00
Female 498 1.45 (0.50–4.17) 0.496
Age group (years)b
20–29 147 8.21 (1.08–62.50)
30–39 362
40–50 33 3.10 (0.41–23.47) 0.001
Ethnic groupb
Malay 359 1.00
Chinese 107 1.68 (0.89–3.18)
Indian 79 1.88 (0.94–3.76) 0.105
Religion
Muslim 362 1.00 1.00
Non-Muslim 183 1.82 (1.07–3.09) 0.028 1.55 (0.88–2.70) 0.127
Employment status
Unemployed 117 1.84 (1.04–3.27) 1.97 (1.08–3.59)
Employed 427 1.00 0.038 1.00 0.027
Household income
<RM2000 59 1.76 (0.56–5.54)
RM2000-RM5000 270 1.08 (0.39–2.93)
RM5000-RM10,000 159 0.83 (0.28–2.44)
>RM10,000 48 1.00 0.413
Highest educational level
Secondary and below 132 1.00
Diploma 163 1.50 (0.73–3.10)
Degree and above 250 1.11 (0.55–2.23) 0.462
Number of children
0a 102 4.11 (1.88–8.99) 3.91 (1.74–8.79)
1–2 313 1.13 (0.53–2.41) 1.05 (0.49–2.28)
>2 130 1.00 <0.001 1.00 <0.001

Bold values indicate significant different (P  0.05).

a
Pregnant mothers expecting their first child.
b
Not included in the multivariate model as there is collinearity between ethnic group with religion, and age group with number of pregnancy.
c
Adjusted for religion, employment status and number of children.

remained significantly associated with vaccine hesitancy. In con-
trast, income or socioeconomic status and education were reported
to be factors affecting vaccine acceptance in a systematic review
[26]. Moreover, determinants of vaccine hesitancy did not influ-
ence hesitancy in only one direction. For example, higher educa-
tion may be associated with both lower and higher levels of
vaccine acceptance [1,26]. Parents with lower socioeconomic class
had shown more concern about the safety of vaccines as compared
to those with higher socio-economic status while some parents in
high income groups may actually relate vaccine safety to concerns
such as autism or long term health conditions [27,28].
Unemployed parents were found to be significantly more vac-
cine hesitant. A recent study on worldwide attitudes to immuniza-
tions found that those unemployed were more likely to hold
negative sentiment for vaccine safety and effectiveness [29]. Fur-
ther analysis in our study showed that unemployed parents were
mostly mothers, had education level of secondary and below, with
family income of <RM 2000 and non-Muslim. Although we did not
find any significant association between educational level and
monthly household income with vaccine hesitancy as mentioned
above, unemployed parents with these characteristics combined
were found to be significantly associated with vaccine hesitancy.
These factors may be interrelated with each other and suggested
that individual factors should not be considered as isolated barriers
to vaccine uptake and promoters of vaccine hesitancy [30].
Younger age and parents who had none or less experience with
childhood vaccination were more vaccine hesitant. From their per-
sonal experience, parents who had at least one child (most likely of
older age group) may have understood the importance of vaccina-
tion on vaccine-preventable diseases and/or the disease impact on
other children [3]. Younger age parents may rely more on the
usage of the internet especially social media networks (such as
Facebook and Twitter) as their primary source of information and
thus, they could be particularly vulnerable to misinformation.
Studies reviewing the content of websites or social networks con-
cerning vaccination found the information was of variable quality
and inexact or negative content was predominant [31–33]. This
is alarming as we found most of our participants trusted the infor-
mation on vaccination they received and the internet was their
most popular source of information. The high level of trust in the
information received may give rise to inaccurate information on
vaccine safety to circulate widely, leading to misperception on vac-
cination contributing to vaccine hesitancy. Benin et al. found that
trust or lack of trust was pivotal for new mothers making decisions
about vaccinating their infants in view of their lack of understand-
ing towards vaccine preventable diseases [14]. Hence, healthcare
workers should be more active in disseminating correct informa-
tion with convincing evidence to the public especially mothers at
the early stage of pregnancy.
Other more popular concerns on vaccination among parents in
Malaysia are religious issues. Vaccination refusal was sometimes
linked with philosophical beliefs or moral convictions regarding
health and immunity, such as a preference for natural over artifi-
cial medicines and hence, refusal of vaccines could also be linked
with strong religious convictions [34]. As Islam is the major reli-
gion in Malaysia, there were reports illustrating Muslims having
misguided belief that vaccines contained DNA from pigs hence
making vaccines forbidden for Muslim [35]. However, in this study,
we found non-Muslims were more vaccine hesitant compared to
Muslims. It is not clear what were the contributing factors for
2960 F.S. Mohd Azizi et al. / Vaccine 35 (2017) 2955–2961
non-Muslim to be vaccine hesitant. The Muslim participants’
responses may be due to the recent action taken by the Depart-
ment of Islamic Development, Malaysia declaring that vaccination
is permissible (harus) and is promoted as a social responsibility
(fardhu kifayah) [36]. In summary, individual decision-making
regarding vaccination is complex and may involve emotional, cul-
tural, social, spiritual and political factors as much as cognitive fac-
tors which made vaccine hesitancy a complicated issue to be
explained [37]. Qualitative studies may be necessary to be carried
out in this aspect.
There are a few limitations which need to be addressed while
interpreting the results. Firstly, casual inferences could not be
drawn in this cross-sectional study. Besides, social desirability bias
may be present as the delay and refusal of vaccination were
self-reported. Convenience sampling of the participants and data
collection in the hospital setting may bias the results. We did not
collect information on actual immunization uptake, thus we could
not check the validity of the Malay-PACV in our setting. However,
the original PACV demonstrated good validity in other populations
and clinical settings [4,6–9,16,18].
Nevertheless, this may be the first study carried out to identify
vaccine hesitancy in Malaysia by using an established and vali-
dated tool such as the PACV questionnaire. The findings will be
useful in understanding parents’ vaccine hesitancy and better
health promotion strategies can be developed. Our sample size
was larger compared to most of the other studies [6–9]. Future
studies should be carried out prospectively, in the community set-
ting and actual uptake of vaccination should be recorded.
5. Conclusions
The Malay-PACV questionnaire can be used to assess vaccine
hesitancy among parents in Malaysia. The prevalence of vaccine
hesitancy among the multi-ethnic Malaysians was comparable
with other populations. Unemployed parents and pregnant moth-
ers expecting their first child were found to be more vaccine hesi-
tant. Majority of the parents were concerned of the safety, side
effects and efficacy of childhood vaccines in addition to other mis-
guided opinions such as children getting too many shots and infec-
tion was a better way to develop immunity. The internet was the
main source of information on vaccination, followed by healthcare
workers. Targeted preventive measures should be carried out, par-
ticularly on the identified high risk groups to prevent the increas-
ing trend of vaccine hesitancy which may contribute to vaccine
refusal eventually.
Contributors’ statement
Foong Ming Moy: Dr. Moy conceptualized and designed the
study, critically reviewed and edited the manuscript, and approved
the final manuscript.
Fatin Shaheera Mohd Azizi, Yueting Kew: Ms. Mohd Azizi and
Dr. Kew carried out data collection, data analysis and interpreta-
tion of data, drafted the manuscript, reviewed and revised the
manuscript, and approved the final manuscript.
Funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of interest
Conflicts of interest: none.
Acknowledgements
The authors would like to express our appreciation to the
Department of Paediatrics and Department of Obstetrics and
Gynaecology of University of Malaya Medical Centre, Kuala Lum-
pur, Malaysia for approving the study. We are grateful to all par-
ents for their participation in this study. Not forgetting students
and staffs of the Faculty of Medicine who assisted in the study.
Appendix A. Supplementary material
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.vaccine.2017.04.
010.
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