Instruments for measuring parents' vaccine hesitancy towards their children based on the COSMIN guidelines: A systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported; COSMIN methodology uses qualitative evidence synthesis rather than p-value-based inference

• Effect Size: Category A recommendation (sufficient evidence of adequate measurement properties): MVHS-M (Malay version of the modified vaccine hesitancy scale), PACV-Viet (Vietnamese version of the parent attitudes about childhood vaccines survey), and PASV (parental attitude scale towards vaccination). Category C recommendation: GVHS, VAX, VAI, VBAT. Remaining instruments: Category B.

• Primary Outcome: COSMIN-graded measurement properties of 31 vaccine hesitancy assessment instruments for parents of children aged 0–18 years

• Nnt Or Sensitivity: Not applicable for a measurement properties review; relevant metrics are reliability coefficients, validity indices, and GRADE certainty ratings reported in the full text

• Confidence Interval: Not applicable in conventional meta-analytic sense; certainty of evidence assessed via modified GRADE system

Clinical Application

Category A instruments are feasible for use in clinical and research settings, subject to language and cultural appropriateness. The COSMIN framework provides a transparent basis for instrument selection. Clinicians should note that measurement error and responsiveness data remain limited for all recommended instruments, which may affect their use in longitudinal monitoring or intervention evaluation contexts. Australia's multicultural population includes substantial Malay-speaking (Malaysian and Indonesian communities) and Vietnamese-speaking communities, making the MVHS-M and PACV-Viet potentially relevant for targeted community health programs. The PASV, as a general parental attitude scale, may have broader applicability across Australian primary care and immunisation clinic settings. The RACGP supports evidence-based approaches to addressing vaccine hesitancy in primary care (RACGP Standards for General Practices; National Immunisation Program context). The TGA and ATAGI do not currently mandate specific vaccine hesitancy measurement tools, but this review provides an evidence base for selecting validated instruments in quality improvement, research, and public health surveillance activities. The Australian Immunisation Register (AIR) tracks coverage but does not capture hesitancy attitudes; validated instruments identified here could complement AIR data in population health research. PBS and TGA considerations are not directly applicable to instrument selection but are relevant to the vaccines being assessed for hesitancy. Parents of children aged 0–18 years in clinical, public health, and research settings where vaccine hesitancy assessment is required. Most directly applicable to populations similar to those in which Category A instruments were validated (Malay-speaking and Vietnamese-speaking communities; general parental populations for PASV).

Abstract

BACKGROUND: Parental vaccine hesitancy undermines immunization gains, leading to resurgent outbreaks and increased child mortality. Reliable assessment instruments are urgently needed to guide effective interventions and improve coverage. Despite multiple vaccine hesitancy assessment instruments, no systematic reviews have evaluated the measurement properties of these instruments against established methodological standards, limiting evidence-based selection. OBJECTIVE: To systematically evaluate the methodological quality and measurement properties of vaccine hesitancy assessment instruments for parents of 0-18 children, providing an evidence-based basis for selecting appropriate instruments. DESIGN: Measurement properties are systematically reviewed according to the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. METHODS: Six electronic databases were systematically searched from inception until July 15, 2025. Methodological quality was assessed using the COSMIN Risk of Bias Checklist and measurement properties were synthesized according to the COSMIN criteria. A modified Grading, Recommendations, Assessment, Development, and Evaluation system was used to assess the certainty of evidence. RESULTS: Forty studies evaluating 31 vaccine hesitancy assessment instruments were included. Based on COSMIN evidence grading, the Malay version of the modified vaccine hesitancy scale (MVHS-M), the Vietnamese version of the parent attitudes about childhood vaccines survey (PACV-Viet), and the parental attitude scale towards vaccination (PASV) received Category A recommendation. The general vaccine hesitancy scale (GVHS), vaccination attitudes examination (VAX), vaccine acceptance instrument (VAI), and vaccine barriers assessment tool (VBAT) received Category C recommendation, while others were Category B recommendation. CONCLUSIONS: This systematic review identified MVHS-M, PACV-Viet, and PASV as effective tools for assessing vaccine hesitancy in parents, suitable for both research and clinical use. Future research should comprehensively assess their measurement properties, especially exploring measurement error and responsiveness. REGISTRATION: A protocol was registered on the PROSPERO (CRD420251070194).

References

1. 1.Cao, T., Chen, B., Chen, S., Liu, H., Li, Y., Ren, X., Gao, J., & Hou, C. (2026). Instruments for measuring parents' vaccine hesitancy towards their children based on the COSMIN guidelines: A systematic review. Vaccine. https://doi.org/10.1016/j.vaccine.2026.128703