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Introduction: Internal validation techniques alone do not guarantee the value of a model. This study aims to investigate the external validity of the Parental Attitude toward Childhood Vaccination (PACV) scale for assessing parents' attitude toward seasonal influenza vaccination., Methods: Using a snowball sampling approach, an anonymous online questionnaire was distributed in two languages (English and Arabic) across seven countries. To assess the internal validity of the model, the machine learning technique of "resampling methods" was used to repeatedly select various samples collected from Egypt and refit the model for each sample. The binary logistic regression model was used to identify the main determinants of parental intention to vaccinate their children against seasonal influenza. We adopted the original model developed and used its predictors to determine parents' intention to vaccinate their children in Libya, Lebanon, Syria, Iraq, Palestine, and Sudan. The area under the curve (AUC) indicated the model's ability to distinguish events from non-events. We visually compared the observed and predicted probabilities of parents' intention to vaccinate their children using a calibration plot., Results: A total of 430 parents were recruited from Egypt to internally validate the model, and responses from 2095 parents in the other six countries were used to externally validate the model. Multivariate regression analysis showed that the PACV score, child age (adolescence), and Coronavirus disease 2019 (COVID-19) vaccination in children were significantly associated with the intention to receive the vaccination. The AUC of the developed model was 0.845. Most of the predicted points were close to the diagonal line, demonstrating better calibration (the prediction error was 16.82%). The sensitivity and specificity of the externally validated model were 89.64 and 37.89%, respectively (AUC = 0.769)., Conclusion: The PACV showed similar calibration and discrimination across the six countries. It is transportable and can be used to assess attitudes towards influenza vaccination among parents in different countries using either the Arabic or English version of the scale., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest., (Copyright © 2023 Ghazy, Waheed Elkhadry, Abdel-Rahman, Taha, Youssef, Elshabrawy, Assem Ibrahim, Al Awaidy, Al-Ahdal, Padhi and Fadl.)

Background: Seasonal influenza vaccine can reduce the risk of influenza-associated hospitalizations and deaths among children. Given that parents are the primary decision makers, this study examined the parental attitude toward childhood influenza vaccine and identified determinants of vaccine hesitancy (VH) in the Eastern Mediterranean region (EMR)., Methods: A cross-sectional study was conducted using an anonymous online survey in 14 EMR countries. Parents of children aged 6 months to 18 years were included. The Parent Attitude about Childhood Vaccines (PACV) was used to assess VH. Chi square test and independent t-test were used to test for association of qualitative and quantitative variables, respectively. A structural equations model (SEM) was used to identify direct and indirect determinants of parental VH., Results: Almost half of the parents were hesitant about vaccinating their children against influenza (50.8%). Parental VH was significantly higher among older mothers (37.06 ± 8.8 years, p  = 0.006), rural residents (53.6%, p  < 0.001), high-income countries residents (50.6%, p  < 0.001), and mothers with higher educational levels (52.1%, p  < 0.001). Parents of school-aged children (5-9 years) (55.6%, p  < 0.001), children free from any comorbidities (52.5%, p  < 0.001), children who did not receive routine vaccination at all (51.5%, p  = 0.03), children who were not vaccinated against COVID-19 (54.3%, p  < 0.001), in addition to parents who were not vaccinated against influenza (57.1%, p  < 0.001) were significantly associated with increased likelihood of VH. Parents who were depending on healthcare provider as a source of information regarding vaccines were less likely to report VH (47.9%, p < 0.001), meanwhile those who used social media as their source of health information showed a significantly higher VH (57.2%, p < 0.001). The SEM suggested that mother's age, residence, country income level, child gender, total number of children and source of information regarding vaccines had a direct effect on VH. Meanwhile, parents vaccinated against influenza, children completely or partially vaccinated with routine vaccines and children vaccinated against Coronavirus disease 2019 (COVID-19) had an indirect effect on VH., Conclusion: A high proportion of included parents were hesitant to vaccinate their children against seasonal influenza. This attitude is due to many modifiable and non-modifiable factors that can be targeted to improve vaccination coverage., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Fadl, Al Awaidy, Elshabrawy, Makhlouf, Ibrahim, Abdel-Rahman, Tookhy, Alsalmani, Al-Saeedi, Al-Sawalha, El-Din, Saad, Ayoob, Rourou, Ali, Tawati, Gadain, Al-saidi, Hassan, Alsanafi, Sandouk, Youssef, Alothman, Yazbek, Al-Ansi, Mehdad, Adam, Gebreal and Ghazy.)