Factors impacting parental uptake of COVID-19 vaccination for U.S. Children ages 5–17

Abstract

COVID-19 vaccination of U.S. children lags behind adult vaccination, but remains critical in mitigating the pandemic. Using a subset of a nationally representative survey, this study examined factors contributing to parental uptake of COVID-19 vaccine for children ages 12–17 and 5–11, stratified by parental COVID-19 vaccination status. Among vaccinated parents, uptake was higher for 12–17-year-olds (78.6%) than 5–11-year-olds (50.7%); only two unvaccinated parents vaccinated their children. Child influenza vaccination was predictive of uptake for both age groups, while side effect concerns remained significant only for younger children. Although parents were more likely to involve adolescents in vaccine decision-making than younger children, this was not predictive of vaccine uptake. These results highlight the importance of addressing the unique and shared concerns parents have regarding COVID-19 vaccination for children of varying ages. Future work should further explore adolescent/child perspectives of involvement in COVID-19 vaccination decision-making to support developmentally appropriate involvement.

1. Introduction

COVID-19 vaccination among U.S. children significantly lags behind adult vaccination, despite the importance of vaccination to decrease children’s disease burden and reduce transmission to others [1]. As of August 2022, 61.8% of adolescents (12–17-years-old) and 34% of younger children (5–11-years-old) had received at least one COVID-19 vaccine dose [2], compared to 78% of U.S. adults [3]. Previous studies indicate that parents are more cautious about vaccinating children against COVID-19 than themselves [[4], [5]], though the majority of studies to date measured intention rather than uptake.

Parental decision-making regarding child COVID-19 vaccination is impacted by a variety of factors, such as desire to protect children and others from infection, ability to resume activities, perceptions of vaccine safety and efficacy, and other sociocultural, political and historical considerations [[6], [7], [8]]. One study completed February-March 2021 (prior to vaccine approval for children under 16-years-old), showed that parents had both low perceived risk of severe COVID-19 infection and low confidence in the safety and effectiveness of COVID-19 vaccines for children [7]. Parental COVID-19 vaccine decision-making may mirror other child vaccine decisions; e.g., acceptance of influenza vaccination [4] and general childhood immunizations [6] has been associated with intention to vaccinate children against COVID-19.

Little is known regarding how parental engagement of children in COVID-19 vaccine decisions impacts uptake. Studies conducted in the U.S. [[10], [11]], Canada [12], and Hong Kong [13] have found that adolescents share similar concerns to adults regarding COVID-19 vaccination; however, there may be discordance between the views of adolescents/children and their parents.

Using a subset of a nationally representative sample who self-identified as parents of minors, we examined factors influencing parental uptake of COVID-19 vaccination for children 5–17-years-old.

2. Methods

Participants were recruited from Ipsos KnowledgePanel®, a national U.S. survey panel of adults aged 18 years and older. Of the 1208 respondents who completed our original Wave 1 survey in April 2021 in English or Spanish [14], 865 were retained for Wave 2, completed between February 7–19, 2022. This study’s sample is a subset of 160 Wave 2 respondents who reported being parents of children aged 12–17 years (n = 110 parents) and 5–11 years (n = 90 parents), and answered vaccine uptake questions. Forty parents had children in both age groups. At the time of survey administration, the Federal Drug Administration had expanded emergency use authorization (EUA) to COVID-19 vaccines for individuals aged 5 years and older [2].

2.1. Questionnaire

Sociodemographics. The following characteristics were used to describe the sample: gender, age, race/ethnicity, education, U.S. region, and political views.

Parental COVID-19 vaccination. Respondents were categorized as “vaccinated parent” if they had received at least one COVID-19 vaccine dose, and “unvaccinated parent” if they had not.

Child COVID-19 vaccine uptake. Parents reported how many of their children in each specific age group (12–17 versus 5–11) had received at least one COVID-19 vaccine dose. For the purposes of analysis, those who vaccinated some or all children within each age group were classified as “child vaccine acceptors”, while those who vaccinated none of their children were categorized as “child vaccine non-acceptors”.

3. Predictors of child COVID-19 vaccination uptake.

Child influenza vaccination. Parents indicated how many of their children in each age group had received an influenza vaccine in the past 6 months (i.e. during that influenza season). Those who vaccinated some or all children within each age group were classified as “received influenza vaccine”, while those who vaccinated none of their children were categorized as “did not receive influenza vaccine”.

Reasons for child COVID-19 vaccination. Parents indicated the importance of the following reasons in their decision to vaccinate children against COVID-19, ‘Getting a vaccine was required to do something that they wanted to do (e.g., school activities, travel)’, ‘Protecting older (over 65 years), younger (under 5-years-old) or medically vulnerable family members (e.g., immunocompromised)’, and ‘The possibility that my children could get seriously sick if they got COVID-19′. Items were rated on a 5-point Likert scale from not at all important (1) to extremely important (5). Responses were collapsed into dichotomous categories of ‘extremely/very important’ versus ‘not at all important, slightly and moderately important’.

COVID-19 vaccine side effect concerns. Parents reported their level of agreement with the following: ‘I am concerned about serious side effects of COVID-19 vaccines for my children’ and ‘I think COVID-19 vaccines might cause lasting health problems for my children’. Items were rated on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Higher mean scores indicated greater concern regarding child COVID-19 vaccination side effects.

Involvement of children in COVID-19 vaccination decision-making. Parents reported whether COVID-19 vaccination decisions were made “primarily by the parents”, “jointly by the child and parents” or “primarily by the child”. Due to the small sample, responses for the latter two answer choices were collapsed into one category because our primary interest was in measuring any degree of child involvement in vaccination decisions.

3.1. Data analysis

Demographics were summarized using descriptive statistics, with frequency and percentages for categorical variables, and mean and standard error for the continuous variable. The analyses were stratified by child age group (i.e. parents of 12–17-year-olds, parents of 5–11-year-olds). Each of the predictor variables were analyzed in a bivariate logistic regression model with child vaccine uptake as the outcome. In addition, a common (multivariable) model was built for child vaccine uptake in each age group. Weights provided by Ipsos were used for all analyses in SAS® Software v.9.4 (SAS Institute Inc., Cary, NC). Standard error estimates were adjusted to account for variability introduced by subsampling.

4. Results

Demographics are presented in Table 1 . Using weighted data, 74.2% of parents of 12–17-year-olds and 71.7% of parents of 5–11-year-olds were vaccinated against COVID-19. Among vaccinated parents, 78.6% of parents of 12–17-year-olds accepted COVID-19 vaccination for their children, versus 50.7% of parents of 5–11-year-olds. In each age group, only one unvaccinated parent vaccinated their children. Given that lack of parent vaccination almost perfectly predicted lack of child vaccine uptake, we focused on examining factors associated with child vaccine uptake only among vaccinated parents.

Table 1.

Demographic & health-related characteristics by parental COVID-19 vaccination status.¹

Categorical variables	Parents of children aged 12–17 Unweighted n = 110 Weighted n = 126.2 (55.2%)		Parents of children aged 5–11 Unweighted n = 90 Weighted n = 102.6 (44.8%)
	Vaccinated ParentUnweighted n = 81 Weighted n = 93.7 (74.2%) Weighted n (%)	Unvaccinated ParentUnweighted n = 29 Weighted n = 32.5 (25.8%) Weighted n (%)	Vaccinated Parent Unweighted n = 68 Weighted n = 73.6 (71.7%) Weighted n (%)	Unvaccinated Parent Unweighted n = 22 Weighted n = 29 (28.3%) Weighted n (%)
Parent gender
Male	29.8 (31.8%)	13.0 (39.8%)	39.6 (53.8%)	10.7 (37.0%)
Female	63.9 (68.1%)	19.5 (60.2%)	34.0 (46.2%)	18.3 (63.0%)
Parent age (years)
18–34	8.0 (8.5%)	12.0 (37.0%)	13.4 (18.3%)	14.0 (48.3%)
35–54	70.0 (74.8%)	17.6 (54.0%)	53.8 (73.1%)	13.8 (47.4%)
55+	15.7 (16.7%)	2.9 (8.9%)	6.3 (8.6%)	1.2 (4.3%)
Parent race/ethnicity
Non-Hispanic White	41.2 (44.0%)	20.0 (61.4%)	44.8 (60.9%)	17.1 (59.0%)
Non-Hispanic Black	15.0 (16.0%)	6.7 (20.5%)	7.8 (10.7%)	6.7 (23.1%)
Hispanic	26.9 (28.7%)	4.2 (12.9%)	11.2 (15.3%)	2.0 (7.0%)
2 + races, other	10.6 (11.3%)	1.7 (5.2%)	9.7 (13.2%)	3.2 (10.9%)
Parent education
Bachelor’s degree or higher	27.3 (29.2%)	2.0 (6.2%)	35.2 (47.8%)	3.4 (11.6%)
Some college	23.3 (24.8%)	12.3 (37.9%)	19.8 (26.9%)	13.6 (46.9%)
High school degree or less	43.1 (46.0%)	18.1 (55.8%)	18.6 (25.3%)	12.0 (41.5%)
Parent U.S. Region
Northeast	10.3 (11.0%)	8.4 (26.0%)	7.9 (10.8%)	1.7 (5.9%)
Midwest	13.7 (14.6%)	5.4 (16.7%)	19.6 (26.6%)	7.7 (26.6%)
South	38.4 (41.0%)	14.4 (44.3%)	28.5 (38.7%)	12.4 (42.9%)
West	31.3 (33.4%)	4.2 (13.0%)	17.6 (23.9%)	7.1 (24.6%)
Parent political views
Very Liberal/Liberal	22.2 (23.7%)	0 (0%)	15.5 (21.0%)	0 (0%)
Moderate/Middle of the Road	34.6 (37.0%)	12.8 (39.2%)	23.6 (32.1%)	14.8 (51.1%)
Very  conservative/conservative	22.5 (24.0%)	14.4 (44.4%)	23.9 (32.5%)	10.3 (35.6%)
Prefer not to answer	14.4 (15.4%)	5.3 (16.4%)	10.6 (14.4%)	3.8 (13.3%)
Child received COVID-19 vaccine2
Yes	73.6 (78.6%)	0.6 (1.8%)	37.3 (50.7%)	1.3 (4.3%)
No	20.1 (21.4%)	31.9 (98.2%)	36.3 (49.3%)	27.8 (95.7%)
Child received flu vaccine in past 6 mo.2
Yes	57.4 (61.3%)	4.1 (12.8%)	45.6 (62.0%)	1.2 (4.3%)
No	36.3 (38.7%)	28.4 (87.2%)	28.0 (38.0%)	27.8 (95.7%)
Reasons to vaccinate child: desired activities/travel
Extremely/very important	31.9 (34.0%)	0 (0%)	22.1 (30.1%)	0 (0%)
Not at all/slightly/moderately important	61.8 (66.0%)	32.5 (100%)	51.4 (69.9%)	29.0 (100%)
Reasons to vaccinate child: protect vulnerable family members
Extremely/very important	45.6 (48.6%)	1.2 (3.7%)	31.7 (43.3%)	4.4 (15.0%)
Not at all/slightly/moderately important	48.1 (51.4%)	31.3 (96.3%)	41.5 (56.7%)	24.7 (85.0%)
Reasons to vaccinate child: child could get seriously sick from COVID-19
Extremely/very important	47.9 (51.1%)	7.3 (22.5%)	39.9 (54.3%)	6.4 (22.0%)
Not at all/slightly/moderately important	45.8 (48.9%)	25.2 (77.5%)	33.6 (45.7%)	22.6 (78.0%)
Child involvement in vaccination decision-making
Decision made jointly or primarily by child	61.54 (65.7%)	19.1 (59.9%)	21.74 (29.6%)	4.0 (15.2%)
Decision made primarily by parents	32.15 (34.3%)	12.8 (40.1%)	51.83 (70.4%)	22.3 (84.8%)
Scale Variable	Mean Score (SE)	Mean Score (SE)	Mean Score (SE)	Mean Score (SE)
Parental concerns about COVID-19 vaccine side effects for their children	3.01 (0.14)	4.34 (0.17)	3.17 (0.17)	4.29 (0.20)

¹Total parent respondents N = 160, 40 parents have children in both age groups.

²Child received COVID/flu vaccine defined as at least some or all of the parent’s children in that age group received COVID/flu vaccine.

The only statistically significant predictors of child COVID-19 vaccine uptake in the bivariate models (Table 2 ) were child influenza vaccination and side effect concerns (among both age groups), and reason for vaccination to protect vulnerable family members (5–11 group only). All predictors were included in the final common model for each age group.

Table 2.

Bivariate & final logistic regression models for child COVID-19 vaccine uptake among vaccinated parents.¹, ²

	Vaccinated parents of children aged 12–17 Acceptors3vs Non-Acceptors		Vaccinated parents of children aged 5–11 Acceptors3vs Non-Acceptors
	Bivariate Unadjusted OR [95% CI]	Final Model Adjusted OR [95% CI]	Bivariate Unadjusted OR [95% CI]	Final Model Adjusted OR [95% CI]
Child received flu vaccine in past 6 mo.
Yes	8.24 [2.15, 31.56]*	9.40 [1.79, 49.31]*	3.48 [1.14, 10.62]	4.73 [1.17, 19.12]
No	Ref	Ref	Ref	Ref
Reasons to vaccinate child: desired activities/travel
Extremely/very important	1.56 [0.43, 5.69]	1.00 [0.21, 4.66]	2.19 [0.67, 7.13]	0.94 [0.11, 7.81]
Not at all/slightly/moderately important	Ref	Ref	Ref	Ref
Reasons to vaccinate child: protect vulnerable family members
Extremely/very important	3.54 [0.94, 13.30]	1.86 [0.38, 9.08]	3.21 [1.07, 9.66]	1.49 [0.22, 10.13]
Not at all/slightly/moderately important	Ref	Ref	Ref	Ref
Reasons to vaccinate child: child could get seriously sick from COVID-19
Extremely/very important	2.37 [0.68, 8.24]	2.72 [0.71, 10.37]	2.51 [0.86, 7.37]	2.29 [0.47, 11.17]
Not at all/slightly/moderately important	Ref	Ref	Ref	Ref
Child involvement in vaccination decision-making
Decision made jointly or primarily by child	1.41 [0.42, 4.75]	1.80 [0.38, 8.45]	2.49 [0.72, 8.55]	3.06 [0.77, 12.25]
Decision made primarily by parents	Ref	Ref	Ref	Ref
Parental concerns about COVID-19 vaccine side effects	0.47 [0.24, 0.92]	0.58 [0.25, 1.37]	0.48 [0.30, 0.76]	0.49 [0.29, 0.83]*

¹Referent group in italics.

²Bolded values are significant at p < 0.05, *p < 0.01.

³Acceptors defined as parents who accepted a COVID vaccine for at least some or all of their children in the respective age group.

In the final model (Table 2), vaccinated parents of 12–17-year-olds were more likely to have accepted child COVID-19 vaccination if children had received an influenza vaccine (OR 9.40, 95% CI = 1.79, 49.31). Reasons to vaccinate, side effect concerns, and child involvement in decision-making were not significant in the final model.

In the final model, vaccinated parents of 5–11-year-olds were more likely to have accepted child COVID-19 vaccination if children had received an influenza vaccine (OR 4.73, 95% CI = 1.17, 19.12). Parents were less likely to have accepted COVID-19 vaccination for 5–11-year-olds if they indicated greater side effect concerns (OR 0.49, 95% CI = 0.29, 0.83). Reasons to vaccinate and child involvement in decision-making were not significant in the final model (Table 2).

5. Discussion

This study built upon reports of parental intent to vaccinate children by examining uptake of COVID-19 vaccination after EUA for those aged 5 years and older. Consistent with other studies, parents were more likely to have accepted COVID-19 vaccination for themselves than for their children, and were more likely to vaccinate children if they were vaccinated themselves [[9], [17]]. Only two unvaccinated parents in our sample accepted a vaccine for their children; thus, the final analysis was limited only to vaccinated parents.

In this subset of a nationally representative sample, parental uptake of child COVID-19 vaccination was higher for adolescents (78.6%) than younger children (50.7%), similar to other reports [[2], [9]]. Given that COVID-19 vaccines for 5–11-year-olds became available more recently (October 2021 versus May 2021 for 12–15-year-olds, and December 2020 for those aged 16+) [16], these findings may be related to hesitancy concerning vaccine “newness” [6].

Another possible explanation for differences between parental uptake for adolescents versus younger children is that parents may perceive younger children as more vulnerable to potential COVID-19 vaccine side effects. In our study, these concerns followed the same direction for both age groups. However, side effect concerns remained significant only in the final model among parents of 5–11-year-olds, consistent with prior findings of substantial vaccine side effect concerns particularly among parents of younger children [[5], [15], [16]].

Concern regarding side effects will be relevant for parents of children aged 6 months to 4 years, for whom COVID-19 vaccines received EUA [18] after our study. A Kaiser Family Foundation survey found that 53% of parents of children under 5-years-old had greater concerns about risks of COVID-19 vaccination for their child’s health than infection, and over 40% would “definitely not” vaccinate their child [18], highlighting the importance of targeting messages to parents that aim to change perceptions of children’s susceptibility to and severity of COVID-19 infection [[4], [19]].

Reasons to vaccinate children (e.g., protection from serious COVID-19 infection) did not hold statistical significance in our final predictive models of uptake, possibly reflecting parents’ low perceived risk of child COVID-19 severity [7]. Perhaps the perceived risk of COVID-19 infections does not outweigh the perceived risk of vaccination. Additionally, there may be other reasons not captured in this survey that would have been predictive of uptake. One other study found that perceived vaccination benefits were associated with uptake among parents of 12–17-year-olds and 5–11-year-olds [9].

Our findings support a relationship between COVID-19 vaccine decision-making and other vaccines. For both age groups, influenza vaccine acceptance was associated with COVID-19 vaccine uptake, consistent with other studies [[15], [19]]. Given the parallel nature of influenza infection as a potentially severe respiratory illness that requires serial vaccination, targeting COVID-19 vaccination messages to parents who are amenable to influenza vaccination may be one strategy to enhance uptake among a receptive group [19].

Our results demonstrated that vaccinated parents of 12–17-year-olds involved their children in decision-making at a higher rate (65.7%) than those with younger children (29.6%), likely reflecting engagement based on developmental stage. Interestingly, this engagement was not significantly associated with vaccine uptake for either age group. One other study did find that parents who considered their adolescent’s intention to receive COVID-19 vaccination were more likely to have positive vaccination intentions, indicating that adolescent attitudes do impact parental decision-making [11]. Another study found that adolescent vaccination intentions were influenced by perceptions of parental vaccination attitudes (more than peers’ attitudes), highlighting the important role parents play in adolescent vaccine attitudes [10]. In the context of ethical and political debate around allowing minors to consent for COVID-19 vaccines without parental consent, it is important to find ways to balance respect for both minors’ autonomy and parental authority [20].

6. Limitations

The study sample drew from a subset of a nationally representative survey of adults; thus, our sample size of parents was relatively small and we limited the number of predictors included in the regression modeling. We were unable to fully capture the complex intricacies of parental COVID-19 vaccination decisions for themselves or each individual child. However, our findings highlight some of the differences in vaccination decision-making between parents of older and younger children.

7. Conclusions

This study provides further evidence that parental decision-making regarding child COVID-19 vaccination varies significantly by child age group and is strongly influenced by side effect concerns for younger children, even among vaccinated parents. This highlights the importance of addressing the unique and shared concerns parents have regarding COVID-19 vaccination for children of varying ages. Given the ongoing evolution of the pandemic, the recent rollout of COVID-19 vaccines for children under 5-years-old, and distribution of additional booster doses in Fall 2022, public health campaigns should promote the safety of COVID-19 vaccines. Directing these efforts to parents who accept child influenza vaccination may be one strategy to tailor messaging to a group with a higher propensity to accept COVID-19 vaccination. Future work should elucidate the primary reasons that parents accept COVID-19 vaccines for their children by age group, and further explore adolescent/child perspectives of engagement in vaccination decisions to support developmentally appropriate involvement.

Ethics approval

Approval was obtained from the Institutional Review Board of Columbia University Irving Medical Center on December 22, 2020. (IRB-AAAT5154).

Consent to participate

All participants in this study are members of the IPSOS KnowledgePanel®. Participants received an information sheet for this study, and completion of the questionnaire indicated consent.

Consent for publication

There is no potentially identifiable data presented, and in fact, the authors only had access to de-identified data.

Availability of data and material

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

We utilized SAS® Software v. 9.4 (SAS Institute Inc., Cary, NC) for descriptive statistics and all regression models.

Authors' contributions

All authors contributed to the study conception and design, material preparation, data analysis and interpretation. The first draft of the manuscript was written by Julen Harris, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Research support

The study was funded by a Merck Investigator Studies Program grant awarded to Dr. Susan L. Rosenthal, Principal Investigator, and administered through Columbia University Medical Center.

Relationships

There are no additional relationships to disclose.

Patents and intellectual property

There are no patents to disclose.

Other activities

There are no additional activities to disclose.

Declaration of Competing Interest

Julen Harris, Christine Mauro, Tucker Morgan, and Ariel de Roche have no conflicts of interest to declare. Outside of the current study, Gregory Zimet has served as an external advisory board member for Merck and Moderna, and as a consultant to Merck. He also has received investigator-initiated research funding from Merck administered through Indiana University and serves as an unpaid member of the Board of Directors for the Unity Consortium, a non-profit organization that supports adolescent health through vaccination. Susan Rosenthal has received investigator-initiated research funding from Merck Investigator Studies Program administered through Columbia University Irving Medical Center.

Data availability

Data will be made available on request.